Non-industrialized countries, home to the majority of the world's population, have an important role in the emergence of global resistance of bacteria to antimicrobial drugs.¹ x 1 World Health Organization. WHO global strategy for containment of antimicrobial resistance. Report No. WHO/CDS/CSR/DRS/2001.2. Geneva: WHO; 2001. Google Scholar See all References Antibiotic use contributes to the selection of resistant microorganisms.² x 2 Tenover, F.C. Development and spread of bacterial resistance to antimicrobial agents: an overview. Clin Infect Dis. 2001; 33: S108–S115 Crossref | PubMed | Scopus (145) | Google Scholar See all References ^{, 3} x 3 Austin, D.J., Kristinsson, A.G., and Anderson, R.M. The relationship between the volume of antimicrobial consumption in human communities and the frequency of resistance. Proc Natl Acad Sci. 1999; 96: 1152–1156 Crossref | PubMed | Scopus (517) | Google Scholar See all References This problem has become so widespread that bacterial resistance to antibiotics is threatening health improvements achieved in the tropics in the past decades.⁴ x 4 Shears, P. Antibiotic resistance in the tropics. Trans Royal Soc Trop Med Hyg. 2001; 95: 127–130 Abstract | Full Text PDF | PubMed | Scopus (27) | Google Scholar See all References Despite the potential impact of this problem, only limited information on resistance of bacteria and antibiotic consumption is available in Indonesia. Most research has been done on diarrheal⁵ x 5 Gani, L., Arif, H., Widjaja, S.K., Adi, R., Prasadja, H., Tampubolon, L.H. et al. Physician's prescribing practice for treatment of acute diarrhoea in young children in Jakarta. J Diarrhoeal Dis Res. 1991; 9: 194–199 PubMed | Google Scholar See all References ^{, 6} x 6 Ismail, R., Bakri, A., Nazir, M., Ryanto, and Haridawati. Indicators for antibiotic therapy in invasive bacterial diarrhoea. J Diarrhoeal Dis Res. 1994; 3: 208–213 Google Scholar See all References ^{, 7} x 7 Subekti, D.S., Lesmana, M., Tjaniadi, P., Machpud, N., Sriwati, Sukarma et al. Prevalence of enterotoxic Escherichia coli (ETEC) in hospitalized acute diarrhea patients in Denpasar, Bali, Indonesia. Diagn Microbiol Infect Dis. 2003; 47: 399–405 Abstract | Full Text | Full Text PDF | PubMed | Scopus (20) | Google Scholar See all References ^{, 8} x 8 Tjaniadi, P., Lesmana, M., Subekti, D., Machpud, N., Komalarini, S., Santoso, W. et al. Antimicrobial resistance of bacterial pathogens associated with diarrheal patients in Indonesia. Am J Trop Med Hyg. 2003; 68: 666–670 PubMed | Google Scholar See all References and sexually transmitted diseases.⁹ x 9 Ieven, M., Van Looveren, M., Sudigdoadi, S., Rosana, Y., Goossens, W., Lammens, C. et al. Antimicrobial susceptibilities of Neisseria gonorrhoeae strains isolated in Java, Indonesia. Sex Transm Dis. 2003; 30: 25–30 Crossref | PubMed | Scopus (23) | Google Scholar See all References Resistance against penicillins and tetracyclines of diarrheal pathogens and Neisseria gonorrhoeae has approached 100% in some areas.⁸ x 8 Tjaniadi, P., Lesmana, M., Subekti, D., Machpud, N., Komalarini, S., Santoso, W. et al. Antimicrobial resistance of bacterial pathogens associated with diarrheal patients in Indonesia. Am J Trop Med Hyg. 2003; 68: 666–670 PubMed | Google Scholar See all References ^{, 9} x 9 Ieven, M., Van Looveren, M., Sudigdoadi, S., Rosana, Y., Goossens, W., Lammens, C. et al. Antimicrobial susceptibilities of Neisseria gonorrhoeae strains isolated in Java, Indonesia. Sex Transm Dis. 2003; 30: 25–30 Crossref | PubMed | Scopus (23) | Google Scholar See all References High resistance rates for enterotoxigenic Escherichia coli have been found against amoxicillin, trimethoprim–sulfamethoxazole, chloramphenicol, and tetracycline.⁷ x 7 Subekti, D.S., Lesmana, M., Tjaniadi, P., Machpud, N., Sriwati, Sukarma et al. Prevalence of enterotoxic Escherichia coli (ETEC) in hospitalized acute diarrhea patients in Denpasar, Bali, Indonesia. Diagn Microbiol Infect Dis. 2003; 47: 399–405 Abstract | Full Text | Full Text PDF | PubMed | Scopus (20) | Google Scholar See all References Ten years ago in a small survey, 70% of patients with diarrhea and about 80% of patients with respiratory tract symptoms were treated with antibiotics.¹⁰ x 10 Santoso, B., Suryawati, S., and Prawaitasari, J.E. Small group intervention vs formal seminar for improving appropriate drug use. Soc Sci Med. 1996; 42: 1163–1168 Crossref | PubMed | Scopus (75) | Google Scholar See all References Doctors in Jakarta prescribed antibiotics for 94% of young children although they believed that the infection was usually of viral origin.⁵ x 5 Gani, L., Arif, H., Widjaja, S.K., Adi, R., Prasadja, H., Tampubolon, L.H. et al. Physician's prescribing practice for treatment of acute diarrhoea in young children in Jakarta. J Diarrhoeal Dis Res. 1991; 9: 194–199 PubMed | Google Scholar See all References

This article estimates the magnitude and quality of antibiotic prescribing in Indonesian hospitals and aims to identify demographic, socio-economic, disease-related and healthcare-related determinants of use. An audit on antibiotic use of patients hospitalized for 5 days or more was conducted in two teaching hospitals (A and B) in Java. Data were collected by review of records on the day of discharge. The method was validated through concurrent data collection in Hospital A. Multivariate logistic regression analysis was performed to determine variables to explain antibiotic prescribing. Prescriptions were assessed by three reviewers using standardized criteria. A high proportion (84%) of 999 patients (499 in Hospital A and 500 in Hospital B) received an antibiotic. Prescriptions could be categorized as therapeutic (53%) or prophylactic (15%), but for 32% the indication was unclear. Aminopenicillins accounted for 54%, and cephalosporins (mostly third generation) for 17%. The average level of antibiotic use amounted to 39 DDD/100 patient-days. Validation revealed that 30% of the volume could be underestimated due to incompleteness of the records. Predictors of antibiotic use were diagnosis of infection, stay in surgical or paediatric departments, low-cost nursing care, and urban residence. Only 21% of prescriptions were considered to be definitely appropriate; 15% were inappropriate regarding choice, dosage or duration, and 42% of prescriptions, many for surgical prophylaxis and fever without diagnosis of infection, were deemed to be unnecessary. Agreement among assessors was low (kappa coefficients 0.13–0.14). Despite methodological limitations, recommendations could be made to address the need for improving diagnosis, treatment and drug delivery processes in this setting.

No detailed reports regarding extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae are currently available from Indonesia, the fourth most populous country in the world. A survey was carried out to investigate the molecular epidemiology and genetic characteristics of clinical ESBL-producing Escherichia coli and Klebsiella pneumoniae isolates originating from the Dr. Soetomo Academic Hospital in Surabaya, Indonesia, over a 4 month period (January to April 2005). ESBLs were characterized by isoelectric focusing and PCR assays. Clonality of the isolates was assessed by PFGE and repetitive-sequence-based PCR (rep-PCR). Phylogenetic grouping was performed among CTX-M-15-producing E. coli. In total, 73 consecutive non-duplicate ESBL-positive E. coli and 72 K. pneumoniae strains were isolated. The bla_CTX-M-15 gene was found to be highly prevalent (69/73 strains, 94.5%) among the 73 ESBL-positive E. coli isolates. The gene was detected in both clonal and non-clonal isolates, as defined by PFGE and rep-PCR. Sixteen CTX-M-15-positive E. coli could be assigned to a single rep-PCR type and phylogenetic group B2 and belonged to the well-known O25b-ST131 clone. Among the 72 ESBL-positive K. pneumoniae isolates, bla_CTX-M-15 was again the most prevalent ESBL (40/72, 55.6%). Several SHV-type enzymes were also frequently detected: SHV-5 (n = 28); SHV-12 (n = 13); and SHV-2 (n = 6). TEM-type ESBLs were not detected in any of the isolates. Indonesia is another developing country affected by the emergence and spread of bacterial strains harbouring ESBL genes, including the CTX-M-15-producing B2-E. coli O25b-ST131 clone.

Background: Antimicrobial resistance is an increasing problem in developing countries and antibiotic use is widespread. Our previous surveys in Java, Indonesia, revealed that most antibiotic use was probably unnecessary or ineffective. The aim of this study was to explore a potential connection between resistance and substandard antibiotics sold in the area. Methods: A cross-sectional field study using the simulated client method was conducted in Surabaya. Five first-line antibiotics were requested with or without prescription (OTC). A certified laboratory analysed the drug content using validated methods. Possible determinants of substandard quality were explored. Results: In total, 104 samples from 75 pharmacies, ten drug stores and 39 roadside stalls (kiosks) were obtained. Pharmacy employees filled all OTC requests. Three quarters of kiosks sold antibiotics. Antibiotics were dispensed as single blister strips or repackaged (16%) without label. Ninety five percent of samples carried the label of 14 Indonesian manufacturers. The pharmaceutical quality did not meet BP standards for 18% of samples. Deviations (less active ingredient) were small. There was no association between low content and type of outlet, sold with or without prescription, registration type, price or packaging. Median retail prices of products carrying the same label varied up to 20 fold. Conclusions: Antibiotics were available OTC in all visited pharmacies and sold in the streets of an Indonesian city. Most samples contained an active ingredient. We urge to increase enforcement of existing regulations, including legislation that categorizes antibiotics as prescription-only drugs for all types of medicine outlets, to limit further selection of antimicrobial resistance.

Few data on the molecular characteristics and epidemiology of Staphylococcus aureus from Indonesia are available. The purpose of the present study was to define S. aureus reservoirs in both the Indonesian community and hospital using a collection of 329 nasal carriage isolates obtained during a survey of 3,995 healthy individuals and patients from Java, Indonesia. Only one strain (0.3%) was identified as methicillin-resistant S. aureus by mecA gene PCR. The Panton-Valentine leukocidin (PVL) genes were detected in 35 methicillin-sensitive S. aureus strains (10.6%). Molecular typing by pulsed-field gel electrophoresis of the 329 isolates showed extensive genetic diversity among both PVL-positive and PVL-negative strains. In Surabaya, Indonesia, however, a cluster was identified that was strongly associated with the presence of the PVL locus ( P < 0.0001). As determined by high-throughput amplified fragment length polymorphism, PVL-positive strains occurred throughout all major AFLP clusters (I to IV). Multilocus sequence typing of a subset of isolates showed that most PVL-positive strains belonged to sequence type (ST) 188, while most PVL-negative isolates belonged to ST45. The high prevalence of PVL-positive S. aureus strains in certain regions of Indonesia is of concern since these strains may cause severe infections in the community and in hospitals.