Progress towards antimicrobial resistance containment and control in Indonesia


I n May 2015 member states at the World Health Assembly endorsed the World Health Organization’s global action plan on antimicrobial resistance (GAPAMR). Through adoption of the GAPAMR, member states committed to having a national action plan on antimicrobial resistance in place by May 2017. 2 The South East Asia region has moved from having one (10%) country with a national action plan in December 2015 to 10 countries (90%) by May 2017. WHO supported the Indonesian Ministry of Health to develop a national action plan, first by conducting a review of current activities. The review focused on a situation analysis of challenges to tackling AMR. The South East Asia Regional Office (SEARO) of WHO has proposed a stepwise, incremental approach to implementing GAP-AMR, consisting of five phases. Phase 5 is defined as a fully operational AMR containment programme with evidence of a sustained funding mechanism and incorporating a functional monitoring and evaluation system. Here we evaluate Indonesia’s progress towards this goal. Antimicrobial resistance in Indonesia With an estimated population of 258 million people, Indonesia is the fourth most populous country in the world and is categorised as a lower middle income country. Despite no formal estimation of its burden, AMR is thought to be high and on the rise. Data on AMR in Indonesia have been patchy, sporadic, and selective, commonly generated by a few laboratories from large universities, which are not connected in a national network. Epidemiological data on Streptococcus pneumoniae carriage and invasive disease are currently limited in Indonesia. In the mid 1990s studies reported 21% and 36% of penicillin non-susceptible and erythromycin resistant S pneumoniae, respectively, in Jakarta. In Lombok Island, the prevalence of S pneumoniae carriage was 48% in healthy children, of which all isolates were susceptible to penicillin and cefotaxime and 12% were non-susceptible to sulfamethoxazole or chloramphenicol. In 2000-01, the prevalence of tetracycline resistant S pneumoniae tested at the University of Jakarta’s microbiology laboratory was 46%, compared with 1-5% in studies from northern Europe. 9 In Semarang, Indonesia, prevalence of S pneumoniae in 2010 was 43% in children aged 6-60 months and 11% in adults aged 45-75 years, of which isolates 24% were penicillin non-susceptible and 45% were resistant to cotrimoxazole. In 2001, E coli from rectal samples showed remarkably high resistance to ampicillin (73%), trimethoprimsulfamethoxazole (56%) and ciprofloxacin (22%), especially at the time of hospital discharge. Until the late 1990s, extended spectrum β lactamase producing bacteria were mainly isolated in hospitals worldwide; later, resistance increased along with the emergence of genes related to CTX-M in hospitals and the community. 13 In 2005 a survey in a hospital in Surabaya, Indonesia, found prevalences of extended spectrum β lactamases (including CTX-M) of 20% and 28% among clinical E coli and Klebsiella pneumoniae, respectively. Over the past decade the emergence of extended spectrum β lactamase producing bacteria and carbapenem resistant Enterobacteriaceae has become a worldwide threat to public health. From 2001 to 2012, resistance to imipenem rates reached 30% in some epidemic areas of the Middle East, while the top two Asian countries with the highest resistance rates to imipenem were Indonesia (6%) and the Philippines (4%). In 2009 the gene for New Delhi metallo-β-lactamase (blaNDM-1) was found in a sample of K pneumoniae in Indonesia. In 2001-02 the nasal carriage of Staphylococcus aureus was surveyed in two cities on Java island (Semarang and Surabaya); low prevalence of meticillin resistant S aureus (MRSA) (<1%) was found among 263 isolates from healthy people in the community. In 2007-08, 24% of surgical patients were screened for MRSA carriage at discharge in three teaching hospitals in Indonesia. Of these, 24% patients carried S Aureus, 4.3% of whom had MRSA. This was surprising low, as the prevalence of MRSA in some Asian countries, such as Taiwan and mainland China, is among the highest in the world, ranging from 28% to over 70%. 21 Prevention of spread of MRSA is crucial in Indonesia because of the surprisingly high prevalence of the PantonValentine leukocidin genes (11%) among MRSA in the country, a virulence factor that is associated with skin infections and severe necrotising pneumonia. The challenges of AMR that Indonesia faces are similar as those of many other low and middle income countries in the region and beyond. Misuse and overuse of antibiotics in humans and in livestock and aquaculture are the key drivers of resistance in the country. With the economy prospering for the past decade and a growing demand for poultry products and the development of aquaculture exports, agricultural use probably exceeds medical use in Indonesia. Despite current policies related to antimicrobial use, common and unnecessary prescription of antibiotics by physicians, high rates of self medication, and over-the -counter purchase of antibiotics are common. Many contextual factors influencing antibiotic use are known, including weak policy enforcement and poor governance, lack of education, and easy access to cheap antibiotics. Key messages

DOI: 10.1136/bmj.j3808

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@inproceedings{Parathon2017ProgressTA, title={Progress towards antimicrobial resistance containment and control in Indonesia}, author={Harry Parathon and Kuntaman Kuntaman and Tri Hesty Widiastoety and Bayu T Muliawan and Anis Karuniawati and Mariyatul Qibtiyah and Zunilda Djanun and Jihane F Tawilah and Tjandra Yoga Aditama and Visanu Thamlikitkul and Sirenda Vong}, booktitle={BMJ}, year={2017} }