Context
Persistently high infectious disease burdens (Mboi et al., 2018), coupled with liberal antibiotic practices and a fragile, decentralised health system makes Indonesia a hotspot for the development and spread of antimicrobial resistance (AMR) (Coker et al., 2011; Zellweger et al., 2017). The limited available data, mostly from Indonesian hospitals, have suggested high rates of drug-resistant infections (Parathon et al., 2017) and high rates of empirical use of broad-spectrum antibiotics (Limato et al., 2021).
Antimicrobial stewardship (AMS) programmes aim to control antimicrobial use, and have been associated with reducing hospital-acquired infections, unnecessary healthcare costs, and potentially drug-resistant infections (Honda et al., 2017; Laundy, Gilchrist, & Whitney, 2016; Schuts et al., 2016). However, AMS programs may jar with local constraints and practices and have been shown to have limited traction when attempts to implement occur without adequate understanding of context (Rolfe et al., 2021), societal values, shared practices, organisational cultures, and political contexts that shape antibiotic practice (Broom et al., 2020).
Nationwide, AMS programmes in Indonesian hospitals were enforced as a national policy in 2015. This policy requires all hospitals to form a hospital AMS team, implement an AMS programme, and perform antibiotic use surveillance. Antibiotic consumption is evaluated using the Defined Daily Dose (DDD) method, and appropriateness of antibiotic prescribing using Gyssens method (Ministry of Health Republic of Indonesia, 2015). In 2018, the national hospital accreditation scheme included the presence of an AMS programme as one of the core requirements to pass accreditation (Hospital Accreditation Committee, 2017). Yet, Indonesian hospitals are at variable stages of AMS implementation, due to limitations in resources, infrastructures and organisational cultures that influence AMS strategies.
Through a research project called “Exploration of Antimicrobial Consumption to Identify Targets for Quality Improvement in Indonesian Hospitals: a mixed-method study” (EXPLAIN study), we explored the current practices, dynamics, and challenges of AMS implementation in Indonesian hospitals. In this case study, we contrast some of the AMS challenges encountered in government-run (or public) versus private-for-profit hospitals. For this case study we made use of qualitative data from 51 semi-structured interviews conducted in 2 public and 3 private hospitals in Jakarta, Indonesia, between January and October 2020. Participants included antibiotic prescribers from medical and surgical departments, a clinical microbiologist, a clinical pharmacist, a hospital AMS leader/team member, a hospital manager, a co-assistant (final year of medical student doing clinical rounds), and national AMS stakeholders.
Overview of antimicrobial stewardship in Indonesian hospitals
All participant hospitals had an AMS team, developed or in progress of developing antibiotic guidelines, and implemented AMS strategies, albeit at variable levels. Pre-prescription authorisation (PPA) was performed in two public hospitals, and one of them also implemented post-prescription review and feedback (PPRF) through weekly AMS rounds. All private hospitals are still at the early stage of AMS implementation, including antibiotic guideline development and finding strategies to execute antibiotic restriction in the face of oppositions from prescribers. All public hospitals and one private receive patients who use national insurance scheme. Below are two scenarios in two different hospitals showcasing different challenges in each respective setting.
Different AMS challenges of two hospitals
Stewardship challenges encountered by a public teaching hospital
Stewardship strategies
Hospital A is a tertiary public teaching hospital that has around 750 inpatient beds. The AMS programme has been running since 2016. The employed AMS strategy is antibiotic restriction or PPA. The AMS team consists of doctors (consultants from medical and infectious diseases specialties), clinical pharmacists and a clinical microbiologist/pathologist. Each day one of the AMS consultants responds to prescribers’ requests for third line or restricted antibiotics (±5 to 10 per day). Communication between AMS consultants is often performed through a nurse. The majority (90%) of prescribers in this hospital reported that they do not have a dialogue with the AMS consultant, they just receive the decision “approved” or “not approved.” Some consultants may give suggestions to increase the antibiotic dose or to switch to a different, unrestricted antibiotic.
Culture test
The interviewed residents and consultants reported challenges in requesting cultures to guide definitive antibiotic therapy in this hospital. There are some logistical challenges including stock out of specimen containers, and in the weekends and national holidays and the laboratory is closed (the samples cannot be processed and therefore, are not taken). In the emergency unit, the use of culture tests is restricted to patients with sepsis (life-threatening organ dysfunction caused by a dysregulated host response to infection, Singer et al., 2016). As mentioned by participants, the aim is to minimise cost. Access to the culture results take around five days, and culture and sensitivity results are unreliable, e.g., reporting contaminants or often come back negative, which contrasts with the severity of the patient condition. A culture test is considered expensive (~USD 35 per sample), especially when it is calculated within the cap of the national health insurance. Therefore, infectious patients without sepsis usually receive empirical treatment, and a culture is requested only when a patient is not improving during the admission.
Hospital infrastructure
Participating surgeons and residents in the surgery department expressed distrust of hospital infrastructures i.e., sterility of operating theatre and in the management wards. These situations encourage them to prescribe prolonged (i.e., 3-7 days) surgical antibiotic prophylaxis (SAP) even for clean surgery. An additional 5 days of antibiotics post-operation is also prescribed, despite many patients came back with surgical site infections post-discharge (despite the prolonged SAP) due to suboptimal hygiene of the wound.
National health insurance
The majority (90%) of the patients in this hospital have national health insurance. A national drug formulary for this scheme was released in 2014 and is updated every year, including the covered antibiotics for different syndromes. Broad-spectrum antibiotics that are not listed in this formulary and/or categorised as third line antibiotics can be released by a strict process of culture testing and approval by the AMS team or hospital director which takes about 5 days. Prescribers and management explained that this strict process is required because some restricted antibiotics are expensive, and few are not reimbursed under this scheme.
Funding for stewardship programme
The AMS team and some prescribers perceived that the AMS programme is not fully endorsed and supported by the hospital management despite the presence of hospital stewardship support letter. The funding available for the AMS programme is generally incidental. Mainly, when hospital accreditation is approaching, the AMS programme is fully supported financially.
Stewardship challenges encountered by a private teaching hospital
Stewardship strategies
Hospital B is a private-for-profit secondary teaching hospital that comprises around 150 inpatient beds. The AMS programme has just started in 2018, with a one-year interruption. Because the hospital accreditation is approaching, the AMS team is pressurised to develop an AMS strategy to meet the accreditation assessment. AMS team consists of infectious disease physicians, clinical pharmacist, clinical microbiologist, nurse, and general physicians. A representative of hospital management is also involved in the team. The first stewardship strategy is to develop hospital antibiotic guidelines for the top 10 most common syndromes from each department. Next is to collect antibiotic use data using a form when prescribers using broad-spectrum antibiotic. The aim is to track the compliance of the guidelines. After a year, AMS team will analyse the data and provide feedback to prescribers. The AMS team dropped the idea to implement a PPA strategy (similar to the one in hospital A), because there was not enough manpower to provide antibiotic consultation 24/7. Besides, the hospital management discouraged the AMS team to restrain specialists/consultants’ antibiotic use through PPA strategy. Management expressed a concern that limiting their clinical decision can make them move their practice to another hospital.
Culture test
The hospital microbiology laboratory is open 24/7, culture samples can be taken and ordered at any time, and laboratory staff is always available. Based on hospital regulation, taking culture sample is only compulsory for patients in the Intensive Care Unit (ICU). No prescribers mentioned any complains about the reliability of the culture test result or any difficulty to request sample taking. For the prescribers, the only challenge to take culture sample is its high cost (~USD 35 per sample), which often makes patients and doctors opt to use the money for empirical treatment instead. Only when patients are deteriorating and/or patients are admitted to the ICU a culture sample is requested.
National health insurance
This hospital does not participate in the national health insurance scheme. Patients have either private health insurance or are self-paid. Prescribers did not feel their practices are limited by the national insurance scheme drug formulary, hospital guidelines or antibiotic form because they can prescribe any antibiotic, and all are dispensed. Few of them stated that they are customised and feel more familiar to do the practices as they were taught as residents rather than following the hospital guidelines.
Funding for stewardship programme
Funding for the AMS programme is incidental. Management mentioned that hospital financially supports the AMS programme which includes sending the AMS team for stewardship training.
Conclusion
When looking at the two hospitals described above, challenges in AMS is context specific. In broader spectrum it can be seen to be private or public sector structure. But different challenges can also occur in different public sectors. Health system constraints, organisational culture, and infrastructure barriers interplay in hospital AMS implementation. In the first hospital, the stewardship issue circles around infrastructures (e.g., sterile operating theatre, culture test facilities), and competing interest of fund allocation within the national health insurance capacity (diagnostic test versus treatment). While in second hospital, the prominent issue is the bargaining power between prescribers’ autonomy and stewardship implementation that is seen to limit prescribers’ autonomy. Some studies proposed that AMS implementation to embrace the social dimensions of antibiotic prescribing practice (Broom et al., 2020; Cars et al., 2021). Stewardship strategies should be generated from the local hospital problem assessment with a consideration of the local issues, culture, and resources to find the best possible solution to the setting.
Points of discussion
Pedagogical notes
Acknowledgements
The authors are grateful to the management, research/medical committees, and clinicians of the participating hospitals for their support to the study. We also acknowledge the EXPLAIN study group: Manzilina Mudia, Monik Alamanda, Helio Guterres, Enty Enty, Elfrida R. Manurung, Ifael Y. Mauleti, Maria Mayasari, Iman Firmansyah, May Hizrani, Roswin Djafar, Anis Karuniawati, Prof Taralan Tambunan, Prof Amin Soebandrio, Decy Subekti, Iqbal Elyazar, Mutia Rahardjani, Fitria Wulandari, Prof Reinout van Crevel, H. Rogier van Doorn, Vu Thi Lan Huong, Nga Do Ti Thuy, and Sonia Lewycka.
Study coordinator at Eijkman-Oxford Clinical Research Unit (EOCRU) and PhD student at the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford.
Professor of Sociology and Director of the Sydney Centre for Healthy Societies at the School of Social and Political Sciences, The University of Sydney.
Internist, tropical and infectious disease consultant at Department of Internal Medicine, Division of Tropical and Infectious Diseases, Faculty of Medicine Universitas Indonesia/Cipto Mangunkusumo National General Hospital and senior researcher of Infectious Disease and Immunology Research Cluster, Indonesian Medical Education and Research Institute.
Associate Professor at the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford; Research Fellow at Faculty of Medicine University of Indonesia, and Senior Clinician Scientist at EOCRU, Jakarta, Indonesia.
