Questions/Answers

The emergence of resistance was firstly officially launch by WHO in 2001 (WHO, 2001), that was not common practice in Indonesia. In 2001 we started the PhD research on Antimicrobial resistance (AMR), and the result were: 1). The resistant Escherichia coli gut flora were increasing during hospital stay 1; 2). The antibiotic used was 21% truly appropriate 2; 3). A risk factor for increasing resistant rate of gut flora were previous hospitalization, consume of antibiotics, and suffering for a disease 3. The study of Extended spectrum beta lactamase (ESBL) producing Escherichia coli and Klebsiella pneumoniae, showed that only limited (3-4 antibiotics) that were sensitive against these agents 4. The study on infected patients in this hospital that caused by carbapenemase producing bacteria were mostly seriously ill with longer Average length of stay (ALoS) was 39.5 days versus 7.68 days for total 5.For handling the problem of AMR, since 2005 have been piloting the program of AMR control in this hospital, but was not effectively run due to the lack of any regulation. Until 2015 in which the Ministerial decree of AMR control was launched. In this starting step of the program some difficulty of how to reach the goal. One of the handicap were: 1). All medical doctor conducting management of infection based on their own concept; 2). The infectious diseases are tackling by all profession, that in some occasion have a different concept and procedure. It makes difficulty for synchronization for the program of AMR control and prevention. For tackling this problem, was proposed AMR Control Program and the forum for coordination and synchronization among stakeholders in management of infection. This forum we call ‘FORKKIT’ (FORUM KAJIAN KASUS INFEKSI TERINTEGRASI = Infectious Disease Integrated Service Team), as part of AMR Control Program.

The mortality due to the AMR is increasing, and attack any traffic accident cases, cancer, surgical patients, immunocompromised patients and other infection during their hospitalization. The ESBL (Extended Spectrum beta Lactamase) producing bacteria that mostly MDRO (Multiple drug resistant organisms), increase from 9% in 2001 6, 28% in 2010, 39.5% in 2013 7 and 60% in 2016 8. It was also Carbapenem resistant producing Gram negative bacilli (CR-GNB), that impact on longer hospital stay (up to more than 5 times) and higher mortality 5. These facts are urgently priority and costly, should be tackled.

This program was appointed against SDG goal 3, sub-goal: 1,2,6,8,3a,3c,3d in area of infectious diseases. Mostly mortalities were caused by healthcare associated infection that mostly Multiple drug resistant organisms (MDRO). After the Government program on National Health Coverage (Insurance) launching since 2014, the referral system was re-structured, that no any patients can directly accessed to tertiary referral hospital, except the emergency patients. The tertiary referral hospitals are mostly get the seriously referral patients, included women post section, neonatal infection due any reason, traffic accident, burn, cancer, chronic diseases and other seriously ill patient that were not able handled by secondary hospital. All these patients ere commonly with infection caused by MDRO. The study of intervention on AMR control program for 3 months, showed: .1). clinical outcome better event though was not significantly different; 2). The antibiotic used decrease from 45.04 DDD to 14.52 DDD/100 patient-days;3). the used of antibiotic class, decrease from 11 Antibiotic Class to 6; 4). Financial outcome among 30 patients intervention and 30 patient control, there was cost saving for the total of IDR. 13,135,000,- The intervention of ASP (Antibiotic Stewardship Program) 2018 (control 2017) showed that meropenem used decrease 61.9% and cost saving (IDR) 53.7%.

The intervention on AMR control program for 30 patients in pediatric hematology 2007, showed: 1). clinical outcome better; 2). The antibiotic used decrease from 45.04 DDD to 14.52 DDD/100 patient-days;3). The used of antibiotic class, decrease from 11 to 6; 4). cost saving for the total of IDR. 13,135,000,- The intervention of ASP (Antibiotic Stewardship Program) 2018 (control 2017) to contain the over use of meropenem showed that meropenem used decrease 61.9% and cost saving (IDR) 53.7%. The pattern of ESBL producing bacteria rate (Escherichia coli and Klebsiella pneumoniae) 2016 was 55%, and in 2018 decrease to 35%.

The services seriously ill infected patients, were commonly empirically therapy without any local data. It has impact of higher (79%) not prudent used of antibiotic (AMRIN Study) and increase the AMR. AMR control program was first conducted by strengthening the clinical microbiology services to provide the fast diagnosis and definitive data, and Pharmacy as gate keeper in filtering the prescription. Meanwhile the professionalisms on infection management was improve by training. Today, it is common that microbiology result can be accessed in 2-3 days, rather than 5-7 days of old fashion. The difficult case that used to solved by doctor in charge ‘alone’ in old fashion, now the AMR Control team (FORKKIT) with global standard competencies is ready to accommodate. Now all professions were accept this activities in one fashion. Decreasing the AMR rate will make easier in infection management. The new problem arise due to the AMR source come from the secondary referral hospital. But it will synchronize to the national program oh Ministry of Health (MoH), targeting to conducting National AMR Control Program against 16 class A & B hospital in 2020; 32 in 2021; 50 in 2022; 65 in 2023 and 82 hospitals in 2024.

The AMR program was targeted on Infected patients, especially the seriously ill caused by Multiple drug resistant organisms. All patients were included in this target in both of male and female, and also since new born until very old patients. It is also for all insurance group, economic level income, education and for all. Dr. Soetomo hospital is a tertiary referral hospital that has a special task: 1). Not allowed to reject the patient; 2). Cannot reject the patients due to the financial reason; 3). Our hospital can provide of other medicine, even not in hospital formulary.

The AMR control program was addressed to all an infected patients or prophylaxis against infection that potentially consume the antibiotic, but also non human sectors as well. The program in human sectors were addressed to improve the quality of health services through increasing the prudent use of antibiotic and the hygienic habit. This program was run by advocating the hospital managements and improving the professionalisms in infection management. The main important target groups were professional groups that used to serve an infection by their own manner, but should change to the updating manner and synchronize among the others. This main handicap has been tackled fluently by the support of hospital management. The group of pharmacist and clinical microbiologist that used to work behind the scene in the old era, but now start to work together in the teamwork. Thus the first step for upgrading their competences of these two groups have a pivotal role in the success story of the AMR Control. The FORKKIT (Integrated team for management of difficult cases of infection) is ready to handle every problematic cases. From this forum many cases can be handled easily manner.

The AMR control in DSGAH Surabaya, actually started in 2005, in the small scale. The process was not easy due to the lack of the regulation. In this not conducive situation, we try to propose the program to MoH, about ‘The infra structure Readiness to support the AMR Control Program. This project was approved by MoH, and we conduct the visitation to 20 Teaching hospital in Indonesia. This project was coordinated by Dr. Soetomo hospital Surabaya (DSGAH) and Dr. Kariadi hospital Semarang, This project success to staging the readiness of 18 hospital (Two coordinator were not included in this review), from the highest score to the lowest score. One year later we conduct the National Seminar on AMR Control program that participated by 4 persons for each hospital, i.e.: 1). 1 person of hospital management; 2). Clinical Microbiology; 3). Clinical Pharmacy; and 4). Infection control team. At this occasion we started to develop the Ministerial decree for AMR Control Program, and many meetings were supported by MoH, until the final draft of MoH decree on AMR control finalized. Based on MoH decree no 8/2015, all hospital should conducted the AMR Control Program, in which all hospital make a progress report yearly and send to MoH, including our hospital. All hospitals in Indonesia were started trained on AMR Control Program, and during this time, our hospital has a better opportunity to proceed the program more intense. The activities of AMR Control program in DSGAH were also regularly evaluated (internal by ARCC), and externally through the National accreditation body, including by JCI (Joint Commission International, 6th Edition, 2017), MMU 1.1. (The hospital develop and implements a program for the prudent use of antibiotic based on the principle of antibiotic stewardship = ASP).

The big problem was the resistance of the doctor in charge against ‘new’ approach in infection management for implementing the program of AMR control. The old era, every doctors in charge were freely work based on their own paradigm. Now they should follow the hospital antibiotic policy according to AMR control program toward the prudent use of antibiotic. This problem was mainly the behaviour rather than the professionalisms and competencies. BUT by the hospital antibiotic policy and the strength leadership of the hospital management, all medical staffs were positively comply the regulation in AMR Control Program.

Since the establishment of Ministry of Health Decree 8/2015, all Indonesian hospital should implemented the AMR control program. The most difficult one is how to manage all profession, that in the ‘old era’ they work as their paradigm but now they should work based on one concept and integrated manner. Their ‘egoistic profession’ is the basic problem, and how to contain this problematic issues, need two factors, 1). Highly motivated and competencies of the team of AMR control committee; and 2). Highly support of the hospital management to implement this program. We have these of two.

How to initiate this activities (successfully AMR control program), we have a regulation and basic competencies. In other countries, they have an Infectious disease specialist that serve as the only profession that handling the infection, but not for Indonesia, in which all medical professionals manage the infection as their own concept. It thus need special approach to embrace all profession to be one concept. We make special approach, strengthen the regulation and improve the competences by work together, led by a AMR control team with high competencies in infectious diseases handling, we call the integrated service team.

According to our success in this AMR Control Program, first we are as the initiative for the development and establishment of Ministry of Health Regulation on AMR control program (MoH Decree No. 8/2015), we have also as a center for training on AMR control program issued by National Hospital Accreditation board. Our core team that also as a National team of Ministry of Health, did any socialization based on GAP (Global Action Plan) on AMR, such as 1) to improve awareness and understanding of antimicrobial resistance; 2). to strengthen knowledge through surveillance and research; 3). to reduce the incidence of infection; 4). to optimize the use of antimicrobial agents; and 5). Development of new medicine. The points of 1,2 and 4 are the important thing and feasible to be implemented by mostly Indonesian hospital, especially the National tertiary referral hospital. The very hard work is about the point 4, that need commitment and seriousness of the team and hospital management, and our experiences would be transferable method for these hospital.

The big problem are about because: 1). The highly committed of core team and hospital management, focus on Director of the hospital; 2). Develop the forum for all, how to suppress their ego center of their own profession. It would be public are not fully understand, why the same infection and same person, but were treated by different method and protocol. Also the AMRIN study (international published) showed that 79% cases were treat with in-appropriately. Most cases with no indication of antibiotic therapy, but prescribe antibiotic (International published). This situation will make not effective and efficient manner, and also was not cost effective. Also have an impact on higher patients side effect, not cost effective that make disturbing the hospital in the era of National health Insurance, and also polluting the environment with resistant bacteria. All top tertiary referral hospital in Indonesia have the similar facilities as our hospital, of both facilities for infection diagnosis and treatment, and also man power. It thus need the commitment and the tricky manner as we did.

This is just a short words, just commitment and hospital management support. All hospital have all facilities, equipment (survey of MoH team in surveillance 2016) and man power. It would be a little bit limitation on the services on clinical microbiology that would be the very important and crucial thing in management in infection. BUT the new MoH regulation and policy on man power in hospital in Indonesia will be able to solve the problem. Again just need the commitment of core team of AMR control and hospital management.

To implement this initiative will not any additional facilities and man power. This activity can increase the prudent use of antibiotic, means effective and efficient in mange the infection. In our experiences, this activity was also cost effective, that is the goal of the government, specially National health insurance and hospital management. Thus all are happy with this activities, and thus there are not any reason for not done, of both internal and external stakeholder

Yes

The activities is run well in our hospital. Some study we did, according to the administrative and medical indicator. Since 2018, AMR control program has been included in the National hospital accreditation body. The last accreditation of our hospital 2018 conducted by JCI, has passed in most area included AMR control program. Secondly, at this moment each of Tertiary referral hospital in Indonesia was appointed to be the centre of excellence in one area on medicine, and our hospital has been issued as the center of AMR control, that will be plan as a center for the training

Actually the instrument for evaluation of AMR control program is accommodated in Ministerial decree (MoH) No. 8/2015. It is also there are two point and 10 element in National Hospital Accreditation Tools. Some indicators are: 1). The quantity of antibiotic use quantity and quality; 2). AMR rate (at this moment ESBL producing bacteria used as AMR indicator); 3). The existence of Integrated service team in infection management. These indicators will split to any sub-indicators, and as an example of cost saving that not explicit written down, but we did.

The ASP (Antibiotic Stewardship Program) that was implemented in 2018, as part of AMR Control program, showed that all processes were handled manually. The IT Software was absolutely needed, but the system in this hospital, even though has the IT system, is still not able to accommodate the ASP program. This is a big challenge to run the ASP. The CDSS (Clinical Decision support system) as an IT software, has been planned in this hospital to start in 2021 and will be finished in 2023. AMR control program aims to improve the quality of infection management, effective efficient and cost effective. The Laboratory facilities and man power are enough, all supporting regulation have been developed.The increasing the compliance of surgeon in following guideline to use cefazolin or cefuroxime as antibiotic prophylaxis (evaluation 2016, 2017, 2018), from around 50% or less before intervention into more than 75% as standard quality in this hospital, showed the impact of this program. It was also the evaluation of AMR indicator (ESBL-Extended spectrum beta lactamase producing bacteria) in this hospital decrease from 2016 (56.4%, National Surveillance on AMR by MoH) to 35.25% in recent evaluation 2018 (data January-December)

As previous explanation, the two man crucial issues are: 1). How the hospital management fully support this program; and 2). How to accommodate many professions to be one concept in infection management.The big handicap in the beginning was how to increase the important of this activity is accepted by hospital management. We did this in 2007 and afterward. The hospital top management should be approached by economic manner, rather than the others thing. Our pilot study in 2007 showed that by intervention of AMR control, we can improve the patient outcome, but the important thing was also cost saving. The secondly bigger handicap was the resistance of our colleagues of many professions that used to manage the infected patients as their own approach, but not now. By the support of the Director as top management in this hospital, we develop the hospital regulation (antibiotic and area of infection). We started with synchronized the protocol in infection management, then launched the antibiotic hospital policy. The new one was conducting the Antibiotic stewardship program (ASP) in Pediatric ward band spread to the other wards and departments. All work without any handicap, except some technical problem.

The core contents of AMR control program are to manage the infected patients prudently and cost effective.But this program are including many stakeholders in infection management, such as: 1).Internal hospital: hospital management, medical staff, paramedical staff, infection control committee, pharmacy, laboratory, cleaning services. It thus we should be able to synchronize all these internal stakeholders; 2).External hospital: Ministry of Health, Health office, Pharmaceutical industry. The internal problem have been solved. There were some crucial and important focus against external stakeholder.it is positive impact that we also sit in MoH team on AMR control progam. We have developed the National Antibiotic Guideline as reference for all medical doctor in Indonesia. Through MoH,we communicate to other ministry (Agriculture, Fishery, Environment,Defence) that have an important function on antibiotic used. At this moment all ministry have AMR Control Committee, and a new regulation on banning of antibiotic growth promoter in animal farming has been launched. WHO is also our closed collaborator. Some activities, mainly development of National Plan (NAP) on AMR in Indonesia, is fully support by WHO, in which we are sit as a core team. Some inter-ministerial meeting was also support by WHO, together with FAO,OIE and all stakeholders in antibiotic use

We note few key points: 1.AMR development can be contained through two ways: 1). Suppressing the antibiotic use through improve the prudent use of antibiotic; 2). Suppressing the spread of AMR through improving the compliance of infection control and prevention, focusing on hand washing/rubbing. 2.The commitment and support of hospital management is absolutely needed, especially in developing countries, Indonesia. But how to make them understand, it should put of both financial and professional aspect as priority. 3. The medical professionals are mostly very committed in health services, but some directed understanding according to the global problem of AMR should be initiated, in both of through understanding or authority. As our experiences, the understanding approach for conducting the program was not enough, it should be integrated with the regulation and hospital authority. 4.Every big program, should be started with the pilot project in small scale. This strategy is written down in MoH decree on AMR control Program, but some hospital do not follow. The pilot study can be used to explore the feasibility and also the preliminary impact information. BUT also educational aspect for the stakeholders. 5.We start with few people, then spread to the others, step by step, then sprint.