Turning the tide of antimicrobial resistance in intensive care units in Indonesia

Antimicrobial resistance of bacteria has emerged worldwide as a major health care problem, but particularly emerges in and affects low-resource countries. It is in the interest of global health that antimicrobial resistance is addressed and combated with a focus on interventions in developing countries. Intensive care units (ICUs) are a hot-spot for the emergence of extremely-drug resistant Gram-negative bacteria. In a pilot study in the ICU of the Dr. Cipto Mangunkusumo Hospital in Jakarta, Indonesia, it was shown that multidrug-resistant (MDR) Pseudomonas aeruginosa, MDR Acinetobacter baumannii, and
carbapenem-resistant Klebsiella pneumoniae were prevalent. Containment strategies such as those recommended by the Centers for Disease Control and Prevention (CDC) are, however, difficult to apply because of constrained budgets that demand prioritisation. In our research project we will implement a set of inexpensive interventions on a ICU in Indonesia, and monitor the effect of these interventions in a before-and-after study with a baseline period of 10 months (phase I), a period for the implementation of the bundle of interventions of 2 months (phase II), and an after period of 10 months (phase III). The target microorganisms will be P. aeruginosa, A. baumannii, and K. pneumoniae, all with reduced susceptibility to carbapenem antibiotics. The primary outcome will be the number of patients who acquire carriage or infection with one of the three target microorganisms per 100 patient-days at risk in the ICU.

Our study will result in a scientifically based, efficient strategy to limit the emergence of resistance bacteria in Indonesian ICUs. This programme could be the starting point for a nationwide action in Indonesian ICUs. The results of our study will also be useful for ICUs in other low-resource countries.

A bundle of inexpensive interventions can reduce the emergence and spread of carbapenem non-susceptible Gram-negative bacteria in a low-resource ICU.

Stool or rectum samples and throat samples will be obtained from patients on the ICU on admission, then weekly until discharge from the ICU and on discharge.

1.Contact Isolation Precautions for patients colonized or infected with a carbapenem non-susceptible Gram-negative bacterium (Pseudomonas aeruginosa, Klebsiella pneumoniae, or Acinetobacter baumannii).

2.Cohorting patients with a carbapenem non-susceptible Gram-negative bacterium (Pseudomonas aeruginosa, Klebsiella pneumoniae, or Acinetobacter baumannii).

3.Source control, for all included patients:

a. Bathing: once daily with chlorhexidine 2%

b. Oral hygiene for intubated patient⇒ 4 times daily -->
2% solutions of chlorhexidine

4. Environmental cleaning

5. Antibiotic Stewardship

6. Multifaceted program to improve hand hygiene compliance (including education, feedback, reminders, interviews and the use of role models).