title: Antimicrobial resistance in uropathogens and appropriateness of empirical treatment: a population-based surveillance study in Indonesia.
abstract: Urinary tract infections (UTIs) are a common reason for empirical treatment with broad-spectrum antibiotics worldwide. However, population-based antimicrobial resistance (AMR) prevalence data to inform empirical treatment choice are lacking in many regions, because of limited surveillance capacity. We aimed to assess the prevalence of AMR to commonly used antimicrobial drugs in Escherichia coli and Klebsiella pneumoniae isolated from patients with community- or healthcare-associated UTIs on two islands of Indonesia.
  
  
  
  We performed a cross-sectional patient-based study in public and private hospitals and clinics between April 2014 and May 2015. We screened patients for symptoms of UTIs and through urine dipstick analysis. Urine culture and susceptibility testing were supported by telemicrobiology and interactive virtual laboratory rounds. Surveillance data were entered in forms on mobile phones.
  
  
  
  Of 3424 eligible patients, 3380 (98.7%) were included in the final analysis, and yielded 840 positive cultures and antimicrobial susceptibility data for 657 E. coli and K. pneumoniae isolates. Fosfomycin was the single oral treatment option with resistance prevalence <20% in both E. coli and K. pneumoniae in community settings. Tigecycline and fosfomycin were the only options for treatment of catheter-associated UTIs with resistance prevalence <20%, whilst the prevalence of resistance to meropenem was 21.3% in K. pneumoniae .
  
  
  
  Patient-based surveillance of AMR in E. coli and K. pneumoniae causing UTIs indicates that resistance to the commonly available empirical treatment options is high in Indonesia. Smart AMR surveillance strategies are needed to inform policy makers and to guide interventions.
authors.affiliation: Department of Clinical Pathology, Faculty of Medicine, Universitas Padjadjaran, Dr Hasan Sadikin General Hospital Bandung, Bandung, Indonesia.
authors.forename: Adhi Kristianto
authors.initials: AK
authors.lastname: Sugianli
authors.affiliation: Department of Internal Medicine, Faculty of Medicine, Universitas Sumatera Utara, H. Adam Malik Hospital Medan, Medan, Indonesia.
authors.forename: Franciscus
authors.initials: F
authors.lastname: Ginting
authors.affiliation: Department of Microbiology, Faculty of Medicine, Universitas Sumatera Utara, H. Adam Malik Hospital Medan, Medan, Indonesia.
authors.forename: R Lia
authors.initials: RL
authors.lastname: Kusumawati
authors.affiliation: Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Dr Hasan Sadikin Hospital Bandung, Bandung, Indonesia.
authors.forename: Emmy Hermiyati
authors.initials: EH
authors.lastname: Pranggono
authors.affiliation: Department of Pediatrics, Faculty of Medicine, Universitas Sumatera Utara, H. Adam Malik Hospital Medan, Medan, Indonesia.
authors.forename: Ayodhia Pitaloka
authors.initials: AP
authors.lastname: Pasaribu
authors.affiliation: Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Firza
authors.initials: F
authors.lastname: Gronthoud
authors.affiliation: Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, The Netherlands.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Geerlings
authors.affiliation: Department of Clinical Pathology, Faculty of Medicine, Universitas Padjadjaran, Dr Hasan Sadikin General Hospital Bandung, Bandung, Indonesia.
authors.forename: Ida
authors.initials: I
authors.lastname: Parwati
authors.affiliation: Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Menno D
authors.initials: MD
authors.lastname: De Jong
authors.affiliation: Department of Global Health-Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Frank
authors.initials: F
authors.lastname: Van Leth
authors.affiliation: Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.|Department of Global Health-Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Constance
authors.initials: C
authors.lastname: Schultsz
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D055499:Catheter-Related Infections / Q000188:drug therapy / Q000382:microbiology; D003430:Cross-Sectional Studies; D024901:Drug Resistance, Multiple, Bacterial; D062665:Epidemiological Monitoring; D004926:Escherichia coli / Q000302:isolation & purification; D004927:Escherichia coli Infections / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology / Q000652:urine; D005260:Female; D005578:Fosfomycin / Q000627:therapeutic use; D006801:Humans; D007214:Indonesia / Q000453:epidemiology; D007710:Klebsiella Infections / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology / Q000652:urine; D007711:Klebsiella pneumoniae / Q000302:isolation & purification; D008297:Male; D000077731:Meropenem; D008875:Middle Aged; D008911:Minocycline / Q000031:analogs & derivatives / Q000627:therapeutic use; D011159:Population Surveillance; D062606:Tertiary Care Centers; D013845:Thienamycins / Q000627:therapeutic use; D000078304:Tigecycline; D014552:Urinary Tract Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000382:microbiology*; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents; D013845:Thienamycins; D005578:Fosfomycin; D000078304:Tigecycline; D000077731:Meropenem; D008911:Minocycline