An Invisible Danger: Antimicrobial Resistance and Health Threats in Indonesia

The end of 2022 was supposed to be one of the happiest times in Sari's life (not her real name). She was pregnant and about to give birth to twins. But her happiness was hampered when the doctor revealed a special condition of her pregnancy; Sari lost one of her babies to a bacterial infection that could not be treated, even with the most powerful antibiotics available.

When she was born, one of her babies had to receive special care due to its less-than-ideal weight and exposure to bacteria. On the 10th day, the baby developed a fever, shortness of breath and flatulence.

“They were given antibiotics, and the blood culture was taken again. After one week, it turned out that the antibiotics did not work on her body,” Sari told detikX.

Due to this condition, the team of doctors decided to give stronger antibiotics. But there was no significant progress. The bacteria in the baby's body seemed immune to them.

On the 12th day, the baby's condition worsened. There were complications that affected some of her internal organs. The team of doctors also performed blood transfusions, but her condition did not improve.

The team of doctors asked Sari for permission to make a last-ditch effort. They gave the baby the strongest antibiotic.

“Finally, the doctor informed me that on the 19th day, the strongest antibiotic was given and it was the last. So, if for example her body refuses, there is no other option. Well, it turned out that on the 20th day, she was gone. On January 3rd, she died at 2am,” Sari recalled.

Later on, Sari learned that what happened to her baby was part of the problem of antimicrobial resistance (AMR). With AMR, various types of antibiotics are no longer effective and can't work against bacteria in the body.

Sari is not alone. In 2019, AMR was estimated to be directly responsible for 1.27 million global deaths and, indirectly, another 4.95 million deaths. This is based on research by the Antimicrobial Resistance Collaborators entitled "Global Burden of Bacterial Antimicrobial Resistance in 2019: A Systematic Analysis" published in 2022 in The Lancet journal. The World Health Organization (WHO) also refers to the results of this study.

In 2019, the Indonesian Ministry of Health estimated that there were 133,800 AMR-related deaths in Indonesia. This puts Indonesia in 78th position with the highest (age-standardized) AMR-related mortality rate out of 204 countries.

Medicine sales data from the Ministry of Health also shows that Indonesia experienced an estimated 2.5-fold increase in national antibiotic consumption between 2000 and 2015. Most of these were penicillins, fluoroquinolones and cephalosporins. This makes Indonesia one of the countries that experienced the largest increase in antibiotic consumption globally.

Antibiotic resistance occurs when bacteria, fungi and parasites no longer respond to antimicrobial drugs, increasing the risk of disease spread. The condition can occur due to overconsumption of antimicrobials, such as antibiotic drugs.

Ika Puspita Sari, a professor at the Faculty of Pharmacy at Gadjah Mada University, confirmed the spread of antimicrobial resistance in Indonesia. According to reports she has received from many health facilities, every day patients are found with conditions that are resistant to antimicrobials or antibiotics.

Because of this condition, her team now conducts many blood sample tests of patients who have consumed high levels of antibiotics. The patients usually have taken antibiotics for more than two weeks or even more than 20 days, but the disease has not improved.

“It's bad. It's really bad. We are in the ICU every day now encountering CRAB (carbapenem-resistant Acinetobacter baumannii), bacteria that cause severe infections that are resistant to carbapenem antibiotics. I encounter it often. Anyway, day to day it adds (a lot),” the professor of pharmacology and toxicology told detikX.

Ika explained that antimicrobial resistance is proven to increase risk of death. The mortality rate increases up to three times for patients who are already resistant and exposed to Acinetobacter baumanniii bacteria. As for resistant patients who are exposed to Klebsiella pneumoniae bacteria, the mortality rate increases fourfold when compared to those who are not antibiotic resistant.

On the other hand, resistant conditions also increase the burden of health costs. In fact, according to Ika, those who are resistant spend longer in the hospital by about 30% to more than 50%.

The free circulation and consumption of antibiotics without a doctor's instructions is one of the reasons for the increasing number of resistant patients. According to Ika, based on a number of studies in 2021-2022, in a number of regions, people consider antibiotics as a febrifuge. Therefore, antibiotics are often bought without a prescription to treat fever like paracetamol.

In addition, the purchase of antibiotics at grocery stalls is done within a retail system. Antibiotics, which should be prescribed by a doctor with a certain dose and quantity, can now be bought. This is despite the fact that the use of antibiotics in health centers, especially for colds, is strictly limited. The antibiotic prescription ratio should not exceed 10%.

“In Bekasi, it turns out that many people feel that antibiotics can reduce fevers. It's even thought to increase antibodies. Well, it's troublesome, even those who are sick with body aches and pains are given antibiotics. He is more confident if he takes antibiotics,” she said.

In addition to the free circulation of antibiotics for human consumption, the worsening resistance is also influenced by the reckless use of antibiotics in livestock, both fish and poultry.

The lecturer of the Department of Pharmacology and Clinical Pharmacy gave an example of a case in Yogyakarta. In the Ministry of Health's 2023 health survey, Yogyakarta Province ranks first as the region with the least circulation of non-prescription antibiotics. However, there are still many patients with resistant conditions in Jogja.

Investigated, the use of antibiotics on livestock in farms around Jogja is not controlled. Based on research conducted by UGM, antibiotic residues are found around the farms, both soil, water, and even livestock products, such as meat and chicken eggs. Unfortunately, according to Rita, based on a number of studies, antibiotic residues of livestock products do not disappear even after cooking or processing. These residues also enter the human body when consumed.

"On this farm, we happened to take samples around Sleman because it is a chicken farming area. It turns out from the samples, both soil, water, meat... there are antibiotic residues and we have tested it too. It turns out that many are resistant," he said.

Former Chairperson of the Antimicrobial Resistance Control Committee (KPRA) of the Ministry of Health 2014-2021 Hari Paraton confirmed that antimicrobial resistance in Indonesia continues to increase. According to Hari, citing data from the Global Antimicrobial Resistance and Use Surveillance System (GLASS), the prevalence rate of antimicrobial-resistant microbes in Indonesia continues to increase. A prevalence rate that was once 40% and is now 68% (Escherichia coli and Klebsiella pneumoniae bacteria do not die with high-class antibiotics). The increase is in line with the overconsumption of antibiotics in the country.

“Well, this increase means that it is in line with antibiotic consumption. The theory is like that, the law of nature. So it means that our country is still over-consuming antibiotics,” the obstetrician and gynecologist explained to detikX.

The spread of resistance can actually be suppressed by reducing overuse and misuse of antibiotics. This misuse occurs when a disease that should not require antibiotics is still treated with antibiotics.

This is exacerbated by the use of medium- and strong-level antibiotics for mild diseases. Worse, there are still many people who self-medicate with antibiotics. According to Hari, citing data from the Ministry of Health, people who self-medicate or buy their own medicine are in the range of 42%. Meanwhile, according to data from the Central Bureau of Statistics, the percentage of the Indonesian population who practiced self-medication throughout 2023 was 79.74%.

“This is very dangerous because they take a little antibiotic and sometimes they use it too. A little cough, a little runny nose, yes strep throat, definitely drink antibiotics, right,” said Hari.

As a result, more and more bacteria are resistant to mid-level or stronger antibiotics. This condition is dangerous because bacteria that have adapted to antibiotics and are immune can switch hosts and infect other humans.

“They should have used the middle class, they were given the high class, too high. The assumption is, if the antibiotic is high, he will recover quickly. But that is wrong. In fact, later, if you have used a high one, if it is resistant, what else can you use?” Hari explained.

In order to avoid infection with resistant bacteria, patients who are already resistant should be provided a special treatment room for isolation. Likewise, health workers and doctors on duty must use personal protective equipment to avoid transmission.

On the other hand, Hari assessed that there are still many doctors who do not understand antimicrobial resistance and prescribe antibiotics without clear indications. This condition occurs because the medical education curriculum in Indonesia does not explicitly teach antimicrobial resistance.

“So it is only mentioned in passing. Why? Because the medical curriculum is trimmed a lot. Among them, this resistance has also been cut. The idea is that maybe in the past this... could be learned on its own. It turns out that doctors do not learn by themselves, the second is because they follow their seniors. The senior is wrong,” said Hari.

In addition, Hari saw the lure of pharmaceutical companies to doctors to prescribe antibiotics from certain companies more often. From this hidden cooperation, the doctors are said to get rewards. The targeted doctors are usually those who already have a "name" and are known to have many patients. Usually doctors with these qualifications tend to be followed by other doctors.

“That's because of the actions of some pharmaceutical companies, yes, lures. All kinds of things, given tickets, given this.... Every drug manufacturer competes with each other. That's good land to fight over. That is why there are practices like that,” said Hari.

The effort is made due to competition between pharmaceutical companies. The goal is to compete for the distribution and trade of antibiotics, which is estimated to be worth trillions of rupiah each year.

According to the data Hari presented, the use of antibiotics according to indications was only about 20%. The test was conducted in a number of hospitals that are kept confidential. The departments that use the most antibiotics are surgery, obstetrics and gynecology, internal medicine, and pediatrics.

In 2021, the Ministry of Health issued guidelines for the use of antibiotics in health facilities. The regulation is part of the Antibiotic Stewardship program. However, according to Hari, only about 38% of doctors in Indonesia see and comply with the guidelines.

“If a doctor makes a prescription, (it is seen) what is the case, for example pneumonia, this antibiotic. If it is reviewed correctly, then the pharmacy or pharmacy will give the antibiotic. But if later, oh this dose is insufficient, oh this dose is excessive. Then the PGA (Antibiotic Stewardship) team will discuss with the doctor to straighten out the use of antibiotics. So that means, the PGA team ensures that patients receive the correct, accurate antibiotics,” Hari explained.

This story is part of a five-part series published in Bahasa Indonesia; read parts two, three, four and five.

It was produced with support from Internews' Earth Journalism Network. It first published in detikX on October 28, 2024, and has been lightly edited for length and clarity.

Banner image: Antimicrobial resistance is increasing in Indonesia and poses serious health threats / Credit: Roberto Sorin via Unsplash.