SG-APSIC1096: Changes in resistance patterns of "ESKAPE” pathogens to azithromincin and levofloxacin in Yogyakarta

Objectives: Bacterial coinfection occurred in 3.5% of COVID-19 patients, and secondary bacterial infection occurred in 14.3% of patients. In Indonesia, one of the guidelines for COVID-19 therapy is to administer azithromycin 500 mg per 24 hours for mild and moderate cases and azithromycin 500 mg per 24 hours and levofloxacin 750 g per 24 hours for severe cases with suspected secondary bacterial infection. At the beginning of the pandemic, many antibiotics were used, even without proven or suspected bacterial infection. We sought to determine changes in the resistance of "ESKAPE” bacteria (ie, Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp) to the antibiotics levofloxacin and azithromycin prior to and during the COVID-19 pandemic. Methods: The study was conducted retrospectively by examining the culture and sensitivity test results of "ESKAPE” bacteria to levofloxacin and azithromycin antibiotics in 2019 (before the pandemic) and April 2020–April 2021 (during the pandemic) in 4 hospitals in Yogyakarta. The number of samples represents all cultures completed within the specified period to detect antibiotic sensitivity patterns. Results: In a top referral hospital, resistance to levofloxacin and azithromycin increased significantly for E. faecium and P. aeruginosa, but at a private hospital, an increase in resistance to azithromycin and levofloxacin occurred for A. baumannii and for Enterobacter spp and resistance to levofloxacin increased significantly. At an academic hospital, there was a considerable decrease in S. aureus and E. faecium resistance to levofloxacin and azithromycin. At the government hospital, S. aureus, K. pneumoniae, P. aeruginosa, Acinetobacter baumannii, and Enterobacter spp developed resistance to levofloxacin. Conclusions: Resistance to azithromycin and levofloxacin by different ESKAPE bacteria increased on average during the COVID-19 pandemic.

Epidemiology of community-acquired pneumonia among hospitalised children in Indonesia: a multicentre, prospective study.

OBJECTIVE: To identify aetiologies of childhood community-acquired pneumonia (CAP) based on a comprehensive diagnostic approach. DESIGN: 'Partnerships for Enhanced Engagement in Research-Pneumonia in Paediatrics (PEER-PePPeS)' study was an observational prospective cohort study conducted from July 2017 to September 2019. SETTING: Government referral teaching hospitals and satellite sites in three cities in Indonesia: Semarang, Yogyakarta and Tangerang. PARTICIPANTS: Hospitalised children aged 2-59 months who met the criteria for pneumonia were eligible. Children were excluded if they had been hospitalised for >24 hours; had malignancy or history of malignancy; a history of long-term (>2 months) steroid therapy, or conditions that might interfere with compliance with study procedures. MAIN OUTCOMES MEASURES: Causative bacterial, viral or mixed pathogen(s) for pneumonia were determined using microbiological, molecular and serological tests from routinely collected specimens (blood, sputum and nasopharyngeal swabs). We applied a previously published algorithm (PEER-PePPeS rules) to determine the causative pathogen(s). RESULTS: 188 subjects were enrolled. Based on our algorithm, 48 (25.5%) had a bacterial infection, 31 (16.5%) had a viral infection, 76 (40.4%) had mixed bacterial and viral infections, and 33 (17.6%) were unable to be classified. The five most common causative pathogens identified were Haemophilus influenzae non-type B (N=73, 38.8%), respiratory syncytial virus (RSV) (N=51, 27.1%), Klebsiella pneumoniae (N=43, 22.9%), Streptococcus pneumoniae (N=29, 15.4%) and Influenza virus (N=25, 13.3%). RSV and influenza virus diagnoses were highly associated with Indonesia's rainy season (November-March). The PCR assays on induced sputum (IS) specimens captured most of the pathogens identified in this study. CONCLUSIONS: Our study found that H. influenzae non-type B and RSV were the most frequently identified pathogens causing hospitalised CAP among Indonesian children aged 2-59 months old. Our study also highlights the importance of PCR for diagnosis and by extension, appropriate use of antimicrobials. TRAIL REGISTRATION NUMBER: NCT03366454.

Etiologies of severe acute respiratory infection (SARI) and misdiagnosis of influenza in Indonesia, 2013-2016.

BACKGROUND: Severe acute respiratory infection (SARI) accounts for a large burden of illness in Indonesia. However, epidemiology of SARI in tertiary hospitals in Indonesia is unknown. This study sought to assess the burden, clinical characteristics, and etiologies of SARI and concordance of clinical diagnosis with confirmed etiology. METHODS: Data and samples were collected from subjects presenting with SARI as part of the acute febrile Illness requiring hospitalization study (AFIRE). In tertiary hospitals, clinical diagnosis was ascertained from chart review. Samples were analyzed to determine the "true" etiology of SARI at hospitals and Indonesia Research Partnership on Infectious Diseases (INA-RESPOND) laboratory. Distribution and characteristics of SARI by true etiology and accuracy of clinical diagnosis were assessed. RESULTS: Four hundred and twenty of 1464 AFIRE subjects presented with SARI; etiology was identified in 242 (57.6%), including 121 (28.8%) viruses and bacteria associated with systemic infections, 70 (16.7%) respiratory bacteria and viruses other than influenza virus, and 51 (12.1%) influenza virus cases. None of these influenza patients were accurately diagnosed as having influenza during hospitalization. CONCLUSIONS: Influenza was misdiagnosed among all patients presenting with SARI to Indonesian tertiary hospitals in the AFIRE study. Diagnostic approaches and empiric management should be guided by known epidemiology. Public health strategies to address the high burden of influenza should include broad implementation of SARI screening, vaccination programs, clinician education and awareness campaigns, improved diagnostic capacity, and support for effective point-of-care tests.