Postgraduate Medicine

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ipgm20

Appropriateness of diagnosis and antibiotic use in

sepsis patients admitted to a tertiary hospital in
Indonesia

Franciscus Ginting, Adhi Kristianto Sugianli, Morris Barimbing, Nina Ginting,

Mardianto Mardianto, R. Lia Kusumawati, Ida Parwati, Menno D. de Jong,
Constance Schultsz & Frank van Leth

To cite this article: Franciscus Ginting, Adhi Kristianto Sugianli, Morris Barimbing, Nina Ginting,
Mardianto Mardianto, R. Lia Kusumawati, Ida Parwati, Menno D. de Jong, Constance Schultsz
& Frank van Leth (2021) Appropriateness of diagnosis and antibiotic use in sepsis patients
admitted to a tertiary hospital in Indonesia, Postgraduate Medicine, 133:6, 674-679, DOI:
10.1080/00325481.2020.1816755

To link to this article: https://doi.org/10.1080/00325481.2020.1816755

© 2020 The Author(s). Published by Informa Published online: 21 Oct 2020.

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POSTGRADUATE MEDICINE
2021, VOL. 133, NO. 6, 674–679
https://doi.org/10.1080/00325481.2020.1816755

CLINICAL FEATURE
ORIGINAL RESEARCH

Appropriateness of diagnosis and antibiotic use in sepsis patients admitted to a

tertiary hospital in Indonesia
Franciscus Gintinga,b, Adhi Kristianto Sugianlic,d, Morris Barimbinge, Nina Gintinge, Mardianto Mardiantof,
R. Lia Kusumawatig,b, Ida Parwatic,d, Menno D. de Jongh, Constance Schultszi,j,h and Frank van Leth i,j
a
Department of Internal Medicine, H. Adam Malik Hospital, Medan, Indonesia; bFaculty of Medicine, University of Sumatera Utara, Medan,
Indonesia; cDepartment of Clinical Pathology, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia; dFaculty of Medicine, Universitas
Padjadjaran, Bandung, Indonesia; eAntimicrobial Stewardship Program, H. Adam Malik Hospital, Medan, Indonesia; fExecutive board, H. Adam
Malik Hospital, Medan, Indonesia; gDepartment of Microbiology, H. Adam Malik Hospital, Medan, Indonesia; hDepartment of Medical Microbiology,
Amsterdam University Medical Centres, Location AMC, Amsterdam, The Netherlands; iAmsterdam Institute for Global Health and Development,
Amsterdam, The Netherlands; jDepartment of Global Health, Amsterdam University Medical Centres, Location AMC, Amsterdam, The Netherlands

ABSTRACT ARTICLE HISTORY

Objective: To evaluate the diagnostic and antibiotic treatment strategies for patients suspected of Received 14 February 2020
sepsis, in a tertiary hospital in Indonesia. This can identify areas for improvement in care provided, and Accepted 27 August 2020
inform diagnostic and antimicrobial stewardship activities within the hospital.
KEYWORDS
Methods: Retrospective review of medical records with regards to the diagnosis and management of
Indonesia; evaluation;
adult patients with sepsis admitted to a tertiary hospital in Indonesia. We assessed the diagnostic antimicrobial stewardship;
process, and whether or not the antibiotic treatment provided was appropriate for the diagnosis. empirical antibiotic
Appropriateness of antibiotic treatment was classified as being definite appropriate, probable appro­ treatment; sepsis
priate, inappropriate, or unknown.
Results: The study included 535 adult patients, of whom 295 (55%) were diagnosed with a community-
acquired sepsis, and 240 (45%) with a hospital-acquired sepsis. A specimen for culture and antimicrobial
susceptibility testing was collected from three out of four patients (392/535). All but 10 patients had
information on antibiotic treatment at the time of sepsis diagnosis. Of those, nearly 50% (257/525) of
the patients received antibiotic treatment with unknown appropriateness because no cultures were
taken (n = 141) or all cultures were negative (n = 116). Just 3.4% and 9.1% of the patients received
definite or probable appropriate antibiotic treatment, respectively.
Conclusions: There is a clear need in encouraging attending physicians to obtain the much-required
blood cultures, or cultures from the suspected source of infection before empirical antibiotic treatment
is started. This will improve the use of appropriate antibiotic treatment strategies, and contribute to
antimicrobial stewardship.

Introduction being updated in 2016[6]. The Indonesian guideline underlines

the importance of obtaining appropriate microbiological cul­
Sepsis, defined as the presence (probable or documented) of an
tures before the start of antibiotic therapy, and the rapid start
infection with systemic manifestations, is a potentially life-
of such therapy (antibiotics from at least two different classes)
threatening condition, the incidence of which remains high world­
as soon as sepsis is suspected[9].
wide [1–5]. International guidelines on the management of sepsis
We set out to evaluate the diagnostic and antibiotic treatment
(Surviving Sepsis Campaign [SSC]) advice is to start empirical broad-
strategies for patients suspected of sepsis, employed by physicians
spectrum antibiotic therapy within one hour when sepsis is sus­
in a tertiary hospital in Indonesia. The objective of the evaluation is
pected[6]. This timely start of antibiotic treatment is associated with
to assess if i) the employed strategies are in line with the prevailing
a reduced mortality [7,8]. An adequate diagnosis of sepsis requires
guidelines in Indonesia, and ii) the antibiotic treatment provided is
that routine microbiological cultures are obtained before the start of
appropriate for the diagnosis. The purpose of the evaluation is to
any antibiotic therapy[6].
identify areas for improvement in care provided and to inform
In Indonesia, the first ever guideline on the diagnosis and
diagnostic and antimicrobial stewardship activities within the hos­
management of patients with sepsis issued by the Indonesian
pital. Such an evaluation is deemed timely, given the continuous
Ministry of Health in 2017 was based on the SSC guidance
increase in the number of patients diagnosed with sepsis in the
from 2012 (Sepsis-2 definition) which includes the central
hospital in previous years (2011: 631, 2015: 731).
concept of the presence of the Systemic Inflammatory
Using an evaluation approach differs from performing
Response Syndrome (SIRS) in sepsis diagnosis[9]. This gui­
a clinical audit, where the evaluation aims to
dance is still operational to-date, despite the SSC guidance

CONTACT Frank van Leth f.c.vanleth@amsterdamumc.nl Amsterdam University Medical Centres, Location AMC, Amsterdam 1105 AZ, The Netherlands
© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.

provide a judgment on the quality of the current service, while
a clinical audit aims to measure clinical practise against pre-set
targets[10]. Although Indonesia provides guidelines for the
diagnosis and management of sepsis, it does not define tar­
gets to define quality of care, precluding the clinical audit
approach.
Methods
Ethics approval
The study was approved by the institutional ethical review
boards of the Faculty of Medicine, Universitas of Sumatera
Utara and H Adam Malik General Hospital, Medan, Sumatra
(286/KOMET/FKUSU/2013). Given the use of data derived
solely from the hospital administrative system, no individual
informed consent was required.
Design and setting
This retrospective study is a review of medical records with
regards to the diagnosis and management of adult patients
with sepsis, admitted to Adam Malik Hospital in Medan,
Indonesia. Adam Malik Hospital is a tertiary facility with 721
beds servicing mostly patients coming from North Sumatera
Province. The hospital admits around 55,000 patients every year.
Patient population and data collection
The identification of patients to be included in the review
followed a hierarchical approach. We extracted all medical
records belonging to patients with a discharge diagnosis of
sepsis in the Hospital Information System for the
complete year of 2016. From these, we selected those records
that used the International Classification of Diseases-tenth
revision (ICD-10) code for sepsis, after which we selected
those records compatible with the Sepsis-2 definition of sep­
sis. The final selection step limited the study population to
adults (17 years of age or older). We hand-searched the
selected medical records for information with regards to
demographic characteristics, underlying condition (Charlson
Comorbidity Index), results of cultures and antimicrobial sus­
ceptibility tests, length of hospital stay, source of infection
leading to sepsis, and antibiotic treatment received.
Information on culture and AST was extracted from the
Hospital Information System if not present in the medical
record, which might have happened if the patient died or
was discharged before these results were received from the
laboratory. The extracted information followed a pre-defined
protocol and was reviewed by two independent physicians.
Outcome
The outcome of interest was the appropriateness of antibiotic
treatment at the time of sepsis diagnosis, which we classified
as being definite appropriate, probable appropriate, inap­
propriate, or unknown. Definite appropriate antibiotic treat­
ment is the administration of antibiotics for which all micro-
organisms identified in blood cultures are susceptible.
POSTGRADUATE MEDICINE 675
Antibiotic treatment is classified as probable appropriate if,
in the absence of a positive blood culture, all micro-organisms
identified in cultures of any other patient specimens are sus­
ceptible for these antibiotics. Inappropriate antibiotic treat­
ment is the administration of at least one antibiotic to which
none of the micro-organism cultured from blood or other
specimens (in the absence of blood culture) is susceptible.
Appropriateness of antibiotic treatment is unknown if there
is no positive culture, or no cultures are performed.
In addition, we compared whether or not the antibiotic treat­
ment at sepsis diagnosis differed from the empirical antibiotic
treatment given during admission, and if this empirical treat­
ment was in line with the Indonesian treatment guidelines.
Antibiotic susceptibility testing (AST) was performed in the
hospital microbiology laboratory using the Vitek2 Compact plat­
form (Biomerieux, France), and following CLSI guidelines. AST
results were interpreted using CLSI-defined breakpoints (version
2016), in which an intermediate test result was considered
resistant.
Analyses were stratified for patients admitted to the inten­
sive care unit (ICU) or non-ICU wards, and the sepsis being
community-acquired or hospital-acquired, the latter being
defined as a sepsis developed at least 48 hours after hospital
admission. Patients who did not receive any antibiotics were
excluded from the analysis of appropriateness.
Statistical analysis
Data on antibiotic use, performance of cultures, and appropri­
ateness of treatment are summarized as frequencies and per­
centages. This study being a process evaluation, we did not
perform any hypothesis testing. Analyses were performed
using STATA version 12 (College Station, Texas, USA).
Results
Study population
The Hospital Information System recorded 1,200 patients with
a discharge diagnosis of sepsis in 2016. Of these records, 950
(79%) had an ICD-10 code for the diagnosis, of which 636
(67%) were Sepsis-2 compatible (Figure 1). The main reason
for not having a Sepsis-2 compatible diagnosis was the
absence of any reference to sepsis in the medical record,
other than the discharge note. The selection procedure iden­
tified 535 medical records of adult patients, the characteristics
of whom are reported in Table 1. Of these, 295 (55%) patients
were diagnosed with a community-acquired sepsis, and 240
(45%) patients with a hospital-acquired sepsis.
Alignment with Indonesian practise guidelines
A specimen for culture and antimicrobial susceptibility testing
(AST) was collected from on average three out of four patients
(392/535; 73%), although this was less often for patients with
a community-acquired sepsis (187/295; 63%, Table 2). Blood
cultures were performed for around half of the patients (269/
535), with a slightly higher frequency in ICU (87/150; 58%)
versus non-ICU wards (182/385; 47%), and hospital-acquired
676 F. GINTING ET AL.

Figure 1. Flow chart for patient inclusion.

ICD-10: International Classification of Diseases, version 10; SSC: Survival Sepsis Champaign; SIRS: Systemic Inflammatory Response Syndrome; CRF: Chronic Renal Failure

Table 1. Patient characteristics. Table 2. Management and appropriateness of antibiotic treatment of patients
Community- Hospital with sepsis.
ICU Non-ICU acquired acquired* Community Hospital
n = 150 n = 385 n = 295 n = 240 ICU Non-ICU acquired acquired*
n % n % n % n % n = 150 n = 385 n = 295 n = 240
Age group n % n % n % n %
17–24 5 3.3 20 5.2 12 4.1 13 5.4 Empirical antibiotic 150 100 381 99.0 293 99.3 238 99.2
25–34 12 8.0 53 13.8 33 11.2 32 13.3 treatment given during
35–44 21 14.0 50 13.0 37 12.5 34 14.2 admission
45–54 31 20.7 94 24.4 69 23.4 56 23.3 Culture performed (at least 116 77.3 276 71.7 187 63.4 205 85.4
55–64 45 30.0 86 22.3 75 25.4 56 23.3 one)
65≥ 36 24.0 82 21.3 69 23.4 49 20.4 Blood culture performed 87 58.0 182 47.3 142 48.1 127 52.9
Gender Growth in blood culture 28 32.2 46 25.3 39 27.5 35 27.6
Female 63 42.0 153 39.7 131 44.4 85 35.4 Antibiotic treatment given 148 98.7 377 97.9 292 99.0 233 97.1
Male 87 58.0 232 60.3 164 55.6 155 64.6 at diagnosis
Charlson index Appropriateness of n = 148 n = 377 n = 292 n = 233
0–3 61 40.7 187 48.6 131 44.4 117 48.7 antibiotic treatment at
4–7 77 51.3 173 44.9 149 50.5 101 42.1 diagnosis**
8–11 11 7.3 23 6.0 14 4.8 20 8.3 Definite# 6 4.1 12 3.2 10 3.4 8 3.4
≥12 1 0.7 2 0.5 1 0.3 2 0.8 Probable† 13 8.9 35 9.3 21 7.2 27 11.6
Focus of infection** Inappropriate$ 57 38.5 145 38.5 71 24.3 131 56.2
Pneumonia 104 69.3 275 71.4 217 73.6 162 67.5 Unknown¶ 72 48.7 185 49.1 190 65.1 67 28.8
Urinary tract infection 38 25.3 81 21.0 56 19.0 63 26.3
SSTI 25 16.7 62 16.1 49 16.6 38 15.8 ICU: Intensive Care Unit; * > 48 hours after admission diagnosed
IAI 11 7.3 26 6.8 15 5.1 22 9.2 ** patients not starting antibiotics at sepsis diagnosis are excluded (n = 10)
#
Other 16 10.7 63 16.4 37 12.5 42 17.5 the administration of antibiotics for which all micro-organisms identified in
blood cultures are susceptible;
* > 48 hours after admission diagnosed; ** multiple foci per patient possible; †
In the absence of a positive blood culture, if all micro-organisms identified in
ICU: Intensive Care Unit; SSTI: Skin and soft tissue infection IAI: intra- any other culture are susceptible;
abdominal infection; $
the administration of antibiotics for which none of the micro-organism identi­
fied in blood cultures, or any other cultures (in the absence of blood culture) is
susceptible.
no positive culture, or no cultures are performed.
sepsis (127/240; 53%) versus community-acquired sepsis (142/
295; 48%, Table 2).
treatment). Cephalosporins were by far the most preferred
All but four patients started on empirical antibiotic treat­
antibiotics in any of the settings (70–80%), followed by the
ment during admission (Table 2), although in around one-third
quinolones (30–50%). Meropenem was used in almost half the
of the patients (147/521), the empirical antibiotic treatment
number of patients with sepsis in the ICU.
provided consisted of antibiotics from a single class (Table 3).
Empirical treatment according to the Indonesian sepsis guide­
lines was provided for 101/150 (67.3%) patients in the ICU,
256/385 (66.5%) patients on non-ICU wards, 154/240 (64.2%) Appropriateness of antibiotic treatment
patients with a hospital-acquired sepsis, and 203/295 (68.9%)
patients with a community-acquired sepsis. The preferred Appropriateness of antibiotic treatment was based on the
combination was a cephalosporin with a fluoroquinolone regimen received at the time that sepsis was diagnosed,
(n = 125, 35% of combination antibiotic treatment), followed defined as the time sepsis was first reported in the medical
by the combination of cephalosporin, fluoroquinolone, and record. Ten patients were excluded from this analysis as they
metronidazole (n = 29, 8.1% of combination antibiotic had died before antibiotics could be started.
 POSTGRADUATE MEDICINE 677

Table 3. Antibiotic treatment, empirical and at sepsis diagnosis.

Empirical antibiotic treatment Antibiotic treatment at time of sepsis diagnosis
ICU Non-ICU Community acquired Hospital acquired* ICU Non-ICU Community acquired Hospital acquired*
n = 150 n = 385 n = 295 n = 240 n = 150 n = 385 n = 295 n = 240
n % n % n % n % n % n % n % n %
No antibiotics 0 0 4 1.0 2 0.7 2 0.8 2 1.3 8 2.1 3 1.0 7 2.9
From 1 class 49 32.7 125 32.5 90 30.5 84 35.0 44 29.3 99 25.7 69 23.4 74 30.8
From 2 classes 64 42.7 179 46.5 138 46.8 105 43.8 59 39.3 171 44.4 133 45.1 97 40.4
From 3 classes 30 20.0 70 18.2 57 19.3 43 17.9 38 25.3 85 22.1` 73 24.8 50 20.8
From 4 classes 6 4.0 7 1.8 8 2.7 5 2.1 7 4.7 20 5.2 15 5.1 12 5.0
From 5 classes 1 0.7 0 0 0 0 1 0.4 0 0 2 0.5 2 0.7 0 0
Antibiotic (Class)
Fluoroquinolone 67 44.7 156 40.5 149 50.5 74 30.8 68 45.3 170 44.1 160 54.2 78 32.5
Cephalosporin 129 86.0 344 89.4 256 86.8 217 90.4 111 74.0 334 86.8 245 83.1 200 83.3
Aminoglycoside 14 9.3 64 16.6 42 14.2 36 15.0 17 11.3 89 23.1 59 20.0 47 19.6
Macrolide 5 3.3 10 2.6 4 1.4 11 4.6 5 3.3 14 3.6 7 2.4 12 5.0
Lincosamides 1 0.7 7 1.8 4 1.4 4 1.7 1 0.7 7 1.8 4 1.4 4 1.7
Folate Pathway Inhibitor 1 0.7 31 8.1 18 6.1 14 5.8 1 0.7 32 8.3 20 6.8 13 5.4
Carbapenem 55 36.7 36 9.4 54 18.3 37 15.4 73 48.7 53 13.8 77 26.1 49 20.4
Metronidazole 21 14.0 62 16.1 40 13.4 43 17.9 22 14.7 69 1.9 47 15.9 44 18.3
Tetracycline 1 0.7 5 1.3 2 0.7 4 1.7 1 0.7 5 1.3 2 0.7 4 1.7
Glycopeptide 1 0.7 2 0.5 0 0 3 1.3 2 1.3 3 0.8 0 0 4 2.1
Penicillin 1 0.7 2 0.5 0 0 5 2.1 1 0.7 3 0.8 0 0 4 1.7
* > 48 hours after admission diagnosed; ICU: Intensive Care Unit;

Figure 2. Appropriateness of antibiotic treatment at the diagnosis of sepsis.

One in two patients, 257/525 (49.9%) received antibiotic
treatment with unknown appropriateness, of whom 141/257
(54.9%) because no cultures were taken, and 116/257 (45.1%)
because all cultures were negative.
The frequency of inappropriate antibiotic treatment was
high, reaching 38.5% of all patients admitted to the ICU
(n = 148) or a non-ICU ward (n = 377). More than half of the
patients (56.2%) treated for hospital-acquired sepsis (n = 233)
received inappropriate antibiotic treatment (Table 2).
Consequently, appropriateness of antibiotic treatment at
the time of sepsis diagnosis was low, with 18/525 (3.4%)
patients receiving definite appropriate antibiotic treatment,
and 48/525 (9.1%) patients receiving probable appropriate
antibiotic treatment (Figure 2).
Of all patients receiving definite or probable appropriate
antibiotic treatment at the time of sepsis diagnosis, 49/66
(74.2%) were using their initial empirical treatment regimen.
However, of all patients receiving inappropriate antibiotic
treatment at the time of sepsis diagnosis, 46/202 (22.8%)
were on a changed treatment regimen.
For 114/525 (21.7%) patients, the antibiotic treatment at
the time of sepsis diagnosis was different from the initial
empirical antibiotic treatment received. This was clearly more
frequent in patients with at least one culture taken (101/384;
26.3%) compared to patients with no cultures taken (13/
141; 9.2%).
Discussion
The current study shows that patients with sepsis frequently
receive inappropriate antibiotic treatment in a tertiary health
facility in Medan, Indonesia, and that appropriateness could
678 F. GINTING ET AL.
often not be assessed due to the absence of any microbiolo­
gical culture, or available cultures being negative.
Inappropriate antibiotic treatment in patients with severe
sepsis or septic shock has been linked to increased mortality.
A systematic review and meta-analysis of this association
including 70 studies reported a doubling in odds for 30-day
all-cause mortality when antibiotic treatment in the first
48 hours was inappropriate[11].
Not only the antibiotic therapy at sepsis diagnosis was
often inappropriate, also the empirical treatment given dur­
ing admission in this patient group was. The received
empirical treatment differed in less than 30% of the patients
from the (often inadequate) antibiotic treatment at sepsis
diagnosis, and the empirical treatment followed prevailing
Indonesian treatment guidelines in less than 70% of the
patients (antibiotics from at least two different classes).
Because we used routine data for the study, we cannot
know for certain why there is a high frequency of inappropri­
ate antibiotic treatment for patients with sepsis. However,
some potential reasons could be envisioned.
Firstly, it may be due to logistical problems when results
of antimicrobial sensitivity testing do not reach the treating
physician in a timely manner for appropriate treatment to
start or initial inappropriate treatment to change. A second
reason may be a mismatch between the prevailing antimi­
crobial resistance (AMR) prevalence in the hospital and
treatment guidelines. Indonesia has its own guidelines for
the treatment of infectious diseases, including sepsis [9].
Its strong reliance on the use of cephalosporins and fluor­
oquinolones is in line with the guidance provided in several
syndrome-specific antibiotic treatment guidelines from the
Infectious Disease Society of America, but clearly does not
consider the high prevalence of AMR for these drugs reported
in the country.
This situation will be compounded if actual knowledge of
the prevalence of AMR is absent. This can occur when there
are no proper data on AMR patterns, and/or if this information
does not reach the treating physician.
Low- and middle-income countries often lack information
on the prevalence of AMR due to the absence of surveillance
networks, and limited laboratory capacity[12]. This also holds
for Indonesia where information on AMR is infrequently
derived from a limited number of university laboratories[13].
We know from our earlier work that AMR prevalence is high in
Indonesia, and can differ markedly between settings and even
hospital wards [14,15].
There is a clear need for strategies that can provide rapid
and locally relevant information on AMR to guide empirical
antibiotic treatment choices in a variety of settings. We
showed earlier that this is possible by assessing whether the
prevalence of AMR is above a clinically relevant level that
precludes the use of an antibiotic, rather than attempting to
assess a precise AMR prevalence[15].
The clinical care of patients with suspected sepsis
requires a careful balance between speed and accuracy in
which the severity of the clinical condition of the patient
plays a crucial role. But designing an appropriate antibiotic
treatment strategy requires all efforts to obtain culture
specimens. Our data show that this careful balance was
not met, as cultures from blood or the suspected focus of
infection were obtained infrequently. When taken, cultures
frequently did not show any growth. This latter observation
is likely due to the known high frequency of self-medication
with readily available antibiotics, or generous antibiotic pre­
scription practises by physicians, including in tertiary care
settings in Indonesia[16]. Combining the absence of cultures
with the observation that a change in antibiotic treatment
could still lead to an inappropriate antibiotic treatment
regimen raises the question whether or not the results of
cultures and AST are an integral part of clinical decision-
making. Diagnostic and antimicrobial stewardship go hand-
in-hand. There is a clear role for the microbiology laboratory
in antimicrobial stewardship programs [17], while continu­
ous education of care providers on antimicrobial resistance
and its stewardship is warranted for curbing AMR[18].
The study included just 45% of patients who had
a discharge diagnosis of sepsis recorded in the hospital
administration system. This points towards poor record
keeping and administration on one hand, and insufficient
quality control on the other hand. The latter refers to the
possibility that a sepsis diagnosis can be recorded in the
system without a matching ICD-10 code available. The for­
mer refers to issuing a discharge note of sepsis by the
attending physician, while the medical file does not provide
adequate proof for the diagnosis. The resulting mismatch of
diagnosis and administrative information is worrisome, as
automated medical record systems are usually the primary
source to assess a wide variety of indices related to hospital
care.
We believe our study sample can be considered sufficiently
representative for this study as it consists of a homogenous
patient group for which sepsis treatment was indicated.
In conclusion, diagnosis and management of patients
with suspected sepsis in a tertiary referral hospital in
Indonesia can be improved. There is a clear need in
encouraging attending physicians to obtain the much-
required blood cultures, or cultures from the suspected
source of infection before empirical antibiotic treatment is
started. This will improve the use of appropriate antibiotic
treatment strategies, and potentially reduce the high mor­
tality currently seen in this patient group. In parallel, the
hospital should review its empirical treatment guidelines in
line with the observed spectrum of sepsis-associated micro-
organisms and their antimicrobial susceptibility profile with
a special attention to multidrug resistance. Relying on glo­
bal treatment guidelines in a setting known for its high
prevalence of antimicrobial resistance is no option. This
intervention fits well with the recommendations of antimi­
crobial stewardship activities in sepsis management[19].
Funding
This work was funded by the Royal Netherlands Academy of Arts and
Sciences as part of the Scientific Program Indonesia–the Netherlands
(SPIN). Peer reviewers on this manuscript have no relevant financial or
other relationships to disclose.

Declaration of interest
The contents of the paper and the opinions expressed within are those of
the authors, and it was the decision of the authors to submit the manu­
script for publication.
ORCID
Frank van Leth http://orcid.org/0000-0002-5490-8968
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