ANTIBIOTIC RESISTANCE PATTERN IN PATIENTS

WITH ULCER, RESPIRATORY, AND DIGESTIVE

TRACT INFECTION AT TURI PRIMARY HEALTH
CARE YOGYAKARTA
Daru Estiningsih1, Ika Puspitasari1*), Titik Nuryastuti2 , Endang Lukitaningsih1

Faculty of Pharmacy, Gadjah Mada University1

Faculty of Medicine, Public Health, and Nursing Gadjah Mada University 2
Corresponding author email : daru_estiningsih@almaata.ac.id

ABSTRACT
Background: The incidence and development of antibiotic resistance has been shown to have an impact on the ineffectiveness
of therapy as it is associated with the increasement of morbidity and mortality, length of hospitalization, and cost of treatment.
Antibiotic-resistant bacteria can spread between bacteria, from treated patients to others, or through the environment.
Therefore, it is very important to map the profile of antibiotic resistance in health care facilities such as hospitals, health
centers and the surrounding environment. Objective : To determine the profile of antibiotic use, antibiotic resistance and
bacteria that cause infection in the community setting. Method : descriptive-analytical observational study with cohort design
in patients with respiratory infections, acute gastroenteritis, or skin infection/ulcer at Turi Primary health care, Yogyakarta .
Result: The bacteria that cause infection are Staphylococcus aureus (36%), Streptococcus pyogenes (16%), Streptococcus beta
hemolyticus (12%), Klebsiella pneumonia (10%), Escherichia coli (6.05%), and other bacteria in amounts less than 5%. The
three largest types of infections that occur are respiratory infections (20%), ulcus (18%), pharyngitis, and pyoderma (12.2%).
Antibiotics that are used in infection therapy are amoxicillin 57%, ciprofloxacin 40%, and doxiciclin 2%. Antibiotic sensitivity
test results obtained amoxicillin resistance 54%, tetracycline 50%, amoxiclav 33%, chloramphenicol 20%, and the rest are less
than 10%. Conclusion : The results showed a pattern of bacterial resistance to antibiotics that are mostly first-line drugs for
infections that occur in the community.

Keywords : resistance, antibiotics, puskesmas, bacteria, resistance

1. INTRODUCTION leading to antimicrobial resistance, continues to threaten the

The incidence of antibiotic resistance is expanding
and poses a very serious threat to public health in all
countries in various sectors. The ever-increasing spread of
resistance requires governments around the worldwide to
pay serious attention to address the threat. The prescribing
pattern is mainly in first-level health care facilities in remote
and rural areas with very limited resources. Several
strategies for addressing antibiotic resistance showed
positive results after pursuing various things aimed at
increasing knowledge, clinical, surveillance and policies on
the use of antibiotics (1).
Antibiotic resistance is one of several examples of
evolution that look real today so it is a very important
research topic to do. The existence of antibiotic resistant
genes in microorganisms in the environment greatly affects
the emergence, spread, and evolution of these resistant
genes. Thus, it is very necessary to have clinical analysis
and non-clinical analysis in the habitat or that the spread
can be stopped although the main factor that is very
important in resistance is the basic ability of pathogenic
microorganisms to increase their immune system in order to
maintain their resistance to antibiotics (2). The spread of
drug-resistant pathogens with new resistance mechanisms,
ability to treat common infections. The rapid global spread
of multi- and pan-resistant bacteria (superbugs) will lead to
infections that cannot be treated with existing antimicrobial
drugs such as antibiotics(3). Multidrug resistant organisms
have been found in several studies such as Acinetobacter
baumannii which in various circumstances combined with
resistance is closely related to Healthcare Associated
Infections (HAIs), reported MDR strains of 27.9% and XDR
of 42.1%. MDR strains show sensitivity to amikacin,
trimethoprim-sulfamethoxazole, tobramycin, ampicillin-
sulbactam, and meropenem. Acinetobacter baumannii strain
XDR only shows a still good sensitivity to amikacin (4).
MDR strains also occur in Mycobacterium tuberculosis
which in 2017 was resistant to rifampicin then 82% became
multidrug-resistant (5). Proper prescribing and the use of
antibiotics with due regard to the principle of antimicrobial
stewardship accompanied by proper diagnosis and
aggressive control of infection will be able to prevent the
occurrence of multidrug-resistant organisms (MDRO) (6).
The emergence and development of antibiotic
resistance has been shown to have an impact on ineffective
and efficient treatments as it is associated with the
increasement of morbidity and mortality, hospitalization and
treatment costs. The United Nations then on a global scale
issued a World Health Assembly Resolution (WHA 68.7)
with the title Global Action Plan on Antimicrobial
Resistance as a form of deep attention to this global
problem(7). The problem in Indonesia is that only limited
hospitals equipped with clinical microbiology laboratory
fasilities. By controlling the spread of antibiotic resistance, it
is expected to increase the rationality of antibiotic usage,
improve the quality of infection control, and inhibit the
increase of antibiotic resistance. Hospitals must prepare
complete facilities to control antibiotic resistance (8). In
subsequent developments, controlling of the spread was also
carried out by primary health care facilities. In addition to
being focused on improper use of antimicrobials, the quality
of the drug is another important thing worth to consider;
drugs with a lower dose of the active ingredient can cause
resistance. Strategies aimed at overcoming antimicrobial
resistance include ensuring the availability, proper
management of existing antimicrobials and the quality of
drugs. Overall, the emergence of AMR in primary health
care has been linked to the prescription and use of high-
volume antibiotics (9). Efforts to prevent and handle the
further spread of resistance are aimed to control the use of
antibiotics and map the pattern of antibiotic resistance in
service facilities and the surrounding environment.
The Government of Indonesia through the
Regulation of the Minister of Health of the Republic of
Indonesia No. 8 of 2015 has required every hospital to carry
out the antimicrobial resistance control program optimally
through the formation of implementation team, the
formulation of antibiotic policies and guidelines,
implementing the use of antibiotics wisely and
implementing the principles of infection control prevention
(10). The next follow-up to strengthen the prevention of
AMR The government issued a Regulation of the Minister
of Health No. 27 of 2017 Concerning Guidelines for
Infection Prevention and Control in Health Service Facilities
which regulate that at the primary service level such as
puskesmas, there is an obligation to manage infection
prevention as an effort to prevent the spread of antibiotic
resistance in primary health care (11).
This study aims to determine the pattern of antibiotic
resistance in Puskesmas in infectious diseases including
ISPA, GEA and ulcers in outpatients, so that it can be
considered to manage the prevention and handling of
antibiotic resistance.
. (ICD) 10, Upper Respiratory Tract Infection, acute
2. METHODS
The research carried out includes a type of descriptive
research with an observational study design and an
analytical approach. Data collection is taken prospectively
using patient medical record data as well as data on the
results of antibiotic sensitivity and sensitivity tests from the
microbiology laboratory to specimens from patients
according to the type of infection
3. MATERIALS
The tool used in this study is a research data
collection form, consisting of patient identity data,
diagnosis, drugs given and swabs to be carried out The
material used is the medical record of the patient who has
been declared to have entered the inclusion criteria and
transport media to bring specimens from patients to be tested
in the microbiology laboratory.
4. RESEARCH
The research began with the selection of patients
who met the inclusion criteria and were willing to follow the
course of the study by filling in informed concerns, followed
by data collection of identities and treatments given, then
specimens were taken, namely nasal swabs for ARI patients,
skin swabs for ulcer patients and specimens from feces for
patients with GEA diagnoses. Specimens with swab
collection are carried with transport media while fecal
specimens are placed in sterile containers. All specimens
will be tested for microbiological test to determine the
infectious bacteria and to be tested for sensitivity and
resistance for later analysis.
.
5. RESULTS AND DISCUSSION
The study was conducted with a total of 49 respondents,
with the disparity of patient sex characteristic is almost
similar; 55.1% women and 44.9% men (Figure 1). The age
group of late adolescence (17–25 years old) became the
largest group with a percentage of 24.49% . Meanwhile for
job characteristic most of the respondents were housewives
and students with consecutive percentages of 26.53% and
28.57%.
Early adolescence 1 2 - 16 years 16.33%
old
Late adolescence = 17 - 25 years
old
24.49%
Man,
44.8979591
Early adult = 26 - 35 years old 8.16%
836735%
Woman,
12.24%
55.1020408
163265%
Late adult = 36- 45 years old
Early ederly = 46 - 55 years old 18.37%
20.41%
Late ederly = 56 - 65 years old
Figure 1 Characteristics of respondents
This study was conducted prospectively with the
inclusion criteria being patients diagnosed with one of the
infections based on International Classification Diseases
gastroenteritis (GEA), ulcers or skin infections. In
accordance with these inclusion criteria, 15 types of
infections were obtained, and the 4 largest groups in a row
were respiratory infection, ulcus pyoderma, and bacterial
scabies. Moreover, the next type of infection with a smaller
percentage are infection with dermatitis, bronchitis,
dysentery impetigo, parotid and rhinitis (Figure 2).
Antibiotics used for the therapy of such infections consisted
of amoxicillin (57.4%), ciprofloxacin (40.82%) and 2.04%
doxycycline (Figure 3).
One of the diseases that is quite widely experienced
by patients in primary health services is pharyngitis. 30% to
60% of acute pharyngitis cases are caused by viruses, but in
practice antibiotics are given (12). In this study, 75%
pharyngitis were given ciprofloxacin therapy for 5 days and and can cause various diseases, ranging from moderately
the rest were given amoxicillin for 5 days, combined with severe skin infections to fatal pneumonia and sepsis.
paracetamol methylprednisolone and acetylcysteine Systemic infection of S. aureus begins with the entry of
according to the symptoms experienced by the patient. bacteria through the bariers of the skin or the spread of
biofilms formed on the medical device used. In the
Respiratory infection 20.41%
bloodstream, bacteria can actively attack and eliminate
Ulcus 18.37%
immune cells such as neutrophils through cytolytic toxins or
Pyoderma 12.24%
persist in those cells to achieve systemic distribution (14).
Bacterial scabies 8.16%

Faryngitis 8.16%

Tonsilofaringitis 6.12% Staphylococcus aureus 36%

Dermatitis 6.12% Streptococcus pyogenes 16%
Rhinosinusitis 4.08%
Streptococcus betahemolyticus 12%
Otitis Media 4.08%
Klebsiella pneumoniae 10%
Rhinitis 2.04%
Eschericia coli O 157 6%
Parotitis 2.04%

Impetigo 2.04% Pseudomonas aeruginosa 4%

GEA 2.04%
Disentri 2.04%
Bronkitis 2.04%
Figure 2 Infectious disease patterns
The second largest type of infection is ulcus, with
diabetic ulcus. Diabetic ulcus being the majority in some
health care facilities have become a serious problem that
continues to develop because it increases morbidity and
causes an increasement in the incidence of amputations in
the lower extremities. The results of the tissue culture test
are very useful to be a reference for the determination of
antibiotic therapy given. Culture result show that the gram-
positive bacteria that cause ulcers are Staphylococcus
aureus, while those in the gram-negative group are
Pseudomonas aeruginosa (13). In this study, the bacteria
that cause ulcers were not only the two bacteria, but also
Salmonella enterica sp Arizona, Klebsiella oxytoca,
Citrobacter koseri, Citrobacter freundii, and Burkholderia
cepacia. B. cepacia is an aerobic gram-negative bacillus,
found in various aquatic environments and often found in
fluids used in hospitals.
57.14%
40.82%
Amoxycilin Ciprofloxacin
Figure 3. Proportion of antibiotic use
During the study period, 49 patients were obtained
who qualifying the respondent inclusion criteria. The results
of microbiology tests, 65 isolates were obtained where 3
isolates of which did not grow and 12 isolates were normal
flora of the body. The pattern of bacteria that cause infection
appeared in figure 4, consisting of 13 types of species with
the majority being Staphylococcus aureus, this bacterium is
one of the most frequent causes of morbidity and mortality
Bulchoderia cepacia 4%
Serratia marcescens 2%
Salmonella enterica sp Arizona 2%
Klebsiella oxytosa 2%
Enterobacter cloacae 2%
Citrobacter freundi 2%
Citobacter koseri 2%
Figure 4. Types of bacteria that cause infection
Escherichia coli, Klebsiella (pneumoniae/oxytoca),
Enterobacter spp., Pseudomonas aeruginosa, Acinetobacter
spp., Bacteroides spp., and Proteus spp. is a gram-negative
bacterium that often causes various types of infections
including: catheter-associated urinary tract infections
(CAUTIs), bloodstream infection (BSI), ventilator-
associated pneumonia (VAP), hospital-acquired pneumonia
(HAP), surgical site infection (SSI) (15).
Antibiotic susceptibility testing (AST) was carried
out in all isolates from specimens taken by respondents.
Specimens were taken in an appropriate way for each type of
infection, namely in ulcers with wound swabs, on ARI with
nasal or throat swabs and fecal samples in GEA infections.
Additionally, 68 isolates were obtained from the specimen
and antibiotic resistance data as shown on the antibiogram
(figure 5). The percentage of ampicillin resistance had the
highest value of 54.05% followed by tetracycline at a
presentation of 50.00%, amoxiclav 33.33%,
chloramphenicol 20.00% as well as vancomycin,
erythromycin, levofloxacin, cotrimoxazole and ciprofloxacin
at a resistance percentage of less than 10% (figure 5).
Similar to previous research conducted at the Jetis Primary
2.04%
Health Center, Yogyakarta where it shows resistance in
Doxycicline gram-negative bacteria such as Klebsiella pneumoniae and
H. influenzae to tetracycline antibiotics, penicillin and
chlorampenicol. In this study, there was also antibiotic
resistance of tetracycline, penicillin and clindamycin for
Gram-positive bacteria, such as Staphylococcus aureus and
Streptococcus ρneumoniae. Penicillin resistance is affected
by the overuse of penicillin antibiotics in the community
because it is easily obtained from drugstores (9).
 Ampicilin 54% AST obtained a result of 100% resistant to amoxicillin, and
resistant to cefazolin, amoxiclav and cotrimoxazole by 67%.
Tetracyclin 50%
Furthermore, Saito (2017) reported that the exceedingly high
Amoxiclav 33% bacterial resistance to. ampicillin and amoxicillin (97%) was
Chloramphenicol 20% dominated by S. Aureus, and was found also in
Vanomisin 7% Acinetobacter spp., Enterobacter spp., E.coli, and Klebsiella
(16). Each bacteria found in this study has a different
Eritromicin 6%
resistance pattern, as illustrated in figures 6, most of them
Levofloxacin 6% are resistant to more than 2 types of antibiotics, even some
Cotrimoxazole 5% of them belong to the category of multidrug-resistant
Ciprofloxacin 5% organisms (MDRO), besides that there are two bacteria,
0% 10% 20% 30% 40% 50% 60%
namely P. aeruginosa and Salmonella sp. which is still
sensitive to all antibiotics tested.
Figure 5. Antibiotic resistance

Staphylococcus aureus was found to be the

bacterium that causes the most infection in health centers.

Figure 6. Multidrug-resistant Organisms (MDRO) in a community setting

Enterococcus, S. aureus, K. pneumoniae, A. include the destruction of antibiotic molecules, decreased

baumannii, P. aeruginosa, and E. coli are the organisms that
cause the majority of infections in health care facilities
around the worldwide. Antibiotic resistance in these bacteria
is strongly associated with increasement of morbidity,
mortality and the threat of economic problems (17). Some of
the mechanisms that are common in gram-negative bacteria
antibiotic penetration by reducing permeability, increased
antibiotic efflux, mutation of the target location, or changes
in antibiotic chemistry (15).
The result of the identification in this study shows
K. pneumoniae became one of the bacteria that causes
respiratory infection. The bacterium is a type of gram-
negative opportunistic pathogenic bacteria, that can cause
respiratory infections, urinary tract infections, nosocomial
infections, and even death up to 10% in humans. This type
of bacteria are easily found in human body fluids, including
blood, urine, and sputum (18). Additionally, antibiotic
resistance also occurs at the Sanglah Central General
Hospital Denpasar where K. pneumoniae is resistant to beta-
lactam antibiotics due to the expression of resistant genes,
namely the blaCTX-M-1 gene group (83.33%) (19). Other
identification result obtained were Enterobacter cloacae,
Klebsiella oxytoca, Serratia marcescens, each of which only
one isolate was found, so that there could be no visible
resistance pattern per bacterium.
4. CONCLUSION
The results showed the bacterial resistance to
antibiotics, most of which are first-line drugs for infections
that occur in a community setting.
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