Assessing the impact of antimicrobial stewardship programs in tertiary hospitals for UTI: does it work alone?

  • Prahara Yuri Division of Urology, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
  • Katsumi Shigemura Division of Urology, Department of Urology, Kobe University Hospital, Kobe, Japan, Department of International Health, Kobe University Graduate School of Health Sciences, Kobe, Hyogo, Japan
  • Andaru Dahesihdewi Department of Clinical Pathology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
  • Andy Zulfiqqar Division of Urology, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
  • Koichi Kitagawa Department of Advanced Medical Science, Kobe University Graduate School of Science, Technology and Innovation, Kobe, Japan
  • Masato Fujisawa Division of Urology, Department of Urology, Kobe University Hospital, Kobe, Japan
Keywords: antimicrobial stewardship;, urinary tract infection;, antibiotic resistance;, Indonesia;, extended-β-lactamase


Antibiotic resistance is currently an emergent global challenge. Urinary tract infection (UTI), one of the most commonly reported infections, are is becoming a difficult case to treat considering the increasing prevalence of antimicrobial resistance (AMR). The objective of this study was to assess the impact of a hospital antibiotic stewardship program on AMR in managing UTI at a tertiary referral hospital in Yogyakarta, Indonesia, while considering the absence of the program in lower-tier referral hospitals. A retrospective cross-sectional study was conducted from January 2017 to December 2020, classified into pediatric and adult samples. Urine samples were collected and cultured from all patients with UTI hospitalized in the Dr. Sardjito General Hospital, Yogyakarta. The UTI causative bacteria and antibiotic susceptibilities were investigated in the comparison of the first 2 years (2017-2018, prior to the hospital antibiotic stewardship program) and the last 2 years (2019-2020, following the implementation of the hospital antibiotic stewardship program). The isolates from 717 adult urine samples were cultured. Escherichia coli (39.1%), Acitenobacter baumanii (9.3%), and Pseudomonas aeruginosa (8.5%) were identified as the most common bacteria prior to the hospital antibiotic stewardship program. Extended-spectrum β-lactamase-producing E. coli and Burkholderia cepacia were still increasing in the following the implementation of the hospital antibiotic stewardship program. Our study indicated that the stewardship program does not exhibit a significant change during the first two years considering the absence of the program in lower-tier referral hospitals.


Stamm WE, Norrby SR. Urinary tract infections: disease panorama and challenges. J Infect Dis 2001; 183 Suppl 1:S1-4.

John AS, Mboto CI, Agbo B. A review on the prevalence and predisposing factors responsible for urinary tract infection among adults. Euro J Exp Bio 2016; 6(4):7-11.

World Health Organization. Antimicrobial resistance: global report on surveillance [Internet]. 2014 Mar. 92 4 156474 8

Sugianli AK, Ginting F, Kusumawati RL, Parwati I, Jong MD, Leth FV, et al. Laboratory-based versus population-based surveillance of antimicrobial resistance to inform empirical treatment for suspected urinary tract infection in Indonesia. PLoS One 2020; 15(3):e0230489.

Sugianli AK, Ginting F, Kusumawati RL, Pranggono EH, Pasaribu AP, Gronthoud F, et al. Antimicrobial resistance in uropathogens and appropriateness of empirical treatment: a population-based surveillance study in Indonesia. J Antimicrob Chemother 2017; 72(5):1469-77.

Hussain Gilani SY, Ali Shah SR, Ahmad N, Bibi S. Antimicrobial resistance patterns in community acquired urinary tract infections. J Ayub Med Coll Abbottabad 2016; 28(3):572-4.

Ramírez-Castillo FY, Moreno-Flores AC, Avelar-González FJ, Márquez-Díaz F, Harel J, Guerrero-Barrera AL. An evaluation of multidrug-resistant Escherichia coli isolates in urinary tract infections from Aguascalientes, Mexico: cross-sectional study. Ann Clin Microbiol Antimicrob 2018; 17(1):34.

Bryce A, Costelloe C, Hawcroft C, Wootton M, Hay AD. Faecal carriage of antibiotic resistant Escherichia coli in asymptomatic children and associations with primary care antibiotic prescribing: a systematic review and meta-analysis. BMC Infect Dis 2016; 16:359.

Schwaber MJ, Carmeli Y. Antimicrobial resistance and patient outcomes: the hazards of adjustment. Crit Care 2006; 10(5):164.

Wrenn C. Introduction of the VITEK 2 compact and implementation of EUCAST guidelines in a Microbiology Department. Dublin R Coll Surg Ireland 2015; 1-121.

Parathon H, Kuntaman K, Widiastoety TH, Muliawan BT, Karuniawati A, Qibtiyah M, et al. Progress towards antimicrobial resistance containment and control in Indonesia. BMJ 2017; 358:3808.

Penta SK, Tarmono, Bambang S Noegroho, Mochtar CA, Wahyudi I, Renaldo J, et al. Penatalaksanaan infeksi saluran kemih dan genitalia pria 2015. Jakarta: Ikatan Ahli Urologi Indonesia; 2015. 1-92.

Pradipta IS, Ronasih E, Kartikawati AD, Hartanto H, Amelia R, Febrina E, et al. Three years of antibacterial consumption in indonesian community health centers : the application of anatomical therapeutic chemical/defined daily doses and drug utilization 90 % method to monitor antibacterial use. J Family Community Med 2015; 22(2):101-5.

Kitagawa K, Shigemura K, Yamamichi F, Alimsardjono L, Raharjo D, Kuntaman K, et al. International comparison of causative bacteria and antimicrobial susceptibilities of urinary tract infections between Kobe, Japan, and Surabaya, Indonesia. Jpn J Infect Dis 2018; 71(1):8-13.

Cantas L, Suer K, Guler E, Imir T. High emergence of ESBL-producing E. coli cystitis: time to get smarter in cyprus. Front Microbiol 2016; 6:1446.

Khoshnood S, Heidary M, Mirnejad R, Bahramian A, Sedighi M, Mirzaei H. Drug-resistant gram-negative uropathogens: a review. Biomed Pharmacother 2017; 94:982-94.

Sköld O. Sulfonamide resistance: mechanisms and trends. Drug Resist Updat 2000; 3(3):155-60.

Maseda H, Yoneyama H, Nakae T. Assignment of the substrate-selective subunits of the MexEF-OprN multidrug efflux pump of pseudomonas aeruginosa. Antimicrob Agents Chemother 2000; 44(3):658-64.

Sekyere JO. Genomic insights into nitrofurantoin resistance mechanisms and epidemiology in clinical Enterobacteriaceae. Future Sci OA 2018; 4(5):FSO293.

Abia ALK, Ubomba-Jaswa E, Momba MNB. High prevalence of multiple-antibiotic-resistant (MAR) Escherichia coli in river bed sediments of the Apies River, South Africa. Environ Monit Assess 2015; 187(10):652.

Procop GW, Tuohy MJ, Wilson DA, Williams D, Hadziyannis E, Hall G. Cross-class resistance to non-β-lactam antimicrobials in extended-spectrum β-lactamase-producing Klebsiella pneumonia. AMP J Clin Pathol 2003; 120:265-7.

Garau J. Other antimicrobials of interest in the era of extended-spectrum β-lactamases: fosfomycin, nitrofurantoin and tigecycline. Clin Microbiol Infect 2008; 14(sppl 1):198-202.

Shigemura K, Kitagawa K, Osawa K, Yamamichi F, Tokimatsu I, Nomi M, et al. Comparison of antibiotics use, urinary tract infection (UTI)-causative bacteria and their antibiotic susceptibilities among 4 hospitals with different backgrounds and regions in Japan. J Chemotherapy 2018; 30(1):31-6.

Paterson DL, Bonomo RA. Extended-spectrum β-Lactamases : a clinical update. Cli Microbiol Rev 2005; 18(4):657-86.

Holá V, Ruzicka F, Horka M. Microbial diversity in biofilm infections of the urinary tract with the use of sonication techniques. FEMS Immunol Med Microbiol 2010; 59(3):525-8.

Meletis G. Carbapenem resistance: overview of the problem and future perspectives. Ther Adv Infect Dis 2016; 3(1):15–21.

Horsley H, Malone-Lee J, Holland D, Tuz M, Hibbert A, Kesley M, et al. Enterococcus faecalis subverts and invades the host urothelium in patients with chronic urinary tract infection. PLoS One 2013; 8(12):e83637.

Gilmore MS, Clewell DB. Ike Y, Shankar N. Enterococci from commensals to leading causes of drug resistant infection. Boston: Massachusetts Eye and Ear Infirmary; 2014.