Cross-Resistance and the Mechanisms of Cephalosporin-Resistant Bacteria in Urinary Tract Infections Isolated in Indonesia.

Urinary tract infection (UTI) by antibiotic-resistant strains has become increasingly problematic, with trends that differ from country to country. This study examined cross-resistance and the mechanisms of cephalosporin resistance in UTI-causative bacteria isolated in Indonesia. Antibiotic susceptibility tests based on Clinical Laboratory Standards Institute (CLSI) standards were done for UTI-causative strains (n = 50) isolated from patients in Indonesia in 2015-2016 and showed resistance against the third-generation cephalosporin. Mechanistic studies were carried out to confirm the presence of extended-spectrum ß-lactamase (ESBL) genes, carbapenemase-related genes, the fosA3 gene related to fosfomycin resistance, and mutations of quinolone-resistance-related genes. Isolated UTI-causative bacteria included Escherichia coli (64.0%), Pseudomonas aeruginosa (16.0%), Klebsiella pneumoniae (10.0%), and others (10.0%). These strains showed 96.0% susceptibility to amikacin, 76.0% to fosfomycin, 90.0% to imipenem, 28.0% to levofloxacin, 92.0% to meropenem, and 74.0% to tazobactam/piperacillin. ESBL was produced by 68.0% of these strains. Mechanistic studies found no strains with carbapenemase genes but 6.0% of strains had the fosA3 gene. Seventy-two % of the strains had mutations in the gyrA gene and 74.0% in the parC gene. Most E. coli strains (87.5%) had Ser-83 → Leu and Asp-87 → Asn in gyrA and 93.8% of E. coli had Ser-80 → Ile in parC. There were significant correlations among mutations in gyrA and parC, and fosA3 gene detection (P < 0.05), respectively. To our knowledge, this is the first mechanistic study of antibiotic-cross-resistant UTI-causative bacteria in Indonesia. Further studies with a longer period of observation are necessary, especially for changes in carbapenem resistance without carbapenemase-related genes.

Genetic analysis of ESBL-producing Klebsiella pneumoniae isolated from UTI patients in Indonesia.

INTRODUCTION: Extended spectrum beta-lactamase (ESBL)-producing Klebsiellapneumoniae is a serious concern for nosocomial infection and the emergence rate in Indonesia is higher than that in developed countries. The purpose of this study was to investigate the genetic characteristics of ESBL-producing K. pneumoniae isolated from UTI patients in Indonesia. MATERIALS AND METHODS: We collected K. pneumoniae resistant to ceftazidime or cefotaxime isolated from UTI patients in Dr. Soetomo's Academic Hospital in Surabaya, Indonesia in 2015. Ninety-four strains were identified as ESBL-producing bacteria by confirmation tests. The isolates were investigated by antimicrobial susceptibility testing with 20 drugs and ESBL gene detection, plasmid replicon typing and virulence genes as hypermucoviscous (HMV) strains were tested by the string test. RESULTS: High rates of resistance to ciprofloxacin (86.2%), tetracycline (80.9%) and nalidixic acid (78.7%) were observed. CTX-M-15 was the most common ESBL gene (89.4%), 33 of which also carried SHV-type ESBL. IncF was the most prevalent plasmid replicon typing (47.6%). Sixteen (17.0%) strains were judged as HMV, all of which had rmpA and more than half of which had fimH, uge, and wab. IncL/M was the most common replicon plasmid in the HMV strains, and the difference in the positive rate was statistically significant (p = 0.0024). CONCLUSION: This study showed the high prevalence of multiple-drug resistant and predominately CTX-M-15-positive ESBL-producing K. pneumoniae in Indonesia. There was a correlation between IncL/M and the HMV phenotype in this study. As such hypervirulent strains continue to emerge, studying their dissemination with resistance determinants is an urgent priority.

An adult patient with suspected of monkeypox infection differential diagnosed to chickenpox.

Background: Monkeypox is a zoonosis. The disease has a similar appearance to chickenpox caused by the varicella-zoster virus (VZV). On May 9th 2019, there was one laboratory-confirmed case of monkeypox reported in Singapore. A man was also suspected of having monkeypox on June 1st 2019 in Surabaya, Indonesia, a neighboring country. Objective: To report on a suspected case of monkeypox with differential diagnosis to chickenpox. Case: A 51-year-old male was suspected of having monkeypox after a differential diagnosis of chickenpox. His chief complaint was multiple blisters on his body. From the dermatological status on his facial, trunk and extremity regions, there were multiple pleiomorphic vesicles, some with umbilication, with a centripetal distribution, and crusts. Methods and Results: A PCR using VZV specific primers, followed by genome sequencing showed homologies of more than 99 % to other VZVs and less than 50% to Monkeypox sequences. Conclusion: Molecular laboratory techniques have confirmed the case as chickenpox.

Difference of Phenotype and Genotype Between Human and Environmental: Isolated Vibrio cholerae in Surabaya, Indonesia.

Cholera due to Vibrio cholerae has been spreading worldwide, although the reports focusing on Indonesian V. cholerae are few. In this study, in order to investigate how V. cholerae transmitted to human from environment. We extended an epidemiological report that had investigated the genotype of V. cholerae isolated from human pediatric samples and environmental samples. We examined 44 strains of V. cholerae isolated from pediatric diarrhea patients and the environment such as shrimps or oysters collected in three adjacent towns in Surabaya, Indonesia. Susceptibilities were examined for 11 antibiotics. Serotype O1 or O139 genes and pathogenic genes including cholera toxin were detected. Multi-locus sequence typing (MLST) and enterobacterial repetitive intergenic consensus (ERIC)-PCR were also performed to determine genetic diversity of those isolates. Serotype O1 was seen in 17 strains (38.6%) with all pathogenic genes among 44 isolates. Other isolates were non-O1/non-O139 V. cholerae. Regarding antibiotic susceptibilities, those isolates from environmental samples showed resistance to ampicillin (11.4%), streptomycin (9.1%) and nalidixic acid (2.3%) but those isolates from pediatric stools showed no resistance to those 3 kinds of antibiotics. MLST revealed sequence type (ST) 69 in 17 strains (38.6%), ST198 in 3 strains (6.8%) and non-types in 24 strains (54.5%). All the ST69 strains were classified to O1 type with more than 95% similarity by ERIC-PCR, including all 6 (13.6%) isolates from environmental samples with resistance to streptomycin. In conclusion, V. cholerae O1 ST69 strains has been clonally spreading in Surabaya, exhibiting pathogenic factors and antibiotic resistance to streptomycin, especially in the isolates from environment.

Antibiotic Susceptibilities and Genetic Characteristics of Extended-Spectrum Beta-Lactamase-Producing Escherichia coli Isolates from Stools of Pediatric Diarrhea Patients in Surabaya, Indonesia.

The purpose of this study was to investigate extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli isolates from pediatric (aged 0 to 3 years) diarrhea patients in Surabaya, Indonesia, where this kind of survey is rare; our study included assessment of their antibiotic susceptibilities, as well as ESBL typing, multilocus sequence typing (MLST), and diarrheagenic E. coli (DEC)-typing. ESBL-producing E. coli were detected in 18.8% of all the samples. Many ESBL-producing E. coli had significantly lower susceptibility to gentamicin (p ＜ 0.0001) and the quinolones nalidixic acid (p＝0.004) and ciprofloxacin (p ＜ 0.0001) than non-producers. In ESBL-producing E. coli, 84.0% of strains expressed CTX-M-15 alone or in combination with other ESBL types. MLST revealed that 24.0% of ESBL-producers had sequence type 617, all of which expressed the CTX-M-15 gene; we also detected expression of 3 DEC-related genes: 2 enteroaggregative E. coli genes and 1 enteropathogenic E. coli gene. In conclusion, CTX-M-15-type ESBL-producing E. coli ST617 appear to have spread to Indonesia.

PREVALENCE OF METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS FROM NOSE AND THROAT OF PATIENTS ON ADMISSION TO MEDICAL WARDS OF DR SOETOMO HOSPITAL, SURABAYA, INDONESIA.

Epidemiological data of methicillin resistant Staphylococcus aureus (MRSA) carriage in Indonesian hospitals are still scarce. These data are required for health management of infectious diseases in order to control hospital MRSA. The carriage rate of MRSA in nose and throat of patients on admission to Dr Soetomo Hospital Surabaya, Indonesia was 8.1% of 643 patients, 5.4% from throat, 3.9% from nose and 1.2% from both sites. Prevalence of MRSA among patients admitted to surgical and non-surgical ward was not different (8.2% and 8.0%, respectively). Although MRSA prevalence in Indonesian hospitals is low compared to many other countries worldwide, appropriate health strategies will be needed to be implemented if this infection is to be controlled.

Religious/spiritual characteristics of indian and indonesian physicians and their acceptance of spirituality in health care: a cross-cultural comparison.

Religious/spiritual (r/s) characteristics of physicians influence their attitude toward integrative medicine and spiritual care. Indonesia physicians collaborate with traditional, complementary, and alternative medicine (TCAM) professionals within modern healthcare system, while Indian physicians are not reported to do so. The aim of the study was to understand the r/s characteristics and their influence on Indian and Indonesian physicians' acceptance of TCAM/spirituality in modern healthcare system. An exploratory, pilot, cross-cultural, cross-sectional study, using Religion and Spirituality in Medicine, and Physician Perspectives (RSMPP) survey questionnaire, compared r/s characteristics and perspectives on integrative medicine of 169 physicians from two allopathic, Sweekar-Osmania University (Sweekar-OU), India, University of Airlanga (UNAIR), Indonesia, and a TCAM/Central Research Institute of Unani Medicine (CRIUM) institute from India. More physicians from UNAIR and CRIUM (89.1 %) described themselves as "very"/"moderately" religious, compared to 63.5 % Sweekar-OU (p = 0.0000). Greater number of (84.6 %) UNAIR physicians described themselves as "very" spiritual and also significantly high (p < 0.05) in intrinsic religiosity as compared to Sweekar-OU and TCAM physicians; 38.6 % of UNAIR and 32.6 % of CRIUM participants reported life-changing spiritual experiences in clinical settings as against 19.7 % of Sweekar-OU; 92.3 % of UNAIR, compared to CRIUM (78.3 %) and Sweekar-OU (62 %), felt comfortable attending to patients' spiritual needs, (p = 0.0001). Clinical comfort and not r/s characteristics of participants was the significant (p = 0.05) variable in full regression models, predictive of primary outcome criteria; "TCAM or r/s healing as complementary to allopathic treatment." In conclusion, mainstreaming TCAM into healthcare system may be an initial step toward both integrative medicine and also improving r/s care interventions by allopathic physicians.

Nasal carriage of methicillin-resistant and methicillin-sensitive strains of Staphylococcus sciuri in the Indonesian population.

Staphylococcus sciuri strains were unexpectedly cultured from healthy persons and patients from Indonesia during a population-based survey on nasal Staphylococcus aureus carriage. Fifty-one S. sciuri isolates were further characterized. The S. aureus mecA gene was detected by PCR in 22 isolates (43.1%), whereas S. sciuri mecA was found in 33 isolates (64.7%). The staphylococcal cassette chromosome mec (SCCmec) regions of S. aureus mecA-positive isolates contained elements of classical S. aureus SCCmec types II and/or III.

Antimicrobial resistance among commensal isolates of Escherichia coli and Staphylococcus aureus in the Indonesian population inside and outside hospitals.

The prevalence of antimicrobial resistance among the commensal microflora was examined in the Indonesian population inside and outside hospitals. A total of 3,995 individuals were screened in two major urban centers. Among Escherichia coli from rectal samples (n = 3,284) the prevalence of resistance to ciprofloxacin and other classes of antibiotics was remarkably high, especially in individuals at the time of discharge from hospital. Staphylococcus aureus isolates (n = 361) were often resistant to tetracycline (24.9%), but this was not associated with hospital stay. Two S. aureus isolates harbored the mecA gene. Regional differences in resistance rates exist, suggesting regional differences in selection pressure, i.e., antibiotic usage patterns. The results show that antimicrobial resistance among commensal E. coli and S. aureus has emerged in Indonesia.