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Aim: to investigate knowledge, attitude and behaviour toward infection control in two teaching hospitals on the island of Java by means of a questionnaire and to evaluate the use of the questionnaire as a tool., Methods: we investigated knowledge, attitude and behaviour toward infection control in two teaching hospitals on the island of Java by means of a questionnaire to identify problem areas, barriers and facilitators. The target was to include at least 50% of all health care workers (physicians, nurses, assistant nurses and infection control nurses) in each hospital, department and profession. Differences between demographic variables and scores for individual questions and groups of questions were compared using the chi-square statistic and analysis of variance and Spearman's rho was used to test for correlations between knowledge, attitude, self-reported behaviour and perceived obstacles., Results: more than half of the health care workers of the participating departments completed the questionnaire. Of the 1036 respondents (44% nurses, 37% physicians and 19% assistant nurses), 34% were vaccinated against hepatitis B, 77% had experienced needle stick accidents and 93% had been instructed about infection control. The mean of the correct answers to the knowledge questions was 44%; of the answers to the attitude questions 67% were in agreement with the correct attitude; obstacles to compliance with infection control guidelines were perceived in 30% of the questions and the mean self-reported compliance was 63%. Safe handling of sharps, hand hygiene and the use of personal protective equipment were identified as the most important aspects for interventions. Significant positive correlations were found between knowledge, attitude, self-reported behaviour and perceived obstacles., Conclusion: the questionnaire in conjunction with site visits and interviews was a valuable strategy to identify trouble spots in the hospitals and to determine barriers to facilitators of change that should be taken into account when planning interventions. Successful interventions should cover hospital management, the infection control team, as well as the health care workers on the wards.

Summary Objectives: To identify determinants of carriage of resistant Staphylococcus aureus in both hospitalized patients and individuals from the community in two urban centres in Indonesia., Methods: Staphylococcus aureus cultures and data on recent antibiotic use, demographic, socioeconomic, disease-related and healthcare-related variables were collected from 3995 community dwellers and hospitalized persons. Nasal S. aureus carriage was found in 362 persons (9.1%). Logistic regression analysis was performed to identify which variables were independently associated with carriage of resistant S. aureus., Results: The penicillins were the most frequently used antibiotics both in the community and in hospitalized patients. In the community, admission to a hospital was associated with carriage of S. aureus resistant to any of the tested antibiotics [odds ratio (OR) 2.5, 95% confidence interval (95% CI) 1.3-4.9] and any tetracycline resistance (OR 2.4, 95% CI 1.1-5.1). Having no symptoms was associated with less carriage of S. aureus with resistance to any of the tested antibiotics (OR 0.5, 95% CI 0.3-0.9) and any tetracycline resistance (OR 0.5, 95% CI 0.3-0.9). Crowding (OR 4.5, 95% CI 1.2-4.9) and low income (OR 8.9, 95% CI 1.8-43.9) were associated with multidrug resistance. In hospitalized patients, the use of penicillins was associated with resistance to any of the tested antibiotics (OR 3.9, 95% CI 1.4-11.6) and any tetracycline resistance (OR 3.7, 95% CI 1.1-12.0)., Conclusions: Antibiotic policies including proper diagnosis, treatment and drug delivery process should be made by healthcare providers in Indonesia to help limit the emergence of antibiotic resistance., (© 2010 Blackwell Publishing Ltd.)

Objectives: To estimate the antibiotic use of individuals visiting public healthcare facilities in Indonesia and to identify determinants of use against a background of high resistance rates., Methods: Patients on admission to hospital (group A), visiting a primary health center (group B), and healthy relatives (group C) were included in the study. A questionnaire on demographic, socioeconomic, and healthcare-related items including health complaints and consumption of antibiotics was used. Logistic regression was performed to determine the co-variables of antibiotic use., Results: Of 2996 individuals interviewed, 486 (16%) had taken an antibiotic. Compared to group C (7% consumption), groups B and A exhibited a three-fold and four-fold higher use of antibiotics, respectively. Respiratory (80%) and gastrointestinal (13%) symptoms were most frequent. Aminopenicillins and tetracyclines accounted for 80% of the prescribed antibiotics. Similar antibiotics were self-medicated (17% of users). Age less than 18 years and health insurance were independent determinants of antibiotic use. Urban provenance, being adult, male, and having no health insurance were independent determinants of self-medication., Conclusions: In addition to health complaints, other factors determined antibiotic consumption. In view of the likely viral origin of respiratory complaints and the resistance of intestinal pathogens, most antibiotic use was probably unnecessary or ineffective. Future interventions should be directed towards healthcare providers.

This article estimates the magnitude and quality of antibiotic prescribing in Indonesian hospitals and aims to identify demographic, socio-economic, disease-related and healthcare-related determinants of use. An audit on antibiotic use of patients hospitalized for 5 days or more was conducted in two teaching hospitals (A and B) in Java. Data were collected by review of records on the day of discharge. The method was validated through concurrent data collection in Hospital A. Multivariate logistic regression analysis was performed to determine variables to explain antibiotic prescribing. Prescriptions were assessed by three reviewers using standardized criteria. A high proportion (84%) of 999 patients (499 in Hospital A and 500 in Hospital B) received an antibiotic. Prescriptions could be categorized as therapeutic (53%) or prophylactic (15%), but for 32% the indication was unclear. Aminopenicillins accounted for 54%, and cephalosporins (mostly third generation) for 17%. The average level of antibiotic use amounted to 39 DDD/100 patient-days. Validation revealed that 30% of the volume could be underestimated due to incompleteness of the records. Predictors of antibiotic use were diagnosis of infection, stay in surgical or paediatric departments, low-cost nursing care, and urban residence. Only 21% of prescriptions were considered to be definitely appropriate; 15% were inappropriate regarding choice, dosage or duration, and 42% of prescriptions, many for surgical prophylaxis and fever without diagnosis of infection, were deemed to be unnecessary. Agreement among assessors was low (kappa coefficients 0.13-0.14). Despite methodological limitations, recommendations could be made to address the need for improving diagnosis, treatment and drug delivery processes in this setting.

Objectives: Antibiotic resistance is a worldwide healthcare problem exacerbated by antibiotic use and transmission of resistant bacteria. Not much is known about resistance in commensal flora and about determinants for resistance in Indonesia. This study analysed recent antibiotic use as well as demographic, socioeconomic, disease-related and healthcare-related determinants of rectal carriage of resistant Escherichia coli in the community and in hospitals in Indonesia., Methods: Carriers of susceptible E. coli were compared with carriers of E. coli with resistance to any of the tested antibiotics. Logistic regression analysis was performed to determine which variables were associated with carriage of resistant E. coli. Individuals in the community with varying levels of contact with healthcare institutions and hospitalized patients were analysed as separate populations., Results and Conclusions: Of 3275 individuals (community 2494, hospital 781), 54% carried resistant E. coli. Recent antibiotic use was the most important determinant of resistance in both populations [community: odds ratio (OR) 1.8, 95% confidence interval (95% CI) 1.5-2.3; hospital: OR 2.5, 95% CI 1.6-3.9]. In the community, hospitalization (OR 2.4, 95% CI 2.0-3.0), diarrhoeal symptoms (OR 1.9, 95% CI 1.3-2.7) and age under 16 years (adults: OR 0.4, 95% CI 0.3-0.5) were associated with carriage of resistant E. coli. For hospitalized patients, having no health insurance was associated with less resistance (OR 0.6, 95% CI 0.4-0.9) and differences were observed between hospitals (Semarang: OR 2.2, 95% CI 1.5-3.3) and departments (Paediatrics: OR 4.3, 95% CI 1.7-10.7). Further research is needed to investigate whether transmission is responsible for these differences.

Standard precautions can prevent transmission of micro-organisms. This study investigated hand hygiene, handling of needles and use of personal protective equipment in an Indonesian teaching hospital, and performed a multi-faceted intervention study to improve compliance. An intervention was performed in an internal medicine ward and a paediatric ward, consisting of development of a protocol for standard precautions, installation of washstands, educational activities and performance feedback. Before, during and after the intervention, observers monitored compliance with hand hygiene, safe handling of needles and use of gloves, gowns and masks. A gynaecology ward served as the control. Unobtrusive observations were performed to check for an influence of the observers on the overt observations. In total, 7,160 activities were observed. Compliance with hand hygiene increased from 46% to 77% in the internal medicine ward and from 22% to 62% in the paediatric ward. Before the intervention, no safe recapping of needles was recorded in either ward. After the intervention, 20% of needles were recapped safely. Inappropriate gown use decreased in the internal medicine ward. There were no significant changes in use of gloves and masks. There may have been an effect of the overt observations in the paediatric ward, but there was no effect in the internal medicine ward. There were no significant changes in the control ward, except for a decrease in the use of gloves. In conclusion, compliance with hand hygiene procedures improved significantly due to an intervention project focused on education and improved facilities. Compliance with safe handling of needles improved slightly due to introduction of the one-handed method for safe recapping of used needles.

A cross-sectional surveillance of healthcare-associated infections (HAIs) and exposure to risk factors was undertaken in two Indonesian teaching hospitals (Hospitals A and B). Patients from internal medicine, surgery, obstetrics and gynaecology, paediatrics, a class department and intensive care were included. Patient demographics, antibiotic use, culture results, presence of HAI [phlebitis, surgical site infection (SSI), urinary tract infection (UTI) and septicaemia] and risk factors were recorded. To check for interobserver variation, a validation study was performed in Hospital B. In Hospitals A and B, 1,334 and 888 patients were included, respectively. Exposure to invasive devices and surgery was 59%. In Hospital A, 2.8% of all patients had phlebitis, 1.7% had SSI, 0.9% had UTI and 0.8% had septicaemia. In Hospital B, 3.8% had phlebitis, 1.8% had SSI, 1.1% had UTI and 0.8% had septicaemia. In the validation study, the prevalence as recorded by the first team was 2.6% phlebitis, 1.8% SSI, 0.9% UTI and no septicaemia, and that recorded by the second team was 2.2% phlebitis, 2.6% SSI, 3.5% UTI and 0.9% septicaemia. This study is the first to report on HAI in Indonesia. Prevalence rates are comparable to those in other countries. The reliability of the surveillance was insufficient as a considerable difference in prevalence rates was found in the validation study. The surveillance method used is a feasible tool for hospitals in countries with limited healthcare resources to estimate their level of HAI and make improvements in infection control. Efficiency can be improved by restricting the surveillance to include only those patients with invasive procedures. This can help to detect 90% of all infections while screening only 60% of patients.