In 2019, Indonesia's first WHO Tricycle Project revealed alarming rates of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli across various sectors. The study found ESBL-producing E. coli in 40% of pregnant women, 57.7% of E. coli-induced bloodstream infections, 67.1% of broiler chicken, and 12.8% of total E. coli in water samples. In the first National Action Plan on Antimicrobial Resistance from Indonesia, the reduction of ESBL was identified as a clear goal. In E-Trike, Tricycle will be repeated, using the same methodology, to determine if a reduction has been achieved. Additionally, ESBL-positive Klebsiella pneumoniae will be included, as important pathogen for humans.

Antimicrobial resistance (AMR) is a global threat and is considered to be a silent pandemic. It is estimated that in 2021, over 4.71 million deaths were associated with AMR, with 1.14 million attributed to AMR. In 2020, the World Health Organization (WHO) Global Antimicrobial Resistance and Use Surveillance System (GLASS) reported the prevalence of cefotaxime-, ceftriaxone, and ceftazidime-resistant Klebsiella pneumoniae from bloodstream infections in South Asian region was 75.9%, 77.4%, 74.8%, respectively. Based on the report from the Indonesian Society for Clinical Microbiologists in 2023, the prevalence of third-generation cephalosporin-resistant Klebsiella pneumoniae in Indonesia was 57%, while third-generation cephalosporin-resistant E. coli was 68%.

The WHO has been at the forefront of AMR through its Global Surveillance extended-spectrum beta-lactamase (ESBL)-positive E. coli Tricycle Project, which employs a "One Health" approach. This innovative surveillance program aims to obtain a comprehensive picture of AMR in humans, animals, and the environment, particularly in countries with limited surveillance capabilities. Indonesia's first pilot Tricycle Project revealed alarming rates of ESBL-producing E. coli across various sectors. The study found ESBL-producing E. coli in 40% of pregnant women, 57.7% of E. coli-induced bloodstream infections, 67.1% of broiler chicken, and 12.8% of total E. coli in water samples. These findings underscore the worrisome pattern of AMR in Indonesia and highlight the urgent need for expanded surveillance and control strategies.

Klebsiella pneumoniae is the second most common Enterobacterales found in humans; its role in animals and the environment is less clear, even more in the Indonesian setting. A better understanding of the presence of this human pathogen in other domains is needed, so that effective intervention strategies on AMR for the Indonesian situation can be designed.

In E-Trike, the original WHO Tricycle protocol (which already includes sample size calculation) will be used, with three modifications:

1. ESBL-K. pneumoniae (ESBL-Kp) will be included for all samples. Additionally, from pregnant women, not only rectal samples will be taken, but also throat samples, as previously it was shown that 15% of adults carry Kp in their throat in Indonesia.
2. In addition to the MacConkey agar supplemented with cefotaxime, CHROMagar plates will be used.
3. The sampling period will only be 5 months, instead of the 10 months that was used in the 2019 Tricycle. However, both "wet" and "dry" months will be included.

Primary aims:

• To determine the prevalence of ESBL-producing E. coli (ESBL-Ec) in humans (hospital and community), the food chain (animals), and the environment.
• To determine the prevalence of ESBL-producing Klebsiella pneumoniae (ESBL-Kp) in humans (hospital and community), the food chain (animals), and the environment.

Secondary aims:

• To compare the yield of the ESBL Chromagar™ plate compared to the MacConkey agar plate supplemented with 4 mg/L cefotaxime.
• To assess the susceptibility of the ESBL-Ec and ESBL-Kp to carbapenem antibiotics and other relevant classes of antibiotic.
• To understand the resistance mechanisms of ESBL-Ec and ESBL-Kp isolates using genomic analysis.

Setting The study will be performed in Jakarta, Indonesia.

Surveillance in humans will include:

Community: rectal and throat carriage in pregnant women in 3 puskesmas. From Hospitals: bloodstream infections with E. coli and K. pneumoniae, Cipto Mangunkusumo Hospital and Persahabatan Hospital; isolates will be included

Surveillance in food chain will include:

Chicken caeca from the live bird open market and slaughterhouse in Jakarta

Surveillance in the environment will include:

River water upstream and downstream, animal slaughter wastewater, human communal wastewater

Inclusion Criteria:

• pregnant women at antenatal visits

Exclusion Criteria:

• no informed consent

Pregnant women at antenatal visits in 3 puskesmas (public health centers)

Due to privacy rules, it will only be provided upon reasonable request and completely anonymized.