Extended Tricyle Project Indonesia for Extended-spectrum Beta-lactamase Positive Klebsiella Pneumoniae and Escherichia Coli
Extended Tricyle Project Indonesia for Extended-spectrum Beta-lactamase Positive Klebsiella Pneumoniae and Escherichia Coli
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:
Primary aims:
Secondary aims:
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:
Exclusion Criteria:
fleming.fellowship@erasmusmc.nl; j.severin@erasmusmc.nl0031-(0)10-7033510