The Clinimetric Profile of 11 Generic Quality Indicators for Appropriate Antibiotic Use in Hospitalized Patients in Indonesia

Background: One of the efforts in antibiotic stewardship for limiting antibiotic resistance is the assessment of the quality of antibiotic use. To date, the quality and appropriateness of antibiotic use in Indonesia, a low-middle-income non-European country, have not yet been assessed using proven quality indicators (QIs). One recommended tool to measure appropriate empiric antibiotic use in hospitalized patients is the generic QIs reported by van den Bosch et. al., which demonstrated good validity and generalizability. Objective: The aim of this study is to assess the clinimetric profile of 11 generic QIs based on van den Bosch et. al. in admitted adult patients receiving empiric antibiotics in Indonesian hospitals. Methods: This is an observational study with a cross-sectional design conducted at two government referral hospitals in Jakarta, Indonesia, from August 1, 2022, to February 2, 2023. Adult inpatients who received empiric antibiotics due to suspected infection for ≥24 hours were included in the study. Results: In 500 inpatients from 2 hospitals, all QIs demonstrated good measurability with less than 10% of missing data. Ten QIs showed good applicability of >10%. Four QIs show good performance, while six QIs have significant potential for improvement (two blood cultures are obtained before empiric antibiotic treatment; culture sample is obtained from location suspected of infection; antibiotic is switched from intravenous to oral when clinically possible; antibiotics are stopped when there is no evidence of infection; a guideline is available and renewed every three years; and a guideline is adjusted to the local resistance pattern) making them priority targets for interventions to enhance the quality of antibiotic use in Indonesia. All QIs display good inter-observer reliability, and no moderate or strong correlations are found between QIs. Conclusion: The clinimetric assessment of QIs is imperative before their implementation in any setting different from their country of origin. Of the 11 generic QIs, 10 demonstrated good reliability and applicability at two hospitals in Indonesia. Future intervention studies can utilize these generic QIs to measure improvement in the appropriateness of antibiotic use. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by PUTI Q1 grant from Universitas Indonesia. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The ethics committee of the Faculty of Medicine, Universitas Indonesia gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.