Since the first community-acquired ESBL-E was reported in the late 1990s, the community carriage rate of ESBL-E has continuously increased worldwide (16, 31, 32). Reported ESBL-E community carriage rates have increased more rapidly in some regions such as Southeast Asia, Eastern Mediterranean, and Western Pacific during the 2000s compared to other regions. Recent studies from these regions often reported an ESBL-E community carriage rate around 50% (16). In the present study, ESBL-E strains were isolated from 74 out of 200 (37%) pregnant women in PHC and hospital settings (Table 2). Other studies in different countries have reported lower rates of ESBL-E carriage in pregnant women compared to this study, for example 2.9% (26 out of 901) in Norway in 2012 (13), 8.6% (18 out of 209) in Germany in 2012–2013 (14), 31.7% (32 out of 101) in Nigeria in 2014 (33), and 18.6% (66 out of 356) in Madagascar in 2014 (21). The high prevalence of ESBL-E carriage in pregnant women in this study is probably associated with the high prevalence of ESBL-E carriage in communities in Indonesia (8–10).
The use of antibiotics is considered as the primary cause of the spread of antimicrobial resistance, and it has been reported that global consumption of antibiotics increased by 65% from 2000 to 2015. At present, there is a strict demand for proper use of antibiotics in the medical field, and the consumption of antibiotics in developed countries tends to be suppressed. In emerging countries, it continues to increase rapidly (34). In the present study ESBL-E strains were more frequently isolated from pregnant women in hospitals (49.5%) than pregnant women in the PHC setting (24.8%) (p < 0.01, Table 2). Consistent with this finding, the rate of antibiotics use in pregnant women in hospitals (41.4%) was significantly higher rather than the pregnant women in PHC (19.8%) (p < 0.01, Table 2). Antimicrobial susceptibility testing showed that all 74 ESBL-E strains were sensitive to carbapenems, including IPM, MEPM, and also sensitive to AMK and TGC. However, ESBL-EC strains isolated from hospitals were more resistant to MI, TE, NA, CL, ST, AZT and TZP compared to ESBL-EC strains isolated from the PHC (Fig. 1). On the other hand, ESBL-EC strains isolated from the PHC showed higher resistance compared to hospitals against FMOX and CMZ, but these resistance rates were still comparatively low (Fig. 1).
When the emergence of ESBL-E strains began in hospitals in the 1980s, the strains were mostly Klebsiella spp. and Enterobacter spp. which contained blaTEM or blaSHV genes (35, 36). In contrast, community-acquired ESBL-E strains emerging after the 1900s were mostly E. coli harboring the blaCTX−M ESBL gene (37). In the present study isolated ESBL-E strains were mostly ESBL-EC (62 out of 74 ESBL-E strains), and 32 of the 62 ESBL-EC strains harbored the blaCTX−M ESBL gene (Table 3). In the 32 ESBL-EC strains harboring the blaCTX−M gene, blaCTX−M−15 was the most frequently identified ESBL genotype, followed by blaCTX−M−55, blaCTX−M−14, blaCTX−M−1 and blaCTX−M−27 respectively (Table 3). In addition, the blaCTX−M−15 genotype in ESBL-EC was more frequently identified in pregnant women in PHC (55%) than in hospitals (19%). Consistent with these findings, the literature review by Bevan et. al. (38) reported that CTX-M15 has been the most common ESBL genotype in Southeast Asia as well as most other parts of the world in the past two decades. The review also mentioned the decline of CTX-M2 and the emergence of CTX-M27, which is a single-nucleotide variant of CTX-M14 (38). In the present study, we detected the blaCTX−M27 gene in 2 strains of ESBL-EC and one strain of ESBL-KP, but we detected no blaCTX−M2 in any ESBL-E strains.
In our previous study (9), we isolated 82 ESBL-E strains, including 75 ESBL-EC and 7 ESBL-KP strains, from 79 (56.0%) out of 141 stool samples from medical students in Surabaya, Indonesia. In that study, blaCTX−M−15 was the most common (44%) genotype in ESBL-EC and the ESBL-EC phylogenetic groups were A (37.3%), B1 (28.0%), B2 (1.3%) and D (33.3%) (9). In the present study, we observed a similar diverse distribution of phylogenetic groups in ESBL-EC: A (19 strains, 30.6%), B1 (16 strains, 25.8%), B2 (11 strains, 17.7%) and D (16 strains, 25.8%) (Table 4), with more frequent B2 group findings (17.7% versus 1.3%). In the XbaI-PFGE banding patterns of ESBL-EC isolates harbouring blaCTX−M−15 gene, both PHC and hospital ESBL-EC isolates showed a variety of PFGE patterns and a clonal spread of ESBL-EC was merely observed (Fig. 2). In general, clonal spread of ESBL-E in the community is rare, according to previous studies including our medical student study (9, 39).