Determinants of Antibiotic Misuse and Barriers to Antimicrobial Stewardship Implementation in Indonesia: A Scoping Review

Antibiotic misuse and suboptimal implementation of Antimicrobial Stewardship Programs (ASPs) represent major drivers of antimicrobial resistance (AMR) in Indonesia. This scoping review systematically maps the determinants of antibiotic misuse and the barriers to ASP implementation across Indonesian healthcare settings. A structured literature search was conducted across PubMed, Scopus, and Google Scholar, supplemented by grey literature, covering publications from 2008 to 2024. Eligible studies addressed antibiotic prescribing, dispensing, self-medication practices, or stewardship program implementation within the Indonesian context. Evidence was synthesized thematically and organized according to a socio-ecological framework encompassing individual, prescriber, institutional, and systemic levels. Findings indicate that antibiotic misuse is driven by multifactorial determinants, including insufficient public health literacy, high rates of self-medication, unrestricted over-the-counter antibiotic availability, and prescriber-related factors such as diagnostic uncertainty and perceived patient demand. At the institutional level, key barriers to ASP implementation include inadequate microbiological infrastructure, limited interdisciplinary collaboration, a shortage of dedicated stewardship personnel, and weak enforcement of existing policies. Systemic barriers include fragmented governance structures, insufficient regulatory oversight, funding constraints, and persistent gaps between national AMR policy frameworks and local practice. Although national stewardship frameworks and regulatory instruments are in place, their operationalization remains inconsistent across hospital tiers and primary care settings. To advance ASP implementation in Indonesia, strategies must incorporate health workforce development, investment in diagnostic infrastructure, strengthened multisectoral governance, digital health integration, task-shifting models, community-based stewardship approaches, and culturally and socioeconomically appropriate community engagement. This review provides a comprehensive evidence base to support policy formulation and programmatic interventions aimed at reducing the AMR burden across Indonesia, including underserved rural and eastern regions.

Antimicrobial Stewardship, Antibiotic Misuse, Antimicrobial Resistance, Indonesia, Scoping Review, Healthcare Policy

1. Abbas, S. (2024). The challenges of implementing infection prevention and antimicrobial stewardship programs in resource-constrained settings. Antimicrobial Stewardship & Healthcare Epidemiology, 4. https://doi.org/10.1017/ash.2024.35 [Google Scholar] [Crossref]

2. Adrizain, R., Setiabudi, D., & Chairulfatah, A. (2019). The inappropriate use of antibiotics in hospitalized dengue virus-infected children with presumed concurrent bacterial infection in teaching and private hospitals in Bandung, Indonesia. PLOS Neglected Tropical Diseases, 13(6), e0007438. https://doi.org/10.1371/journal.pntd.0007438 [Google Scholar] [Crossref]

3. Baraka, M., Alsultan, H., Alsalman, T., Alaithan, H., Islam, M., & Alasseri, A. (2019). Health care providers' perceptions regarding antimicrobial stewardship programs (AMS) implementation—facilitators and challenges: a cross-sectional study in the Eastern province of Saudi Arabia. Annals of Clinical Microbiology and Antimicrobials, 18. https://doi.org/10.1186/s12941-019-0325-x [Google Scholar] [Crossref]

4. Centers for Disease Control and Prevention. (2019). Core elements of hospital antibiotic stewardship programs. Atlanta: CDC. [Google Scholar] [Crossref]

5. Chukwu, E., Abuh, D., Idigbe, I., Osuolale, K., Chuka-Ebene, V., Awoderu, O., et al. (2024). Implementation of antimicrobial stewardship programs: A study of prescribers' perspective of facilitators and barriers. PLOS ONE, 19. https://doi.org/10.1371/journal.pone.0297472 [Google Scholar] [Crossref]

6. Hadi, U., Duerink, D. O., Lestari, E. S., Nagelkerke, N. J., Keuter, M., In't Veld, D. H., et al. (2008). Problem of antibiotic use and antimicrobial resistance in Indonesia: are we really making progress? Indonesian Journal of Tropical and Infectious Disease, 1(4), 197-204. [Google Scholar] [Crossref]

7. Hadi, U., van den Broek, P., Kolopaking, E. P., Zairina, N., Gardjito, W., & Gyssens, I. C. (2010). Cross-sectional study of availability and pharmaceutical quality of antibiotics obtained from drug outlets in Indonesia. Tropical Medicine & International Health, 15(8), 960-965. [Google Scholar] [Crossref]

8. Harun, M., Sumon, S., Hasan, I., Akther, F., Islam, M., & Anwar, M. (2024). Barriers, facilitators, perceptions and impact of interventions in implementing antimicrobial stewardship programs in hospitals of low-middle and middle countries: a scoping review. Antimicrobial Resistance & Infection Control, 13. https://doi.org/10.1186/s13756-024-01369-6 [Google Scholar] [Crossref]

9. Herawati, F., Ananta, S. C., Parwitha, I. A. A., Ressandy, S. S., Rahmatin, N. L., Rachmadini, N. A., et al. (2020). Interview-based cross-sectional needs assessment to advance the implementation of an effective antibiotic stewardship program in Indonesian hospitals. Health Policy OPEN, 1, 100002. https://doi.org/10.1016/j.hpopen.2019.100002 [Google Scholar] [Crossref]

10. Herawati, F., Jaelani, A. K., Wijono, H., Rahem, A., Setiasih, Yulia, R., et al. (2021). Antibiotic stewardship knowledge and belief differences among healthcare professionals in hospitals: A survey study. Heliyon, 7(6), e07377. https://doi.org/10.1016/j.heliyon.2021.e07377 [Google Scholar] [Crossref]

11. Hijazi, K., Joshi, C., & Gould, I. (2019). Challenges and opportunities for antimicrobial stewardship in resource-rich and resource-limited countries. Expert Review of Anti-infective Therapy, 17, 621-634. https://doi.org/10.1080/14787210.2019.1640602 [Google Scholar] [Crossref]

12. Hulscher, M. E. J. L., & Prins, J. M. (2017). Antibiotic stewardship: does it work in hospital practice in low- and middle-income countries? Clinical Microbiology and Infection, 23(11), 799-805. [Google Scholar] [Crossref]

13. Jeffs, L., McIsaac, W., Zahradnik, M., Senthinathan, A., Dresser, L., McIntyre, M., et al. (2020). Barriers and facilitators to the uptake of an antimicrobial stewardship program in primary care: A qualitative study. PLOS ONE, 15. https://doi.org/10.1371/journal.pone.0223822 [Google Scholar] [Crossref]

14. Kakkar, A., Shafiq, N., Singh, G., Ray, P., Gautam, V., Agarwal, R., et al. (2020). Antimicrobial stewardship programs in resource constrained environments: Understanding and addressing the need of the systems. Frontiers in Public Health, 8. https://doi.org/10.3389/fpubh.2020.00140 [Google Scholar] [Crossref]

15. Kapatsa, T., Bwanali, A., Kambewa, L., Mkandawire, V., Mwale, G., Harawa, G., et al. (2025). Assessing the implementation determinants of antimicrobial stewardship programmes in sub-Saharan Africa through the complexity lens: A CFIR-guided systematic review. Frontiers in Microbiology, 16. https://doi.org/10.3389/fmicb.2025.1660778 [Google Scholar] [Crossref]

16. Khanal, S., Acharya, U., Trotter, A., Tripathi, P., Koirala, S., Pahari, B., et al. (2023). Challenges and opportunities in the implementation of an antimicrobial stewardship program in Nepal. Antimicrobial Stewardship & Healthcare Epidemiology, 3. https://doi.org/10.1017/ash.2022.359 [Google Scholar] [Crossref]

17. Sinto, R., Limato, R., Radiani, S. P., Huda, M. N., Surendra, H., Praptiwi, A. W., Herman, Y., Musaffa, B. A., Lazarus, G., Day, N. P. J., Limmathurotsakul, D., Karuniawati, A., & Hamers, R. L. (2024). A nationwide mixed-methods study of gaps and barriers to implementation of antimicrobial stewardship programmes in hospitals in Indonesia. Journal of Hospital Infection, 154, 77–87. https://doi.org/10.1016/j.jhin.2024.10.001 [Google Scholar] [Crossref]

18. Limato, R., Lazarus, G., Dernison, P., Mudia, M., Alamanda, M., Nelwan, E. J., et al. (2022). Optimizing antibiotic use in Indonesia: a systematic review and meta-analysis. BMC Infectious Diseases, 22, 481. [Google Scholar] [Crossref]

19. Limato, R., Mudia, M., Nelwan, E. J., et al. (2020). Antibiotic prescribing practice in Indonesian hospitals and implications for antimicrobial stewardship. Tropical Medicine & International Health, 25(9), 1115-1125. [Google Scholar] [Crossref]

20. Limato, R., Nelwan, E. J., Mudia, M., de Jong, M. D., & van Doorn, H. R. (2022). A qualitative study of barriers to antimicrobial stewardship in Indonesian hospitals: governance, competing interests, cost, and structural vulnerability. Antimicrobial Resistance & Infection Control, 11, 89. [Google Scholar] [Crossref]

21. Limato, R., Nelwan, E. J., Mudia, M., et al. (2021). A multicentre point prevalence survey of patterns and quality of antibiotic use in Indonesian hospitals. JAC-Antimicrobial Resistance, 3(3). [Google Scholar] [Crossref]

22. Lutfiyati, H., Yasin, N. M., Thobari, J. A., & Ikawati, Z. (2022). The implementation of antimicrobial stewardship in Indonesia: a regional survey in hospitals. Journal of Advanced Pharmacy Education & Research, 12(4), 19-26. [Google Scholar] [Crossref]

23. Ministry of Health Republic of Indonesia. (2021). Antimicrobial Resistance Situation in Indonesia: A Challenge of Policy and Implementation. Jakarta: Ministry of Health. [Google Scholar] [Crossref]

24. Muliawan, B. T., Limato, R., Nelwan, E. J., et al. (2021). Perceptions, views and practices regarding antibiotic prescribing and stewardship among hospital physicians in Jakarta, Indonesia: a questionnaire-based survey. BMJ Open, 11, e054768. [Google Scholar] [Crossref]

25. Murni, I. K., Duke, T., Kinney, S., Daley, A. J., & Soenarto, Y. (2015). Reducing hospital-acquired infections and improving the rational use of antibiotics in a developing country: an effectiveness study. Archives of Disease in Childhood, 100(5), 454-459. [Google Scholar] [Crossref]

26. Puspitasari, H. P., Faturrohmah, A., & Hermansyah, A. (2011). Community pharmacies, drug stores, and antibiotic dispensing in Indonesia: a qualitative study. BMC Health Services Research, 11, 1-10. [Google Scholar] [Crossref]

27. Rajendran, R., Chitrapady, S., Tejashree, M., Haritha, K., Balakrishnan, J., Nair, S., et al. (2025). Antimicrobial stewardship programs in primary and secondary care settings in India: current challenges, facilitators, perceptions, and impact—a scoping review. BMC Infectious Diseases, 25. https://doi.org/10.1186/s12879-025-11851-0 [Google Scholar] [Crossref]

28. Raka, L., & Kurti, A. (2024). Addressing barriers in antimicrobial stewardship: a guide from research to implementation. Journal of Global Antimicrobial Resistance. https://doi.org/10.1016/j.jgar.2024.10.082 [Google Scholar] [Crossref]

29. Ramdas, N., Meyer, J., Schellack, N., Godman, B., Turawa, E., & Campbell, S. (2025). Knowledge, attitudes, motivations, expectations, and systemic factors regarding antimicrobial use amongst community members seeking care at the primary healthcare level: A scoping review. Antibiotics, 14. https://doi.org/10.3390/antibiotics14010078 [Google Scholar] [Crossref]

30. Restika, R. A., Mardhia, M., Mahyarudin, M., Liana, D. F., & Hariyanto, I. H. (2025). Knowledge and behavior regarding antibiotic stewardship in health workers at Sultan Syarif Mohammad Alkadrie Hospital, Indonesia. Pharmacology and Clinical Pharmacy Research, 9(3), 2. [Google Scholar] [Crossref]

31. Setiawan, E., Limato, R., Nelwan, E. J., et al. (2022). Indonesian healthcare providers' perceptions and attitude toward antimicrobial resistance and stewardship. Future Microbiology. https://doi.org/10.2217/fmb-2021-0193 [Google Scholar] [Crossref]

32. Siahaan, S., Usman, Y., Puspitasari, H. P., et al. (2023). Determinants of non-prescription antibiotic use in Indonesia: a community-based study. BMC Public Health, 23. [Google Scholar] [Crossref]

33. Sinto, R., Limato, R., Radiani, S. P., et al. (2024). A nationwide mixed-methods study of gaps and barriers to implementation of antimicrobial stewardship programmes in hospitals in Indonesia. Journal of Hospital Infection, 154, 77-87. [Google Scholar] [Crossref]

34. Truppa, C., Alonso, B., Clezy, K., Deglise, C., Dromer, C., Garelli, S., et al. (2023). Antimicrobial stewardship in primary health care programs in humanitarian settings: the time to act is now. Antimicrobial Resistance & Infection Control, 12. https://doi.org/10.1186/s13756-023-01301-4 [Google Scholar] [Crossref]

35. Wang, X., Lin, L., Xu, X., Harbarth, S., Yakob, L., Zhang, R., et al. (2025). Implementing the Chinese mandatory antimicrobial stewardship program: barriers to continuous improvement. Health Policy and Planning, 40, 591-599. https://doi.org/10.1093/heapol/czaf019 [Google Scholar] [Crossref]

36. Wardhani, D. K., Wibowo, Y. I., & Setiawan, E. (2020). Persepsi dokter tentang strategi antimicrobial stewardship program di sebuah rumah sakit umum di Surabaya. Jurnal Sains Farmasi & Klinis, 7(1), 5–14. [Google Scholar] [Crossref]

37. Widayati, A., Suryawati, S., de Crespigny, C., & Hiller, J. E. (2011). Self-medication with antibiotics in Yogyakarta City Indonesia: a cross sectional population-based survey. BMC Research Notes, 4, 491. [Google Scholar] [Crossref]

38. Widayati, A., Suryawati, S., de Crespigny, C., & Hiller, J. E. (2011). A cross-sectional study of availability and pharmaceutical quality of antibiotics obtained from private drug retail outlets in Indonesia. BMJ Open, 1, e000203. [Google Scholar] [Crossref]

39. Widayati, A., Suryawati, S., de Crespigny, C., & Hiller, J. E. (2012). Knowledge and beliefs about antibiotics among people in Yogyakarta City Indonesia: a cross sectional population-based survey. Antimicrobial Resistance & Infection Control, 1, 38. [Google Scholar] [Crossref]

40. World Health Organization. (2023). Antimicrobial resistance in the South-East Asia Region: situation analysis and recommendations. Geneva: WHO. [Google Scholar] [Crossref]

41. Yau, J., Thor, S., Tsai, D., Speare, T., & Rissel, C. (2021). Antimicrobial stewardship in rural and remote primary health care: a narrative review. Antimicrobial Resistance & Infection Control, 10. https://doi.org/10.1186/s13756-021-00964-1 [Google Scholar] [Crossref]

42. Yuniar, Y., Handayani, R. S., & Aryani, K. (2020). Quality of antibiotic prescribing for respiratory tract disease in primary healthcare centers in Tegal District, Central Java, Indonesia. Journal of Infection and Public Health, 13(4), 560-566. [Google Scholar] [Crossref]

43. Zakhour, J., Haddad, S., Kerbage, A., Heiman, W., Tattevin, P., Voss, A., et al. (2023). Diagnostic stewardship in infectious diseases: a continuum of antimicrobial stewardship in the fight against antimicrobial resistance. International Journal of Antimicrobial Agents. https://doi.org/10.1016/j.ijantimicag.2023.106816 [Google Scholar] [Crossref]

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