Comparative study of cefixime and tetracycline as an evaluation policy driven by the antibiotic resistance crisis in Indonesia

Antibiotic resistance is a serious threat that occurs globally in the health sector due to increased consumption of inappropriate antibiotics. Guidelines for prescribing antibiotics for ARTIs have been issued in general practice to promote rational antibiotic prescribing. This study was conducted to compare the effectiveness of cefixime and tetracycline as a solution to improve monitoring of appropriate antibiotic use in the treatment of ARTIs. All stock isolates were rejuvenated first, and cultured on standard media and Kirby–Bauer disc diffusion method was used for susceptibility testing in accordance with the Clinical and Laboratory Standard Institute’s (CLSI) recommendations. Identification of bacteria from a single isolate was carried out to determine which bacteria were resistant to cefixime and tetracycline. A total of 466 single isolates of bacteria were analyzed, which showed a percentage of resistance to cefixime 38.0%, and tetracycline 92.86%. Bacterial isolates were resistant to cefixime and tetracycilne was a genus of Haemophilus, Streptococcus, Corynebacterium, Staphylococcus, and bordetella. Cefixime compared to tetracycline was proven to be superior in terms of the effectiveness of ARIs treatment.

www.nature.com/scientificreports/ recommendations are also given to patients with chronic airway obstruction receiving antibiotics, and also if they show symptoms of acute infection 10 .
The study reported by Ramdhani et al., regarding the management of ARTIs patients in a public health center of Tasikmalaya, Indonesia, described a fairly serious case of antibiotic resistance. The use of several antibiotics showed decreased effectiveness with a high resistance value, including amoxicillin (70.25%), levofloxacin (50.0%), ciprofloxacin (43.03%) [11][12][13] .
This study was conducted to evaluate the comparative effectiveness of cefixime and tetracycline through antimicrobial susceptibility testing (AST) in the empirical treatment of ARTIs. In addition, this study was also to determine the genus of total clinical isolates of patients who had resistance to cefixime and tetracycline antibiotics. Tests were carried out using stock isolates from patients obtained from previous studies.

Materials and methods
The test sample was a combined stock isolate from previous ARTIs research totaling 466 single bacterial isolates. This sample has been purified from bacterial contaminants, and rejuvenated.
The bacterial growth medium used was Mueller Hinton Agar (MHA) (Oxoid) with a concentration of 38 g/L, according to the guidelines from the CLSI 14 .
Biochemical test materials for bacterial identification include Lactose (Merck), Mannose (Merck), Maltose (Merck), peptone (Oxoid), phenol red (Taylor), Kovac`s reagent (Bio-Rad), TSIA , methyl red (HiMEdia), α-naphthosl (Merck).  Antimicrobial susceptibility testing (AST). The Kirby-Bauer disc diffusion test was used to determine the sensitivity of antibiotics to bacterial isolates 17 . This test can evaluate the effectiveness of antibiotics that are already resistant or are still sensitive by measuring the diameter of the inhibition zone. This testing technique is based on the diffusion principle through antibiotic paper disks. This test was carried out with 3 repetitions. Determination of the resistance value of the tested bacteria to cefixime and tetracycline were carried out by comparing the diameter of the inhibition zone with the standard diameter of the resistance zone formed 14 . The value of the resistance level category can be seen in Table 1.

Identification and morphologic and biochemical characterization. The gram stain technique,
with microscopic visualization at × 100 magnification was used to ascertain cellular morphology, and bacterial classification. After identifying the phenotype and cell colonies, a conventional biochemical test was carried out to determine the classification of the isolated bacteria according to the existing biochemical testing protocol 18

Results and discussion
Biochemical conventional identification. Bacterial isolates were obtained from patients who had been confirmed by a doctor indicating that they had suffered from respiratory tract infections. Statistically showed that the number of bacterial isolates consisted of the genus Staphylococcus (35%), Streptococcus (29%), Bordetella (15%), Hamophyllus (12%), and Corynobacterium (9%).
Biochemical identification were carried out on 466 stocks of bacterial isolates, identified as Gram-negative, Gram-positive, bacilli (rod-shaped), coccoid (rod-shaped), coccobacilli. Results analyzed bacteria, the biochemical conventional tests revealed 5 genus of bacteria: Bordetella, Corynebacterium, Staphylococcus, Streptococcus, Haemophilus (  9 . Cefexime is also reported to have started decreasing susceptibility patterns of these bacterial pathogens, Streptococcus pneumoniae, Haemophilus influenzae with low resistance levels. 24 . Schico GC reported relevant information that cefexime showed decreased sensitivity to Staphylococcus, and streptococcus but was still very active than cefaclor and cefuroxime against Gram-negative respiratory pathogens 25 . However, some authors still highly recommend cefexime as a first-line antibiotic in overcoming cases of resistance to URTI and LRTI, especially against the pathogens Streptococcus pneumonaie, Streptococcus pyogenes, Hemophylus influenza, Moraxella catarrhalis [26][27][28] . Other studies have also demonstrated good clinical efficacy data of cefexime in URTI and acute otitis media (AOM) cases, where community-induced infections exhibit high rates of resistance to macrolides and are highly sensitive to cefexime 29,30 . Antibiotic susceptibility profile. The main focus of our study was to evaluate the current prevalence of bacteria responsible for ARTIs among the population in the urban area of Tasikmalaya, Indonesia. Our study investigated the correlation between pathogenic bacteria causing ARTIs and the antibiotic susceptibility profile commonly used by medical practitioners in public health centers. The test results obtained can be a comparative study regarding the effectiveness of cefixime and tetracycline as drugs of choice in the treatment of ARTIs. The disk antibiotic concentration used in accordance with CLSI guidelines are cefixime 5 µg, and tetracycline 30 µg 14 .
Antibiotic susceptibility test carried out on 466 bacterial isolate stocks showed that cefixime was superior to tetracyclines in the treatment of ARI. Cefixime showed a lower resistance level of 38.0% when compared to 92.86% tetracyclines. The level of tetracycline resistance was obtained from the number of bacteria genus Staphylococcus (158), Streptococcus (121), Bordetella (64), Hamophyllus (52), and Corynobacterium (37). In addition, the value of the cefixime resistance level was derived from the number of each bacterial genus Staphylococcus (69), Streptococcus (45), Bordetella (27), Hamophyllus (21), and Corynobacterium (15).
Additionally, the chi-square test was 308.0892, with the p-value was < 0.00001 and the result was significant at p < 0.05. These statistical data provide information for comparisons of resistant and non-resistant conditions from cefixime and tetracycline antibiotics described a significant difference in the level of resistance in the use of the two antibiotics for the treatment of ARTIs. These results are also consistent with other studies that cefexime is more effective in the treatment of respiratory infections compared to other drugs (eg ofloxacin, amoxicillin, and ciprofloxacin) 24,31 . The susceptibility of categories of isolates of both antibiotics are shown in Fig. 2.
These results will provide important information to the Health Office of the City of Tasikmalaya to determine the antibiotic procurement policy for public health centers, and evaluate the pattern of prescribing antibiotics for ARTIs treatment by practicing doctors. Synergic cooperation and coordination between all health professions in the prevention of ARI is also very necessary.
Coordination with local policy holders of the Tasikmalaya City Health Office regarding the evaluation of the use of antibiotics in the treatment of ARTIs has been carried out. Preventive policies and education such as the intervention of antimicrobial stewardship programs (ASPs) at reducing unnecessary antibiotic prescribing, including training communication between health professionals, accountable justification of health programs, feedback by comparing socio-behavioral responses through questionnaires. Making handouts that are distributed www.nature.com/scientificreports/ to patients in community health centers as part of a program to educate the public about the use of appropriate antibiotics can support the success of ARTIs therapy. We plan to measure the impact of these interventions in the near future.

Conclusions
Cefexime treatment has shown superior effectiveness compared to tetracyclines in the case of ARTIs. Cefexime can still be used as a front line antibiotic option in the management of ARTIs.
The study also reported the identification of pathogenic bacterial organisms causing ARTIs and antibiotic resistance in accordance with research reports from another bacterial group Bordetella, Corynebacterium, Staphylococcus, Streptococcus, Haemophilus.