Suci - Tresna, I.G.A.A Putri Sri Rejeki, Puspa - Wardhani





1Suci Tresna, IGAA Putri Sri Rejeki1 Puspa Wardhani1




1Clinical Pathology Spesialization Programme, Department of Clinical Pathology Faculty of Medicine Airlangga University-DR Soetomo Hospital Surabaya


2Department of Clinical Pathology, Faculty of Medicine Airlangga University

Dr. Soetomo Hospital, Surabaya







Background : Diarrhea infection is common in developing countries and causes death of around 3 million people every year. Diarrhea is also the second leading cause of death in infants. Riskesdas in 2013 showed 30,775 cases of diarrhea. Causes such as bacterial infections Salmonella, shigella, Vibrio, Entamoeba and Yersinia. Other influences can occur due to viral and fungal infections. Diarrhea is a nosocomial infection that is common in hospitalized patients due to long-term use of antibiotics caused by Clostridium difficile. This study was a follow-up study of diarrhea patients who received antibiotic therapy for more than 2 days with the results of C.difficile negative toxin, then continued with faecal culture examination. This study aims is to look the description causes of diarrhea other than c.difficile in patients that receiving long-term antibiotic therapy

Methods: This research is experimental descriptive. Samples were taken from 30 diarrhea patients with 2 x 24 hours of antibiotic use who were hospitalized in the ICU, Dr. Soetomo Hospital Surabaya from August 2017-May 2018. Samples with negative C.difficile toxin results are then followed by faecal culture examination using conventional methods.

Results: The results of culture examination from  30 samples there were 3 samples with positive culture results ESBL, 25 other samples showed negative culture results.

Conclusion: The results of faecal culture examination showed a description causes of the diarrhea in patients that receiving antibiotic therapy is pathogenic E.coli (ESBL). The possibility of other causes that cannot be detected from the culture such as viral and fungal infections still requires further research.


Key words: Faecal culture, bacterial infections, ESBL



The sample in this research were 30 samples, consisting of 20 female patients and 10 male patients. Demographic data and clinical characteristics of patients can be seen in Table 1 below:

Table 1. Demographic data and clinical characteristics of patients (n = 30)

Total Percentage(%)

Age (year) Mean: 48.94 (21-86)

Gender (male/ female) 10/20 35/65


Chronic Kidney Disease

Diabetes Mellitus

Observation of Febrile

Typhoid fever

Hepatitis B


Urinary tract infections

Colic Abdomen


Therapy of antibiotics





Day of hospitalization Mean : 7.65 (3-21)

The percentage of sex of patients in this study consisted of 10 men and 20 women, all of whom were adult patients admitted to the inpatient ward and ICU Hospital Dr. Soetomo Surabaya. The percentage of the patient's gender in this study can be seen in Figure 1.

Figure 1. Percentage of gender

Based on the sex, in this study the percentage of patients who experienced diarrhea which was accompanied by antibiotic use was greater in female patients, which was 65% compared to men who only had 35%.

The diagnosis of each patient included in this study varied greatly. The data are as follows: 2 or 7% suffered from chronic kidney disease, 5 people or 16% suffered from diabetes mellitus, 5 people or 16% diagnosed with febrile observation, 3 people or 10% suffered from typhoid fever, 3 people or 10% suffereded from hepatitis B, 4 people or 13% suffered from pneumonia, 2 or 6% suffered from urinary tract infections, 2 or 6% suffered from abdominal colic and 4 or 16% suffered from other diseases namely SLE, Ca cecum, pulmonary TB HELLP syndrome and hypertension (Figure 2).

Figure 2. Percentage of patient diagnosis

Based on the diagnosis, most diarrhea patients were found in those with a diagnosis of diabetes mellitus and febrile which was as much as 16% and other diseases were also 16%. This was probably due to the fact that patients with DM and febrile might have an infection process which was then aggravated by irrational antibiotics.

Antibiotic therapy given to patients was also divided into several types : 21 people or 71% treated with ceftriaxon, 5 people or 16% received cefotax therapy, 3 people or 10% received ciprofloxacin therapy and 1 patient or 3% received meropenem therapy. All drugs were given by intravenous injection (Figure 3).

Figure 3. Percentage therapy of antibiotics

Comparison of the characteristics of cases with C.ifficile infection and non-cases of C.difficile infection in 2015 showed antibiotics used in patients with C.difficile positivity included penicillin, cephalosporin, macrolide, and metronidazole. Data on antibiotic use in patients in this study also showed more or less the same results. The mostly used antibiotics in patients in this study were the 3rd generation cephalosporin antibiotics, ceftriaxone.

All samples that were examined for culture gave 27 samples which showed no pathogenic germ growth, and 3 samples with positive pathogenic E. coli (ESBL) culture (Figure 4). Literature states that diarrheal-causing bacteria included Salmonella, Shigella, pathogenic E. coli, Camphylobacter, Vibrio cholera and Yersinia, but in faecal culture the conventional method carried out in this study could only detect Salmonella, Shigella, E. coli pathogens, Staphylococcus aureus and Vibrio cholerae

Figure 4. Faecal culture results

The results of positive pathogenic E. coli (ESBL) cultures from the three samples showed varying resistance as shown in Table 2 below:

Table 2. Resistance of antibiotic sample with positive ESBL

Antibiotics 1 2 3

Ampicillin-Sulbactam S S S

Amoxycillin-Clavulanic acid S S S

Cephazolin R R R

Cefotaxime R R R

Ceftriaxone R R R

Ceftazidime R R R

Cefixime R R R

Trimetoprim-sulfamethoxazole R R R

Amikacin S R S

Gentamycin S R S

Tetracyclin R R R

Chloramphenicol R R R

Ciprofloxacine R S R

Levofloxacin R S R

Meropenem S S S

Piperacillin tazobactam S S S


The sample collection period was 10 months starting from August 2017 - May 2018. The results are 30 samples and all of the samples had been examined for toxins and GDH enzymes in the previous studies using ICT and giving negative results. The sample with a negative result was then followed by examination of faecal culture.

Patient demographic data in this study showed that of 30 adult patients taken from the inpatient ward and ICU Dr. Soetomo Surabaya, consisting of 20 female patients and 10 male patients. Based on the diagnosis, the most was diagnosed with diabetes mellitus, febrile observation and other diseases as much as 16%. The type of antibiotics obtained also varied, but the most common type was Ceftriaxone which was 71%, followed by Cefotaxime which both were generation III cephalosporins. The use of antibiotics that were large and not as indicated was a factor that triggered resistance, which in turn could cause a decrease in the immune system.

Some published research evidences show that the most common cause of acute diarrhea in various parts of the world, including Indonesia, is rotavirus. The prevalence of bacterial, parasitic and viral pathogens in 3875 patients with diarrhea in the community and hospitals studied from March 1997 to August 1999 in Jakarta were distinguished using routine bacteriology and molecular testing techniques. Pathogenic bacteria isolated include Vibrio cholera O1, Shigella flexneri, Salmonella spp and Campylobacter jejuni. Pathogenic bacterias was isolated by 14% with diarrhea. Enterotoxigenic E. coli was detected in 18% of rectal swabs. The smallest percentage of E. coli enterohemorrhagic was only 1%, Clostridium difficile 1.3%, and parasite infection 11%, rotavirus 37.5%

The results of faecal culture from the 30 samples examined showed the results of 3 samples resulting from positive E. coli pathogens (ESBL / Extended Spectrum Beta-Lactamase) and 27 other samples that did not develop pathogenic germs. These results indicated that in 30 patients with diarrhea who received antibiotics at least 2 x 24 hours the cause of the diarrhea was non-bacterial infections such as viral infections. Patients with long-term antibiotic use could cause antibiotic resistance so that sensitive bacteria became resistant.

A study conducted by Sangeetha et al. (2014) in India, 69% of shigella bacteria in children with dysentery were resistant to ciprofloxacin and ceftriaxone. Rajeshwari et al., (2013) also conducted the same study in New Delhi with the result of Shigella bacteria resistant to nalidixic acid (95.7%), norfloxacin (87%), and amoxicillin (56.5%). Tjaniadi et al., (2003) also conducted a study of the bacteria that caused diarrhea in Indonesia. The result was Shigella sp. and V.cholerae O1 was resistant to ampicillin, cotrimoxazole, chloramphenicol and tetracycline; Campylobacter jejuni and V.cholerae non-O1 were resistant to ciprofloxacin, norfloxacin, ceftriaxone. (6)

The culture results from the three samples with the ESBL results showed that almost all antibiotics were resistant, except beta lactamase inhibitors, aminoglycosides, carbapenem and piperacillin tazobactam which still showed sensitive results in samples 1 and 3. The second sample showed more resistance results than sample 1 and 2, which still showed sensitive results only in beta lactamase inhibitors (ampicillin-sulbactam, amoxicillin-clavulanic acid), ciprofloxacine and levofloxacin and meropenem and piperacillin tazobactam.

Negative culture results provided an overview of other possible causes of diarrhea experienced, including those caused by viral, fungal and parasitic infections. Certainty of the cause of diarrhea that occured still requires further examination.


The results of the research that had been carried out on 30 samples obtained, as a whole aimed to see the picture of culture results in diarrhea patients who received antibiotic therapy for more than 2 days other than those caused by C. difficile infection. The causes of diarrhea that were very varied indicated by the results of culture which only give positive results in 3 samples from 30 samples examined. The three samples that showed the results of E. coli pathogenic bacteria (ESBL) were associated with the presence of drug resistance, but were not the cause of the diarrhea. The cause of diarrhea that occurred was probably caused by non-bacterial infections such as viral infections and most diarrhea that occured in patients in this study was caused by non-bacterial infections such as viruses, fungi or parasites. Determining the exact cause of diarrhea that occured still requires further examination. The final conclusion was that diarrhea patients accompanied by antibiotics that were not due to C.difficile infection were due to non-bacterial infections such as viral infections and possibly other bacteria that could not be detected by this conventional method culture.

Limitations in the collection of samples that were still small and the culture method used can be a reference for other researchers to continue the study using a larger number of samples and was more sophisticated examination methods to get better results.


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