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

Abstract

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.