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SYSTEMATIC / NARRATIVE REVIEW ARTICLE

Trends in antimicrobial resistance in Malaysia

Nashreeyn Mohamed Naeemmudeen, MSc1, Nur Ainaa Nabihah Mohd Ghazali, MSc1, Hasnah Bahari, PhD2,
Rosni Ibrahim, MPath1, Ahmad Dzulfikar Samsudin, MClinDent3, Azmiza Syawani Jasni, PhD1

1
Department of Medical Microbiology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM Serdang,
Selangor, Malaysia, 2Department of Human Anatomy, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM
Serdang, Selangor, Malaysia, 3Department of Oral and Maxillofacial Surgery, Pathology and Medicine, Faculty of Dentistry,
Universiti Sains Islam Malaysia, Ampang, Selangor, Malaysia

ABSTRACT
Introduction: Antibiotic resistance is a burgeoning problem
which were obtained from various studies, as well as the

worldwide. The trend of bacterial resistance has increased

Malaysian National Surveillance on Antimicrobial

over the past decade in which more common bacteria are

Resistance (NSAR) annual reports.

becoming resistant to almost all the antibiotics currently in

use, posing a threat to humans and even livestock.
Antibiotic Resistance Trends
The emergence of antibiotic-resistant microorganisms is a

Methods: The databases used to search for the relevant

serious public health problem.2 Developed countries have

articles for this review include PubMed, Science Direct, and

shifted their drugs towards more expensive one due to the

Scopus. The following keywords were used in the search:

lack of potency of the drugs towards common pathogens.

Antimicrobial resistance, Malaysian action plan, antibiotic-

Meanwhile, the developing and least developed countries opt

resistant bacteria, and Malaysian National Surveillance on

for alternative drugs due to financial constraints which has

Antimicrobial Resistance (NSAR). The relevant articles

led to the increased morbidity and mortality.3

published in English were considered. The World Health Organization (WHO) has come up with a

Results: The antibiotic-resistant bacteria highlighted in this

surveillance system called the Global Antimicrobial

review showed an increase in resistance patterns to the

Surveillance System or GLASS. An early release of the data

majority of the antibiotics tested. The Malaysian government

has shown that there was high antibiotic resistance incidence

has come up with an action plan to create public awareness

in both high-income and low-income countries with the

and to educate them regarding the health implications of

occurrence of up to 500,000 cases across 22 countries.4

antibiotic resistance. A report by World Bank in 2016 on antimicrobial resistance

Conclusion: Antimicrobial resistance in Malaysia continues

had predicted that financial burden will mostly be felt by low-

to escalate and is attributed to the overuse and misuse of

income and middle-income countries.5 The antimicrobial

antibiotics in various fields. As this crisis impacts the health

resistance rate has increased by two folds in the last 20 years

of both humans and animals, therefore a joined continuous

and has killed approximately 700,000 people per year

effort from all sectors is warranted to reduce the spread and

globally. The number is estimated to escalate to 10 million

minimize its development.

deaths annually by 2050 whereas the financial burden could
cost up to US$100 trillion (RM416.65 trillion).6 This situation

KEYWORDS:
highlights the urgency of an action plan to combat the issue
comprehensively.
Antimicrobial resistance, Malaysian action plan, antibiotic-
resistant bacteria Prevalence of Antibiotic-Resistant Bacteria in Malaysia
Escherichia coli

INTRODUCTION
The urinary tract infections caused by Escherichia coli (E. coli)
is the most common bacterial infection in patients
Antimicrobial resistance arises as microorganisms survive worldwide7 and its occurrence is estimated to be up to 88.0%.8
and reproduce when exposed to antimicrobial drugs. Back in Malaysia is one of the countries with higher E. coli resistance
1907, Paul Ehrlich, the father of modern chemotherapy towards aminopenicillin.9 Data from various public hospitals
observed that the organism in trypanosome infections in Malaysia revealed that the majority of the tested E. coli
sometimes appears to be resistant to the agent used. Due to isolates showed the highest resistance rate to penicillins
specific resistance, he observed that fuchsin dye-resistant ranging from 68-100% (Table I). This resistance pattern
strain was still susceptible to an arsenic compound, while a remains for years and in fact, some of the isolates were also
strain resistant to the arsenic compound retained sensitivity resistant to two or more antibiotics (multidrug-resistant).10
to the dye. Later in 1908, he proposed that the resistance can Data also showed that from the year 2004 to 2018, the
be steadily inherited once it is acquired.1 resistance of E. coli to carbapenems remains low within the
range of 0-5%, with a steady increment reported over the
This review provides a general overview of the antimicrobial years.11-16
resistance trends of selected clinical isolates in Malaysia

This article was accepted: 11 June 2021

Corresponding Author: Azmiza Syawani Jasni
Email: azmiza@upm.edu.my

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Trends in antimicrobial resistance in Malaysia

Additionally, an imipenem-resistant E. coli was reported mecA gene.27 One of the earliest reports from Hospital Kuala
between 2006 and 2009 and were among the first resistant Lumpur (HKL) recorded all 539 MRSA isolates were resistant
isolates reported in the country.12 Resistance rates of more to penicillin.28 The resistance rates remained constant until
than 85% for ciprofloxacin and cefuroxime were also 2018 with 100% isolates were resistant (Table IV). Likewise,
reported between 2017 and 2018.15 The data presented the resistance rates to gentamicin persisted over the years
showed that E. coli is resistant to antibiotic groups that have with the highest rates reported between 1990-1991 and 2002-
been widely used for the longest time, although some 2007.28,29 Resistance to erythromycin showed a steady declined
fluctuations were observed which is due to the number of over the years, while the isolates showed an increase in
isolates tested in the individual hospitals. Many studies have resistance patterns to clindamycin, from 0% in 2006-2007 to
suggested that the intrinsic resistance and the expression of an average of 83% in 2011-2013.30-32 Until 2018, none of the
numerous efflux pumps could be the major contributors to S. aureus isolates is resistant to linezolid or vancomycin.28-33
the resistance patterns observed in this organism.
Enterococcus sp.
Acinetobacter baumannii Enterococcus sp. are part of the normal flora and are natural
Acinetobacter baumannii (A. baumannii) is an opportunistic inhabitants of nature. They are also opportunistic pathogens
pathogen that can easily acquire resistance elements such as that can pose serious threats to human life. Treatment for
plasmids and conjugative transposons.17 The broad-spectrum enterococci infections is challenging as they are intrinsically
carbapenems are the antibiotic of choice for complications resistant to multidrug and can develop resistance to other
associated with A. baumannii although the resistance rate has classes of antibiotics. From the year 2007 to 2008,
been increasing in the last two decades. Enterococcus faecium (E. faecium) isolates showed complete
resistance to vancomycin, ampicillin, and teicoplanin.34
A report by University Malaya Medical Centre (UMMC) Although ampicillin-resistant Enterocccus faecalis (E. faecalis)
between 1996 and 1998 showed a 100% carbapenems- was also reported, the rates were much lesser than the ones
resistant Acinetobacter baumannii (CRAB) resistance towards reported in E. faecium.13,35-36
amoxicillin-clavulanate, ampicillin, cefoperazone, and
cefuroxime. Additionally, more than 90% resistance was Despite that 100% vancomycin-resistant E. faecium was
observed for cephalosporins, gentamicin, and ciprofloxacin.18 reported between 2007-2008, the rates fall to 14.1% in 2018.
Over the years, the resistance rates for penicillins showed a Unlike E. faecium, the number of vancomycin-resistant E.
decrement up to 50%.13,16,19-23 faecalis isolates were very less, with the highest rate of 6%
reported over the years.13,35-36 The resistance rates for
The resistance rates for cephalosporins do not show gentamicin and linezolid were reasonably constant over the
substantial change, although in 2018 for the first time in years for both E. faecium and E. faecalis isolates.13,16,34-36
several years, the resistance rate plummeted to 37.9% (Table Conversely, the resistance rates of erythromycin and
II). Conversely, the resistance rates to carbapenems and tetracycline among the enterococci isolates were high with an
aminoglycosides fluctuated with the highest rates reported average of 98% (Table V).36
between 2017 and 2018. The data also showed an increasing
trend of resistance to fluoroquinolones with an average of The Contributing Factors
93% in the last two years.16,23 According to WHO, misuse and overuse of antimicrobial
agents are the main causes of antibiotic resistance.4 As of
Klebsiella pneumoniae 2016, the National Medical Care Survey (NMCS) has
Klebsiella sp. are a reservoir for antibiotic-resistant genes and gathered data of 27,587 patients from 545 healthcare clinics
can transfer the gene to other Gram-negative bacteria. and 5810 (21.1%) patients that received antibiotic
Studies on Klebsiella pneumoniae (K. pneumoniae) infections prescriptions through which 197 (3.4%) of them were
and antibiotic resistance in Malaysia are scanty. Between prescribed with more than one antibiotic.37
2010 and 2012, the majority of the K. pneumoniae isolates
tested were resistant to second and third generations Another observation revealed that the rate of antibiotic
cephalosporins (97-100%).24,25 As shown in Table III, the prescriptions in private clinics (30.8%) is higher than in
ampicillin, amoxicillin-clavulanate acid and aztreonam public or government clinics (6.8%). Almost half of the
resistances were high among K. pneumoniae species with an prescribed antibiotics are for acute upper respiratory tract
average of 94-100%.25 The trends plunged drastically in 2013 infections (URTI) followed by other diagnoses such as fever
and 2017 13 with the lowest resistance rates recorded that is and gastroenteritis.
possibly due to the significant number of isolates tested as
compared to the earlier years. The resistance rate to Consumption of foods contaminated with pathogenic E. coli
gentamicin was recorded between 2010 and 2017, with the may lead to bacterial infections and many studies on E. coli
lowest resistance rate recorded in 2017 (8.5%).13 Data also are concerned with beef samples. A study isolated 55 E. coli
revealed a steady increase in the resistance pattern to strains from ducks in Penang and showed that they are
carbapenems.13 completely resistant to vancomycin and more than 60% are
resistant to tetracycline, ampicillin, and streptomycin.38
Staphylococcus aureus Another study reported that out of 40 beef samples taken
Staphylococcus aureus (S. aureus) possesses the ability to from two local abattoirs in Selangor contains

its resistance towards β-lactams is due to the presence of the

develop a resistance mechanism to various antibiotics 26 and Enterobacteriaceae (82.5%) and E. coli (55%).39 Although a
total of 97 antibiotics have been approved in Malaysia and

Med J Malaysia Vol 76 No 5 September 2021 699

 Table I: The Prevalence of Antibiotic-Resistant Escherichia coli in Malaysia

700
Year Type of Antibiotics Source*

Ampicillin %
Piperacillin %
Amoxicillin %
Cefuroxime %
Ceftazidime %
Cefepime %
Imipenem %
Meropenem %
Amikacin %
Gentamicin %
Ciprofloxacin %
Trimethoprim-
sulfamethoxazole %
2004 77 64 17 6 0 2 21 33 10
(47) (47) (47) (47) (47) (47) (47) (47)
Systematic / Narrative Review Article

2006-2008 48.9 0 11.1 56 71.1 97.8 11

(45) (45) (45) (45) (45) (45)
2006-2009 71.7 5.6 5.6 4.9 3.8 8.4 9.7 12
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(1642) (1642) (1642) (1642) (1642) (1642) (1642)

2013 68.9 22.6 0.3 0.3 0.8 23.4 13
(28720) (12974) (28696) (27759) (11924) (29400)
2014 69.8 0 0 0 14
(149) (149) (149) (149)
2016 0.8 0.9 1.5 13
(29312) (28602) (28139)
2017-2018 100 95 86 15
(100) (100) (100)
2018 24.5 0.7 23.0
(31817) (30153) (31150) 16

*The source of isolates is listed in the respective references.

**No. of isolate tested is represented in the bracket.

Med J Malaysia Vol 76 No 5 September 2021

 Table II: The Prevalence of Antibiotic-Resistant Acinetobacter baumannii in Malaysia
Year Type of antibiotics Source*

Amoxicillin-
Clavulanate %
Ampicillin %
Piperacillin %
Cefoperazone %
Cefuroxime %
Ceftazidime %
Ceftriaxone %
Cefotaxime %
Imipenem %
Ciprofloxacin%
Amikacin %
Gentamicin %
Netilmicin %
Colistin %
1996-1998 100 100 100 100 97.7 97.7 97.7 36.4 90.9 95.5 18
(88) (88) (88) (88) (88) (88) (88) (88) (88) (88)
2008-2009 92 60 59 55 48 0 20

Med J Malaysia Vol 76 No 5 September 2021

(100) (100) (100) (100) (100) (100)
2009 63 90 68 95 79 87 22 21 21
(111) (111) (111) (111) (111) (111) (111) (111)
2010-2011 78.4 79 79.6 22
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(162) (162) (162)

2017 57.1 46.8 58 61.7 49.8 53.2 13
(7627) (5655) (8183) (7795) (8155) (7860)
2017-2018 99.06 100 95.6 63.73 81.11 23
(102) (102) (102) (102) (102)
2018 56.0 37.9 41.3 90.9 31.5 31.5 16
(7272) (7377) (7261) (88) (7348) (7202)

*The source of isolates is listed in the respective references.

**No. of isolate tested is represented in the bracket.

Table III: The Prevalence of Antibiotic-Resistant Klebsiella pneumoniae in Malaysia

Year Type of antibiotics Source*

Ampicillin %
Amoxicillin +
clavulanic acid %
Aztreonam %
Cefepime %
Ceftriaxone %
Cefuroxime %
Cefoperazone %
Cefotaxime %
Ceftazidime %
Imipenem %
Gentamicin %

2010-2012 86.7 61.5 24

(321) (321)
2010-2012 100 94.6 98.9 100 100 100 100 97.8 1.1 74 25
(93) (93) (93) (93) (93) (93) (93) (93) (93) (93)
2013 18.3 15.5 25.9 27 24.2 1.5 13
(25916) (19158) (26127) (21453) (24691) (24477)
2017 20.1 16.4 25.1 22.2 1.7 8.5 13
(30470) (29798) (31104) (30840) (31143) (30801)

*The source of isolates is listed in the respective references.

**No. of isolate tested is represented in the bracket.

701
Trends in antimicrobial resistance in Malaysia
 Table IV: The Prevalence of Antibiotic-Resistant Staphylococcus aureus in Malaysia

702
Year Type of antibiotics Source*

Penicillin %
Oxacillin %
Ampicillin %
Cefoxitin %
Amikacin %
Gentamicin %
Erythromycin %
Ciprofloxacin %
Co-Trimoxazole %
Clindamycin %
Linezolid %
Vancomycin %
1990-1991 100 92 98 94 0 28
(539) (539) (539) (539) (539)
2002-2007 100 92 98 94 0 29
Systematic / Narrative Review Article

(1979) (1979) (1979) (1979) (1979)

2006-2007 100 100 100 100 78.1 78.1 0 0 0 30
(32) (32) (32) (32) (32) (32) (32) (32) (32)
2011-2012 100 100 88 93.7 88 0 0 31
14-Trends00102_3-PRIMARY.qxd 9/3/21 4:08 PM Page 702

(175) (175) (175) (175) (175) (175) (175)

2013 100 87.9 59.1 87.9 83.3 78.8 0 32
(66) (66) (66) (66) (66) (66) (66)
2018 100 100 88.8 33.3 0 33
(36) (36) (36) (36) (36)

*The source of isolates is listed in the respective references.

**No. of isolate tested is represented in the bracket.

Med J Malaysia Vol 76 No 5 September 2021

 Table V: The Prevalence of Antibiotic-Resistant Enterococci in Malaysia
Year Type of antibiotics Source*

Ampicillin %
Vancomycin %
Teicoplanin %
Gentamicin %
Linezolid %
Tazobactam-
piperacillin %
Erythromycin %
Tetracycline %
Enterococcus faecium
2007-2008 100 100 100 50 0 34
(3) (3) (3) (3) (3)

Med J Malaysia Vol 76 No 5 September 2021

2009-2010 92.9 0 0 82.1 96.4 35
(28) (28) (28) (28) (28)
2013 84 84 0 100 100 36
(25) (25) (25) (25) (25)
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2013 83.3 8.4 43 1.1 13

(653) (667) (393) (540)
2017 87.5 15.6 42.7 1.5 13
(1050) (1033) (655) (876)
2018 89.8 14.1 43.5 1.0 16
(996) (1037) (614) (878)
Enterococcus faecalis
2009-2010 3.2 0 0 38.7 3.2 35
(31) (31) (31) (31) (31)
2009-2010 24 6 48 0 96 98 36
(50) (50) (50) (50) (50) (50)
2013 5.5 1.4 19.4 4.7 13
(1356) (1359) (806) (1029)
2017 6 1.3 23.7 2.2 13
(2374) (2313) (1513) (1905)

*The source of isolates is listed in the respective references.

**No. of isolate tested is represented in the bracket.

703
Trends in antimicrobial resistance in Malaysia
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Systematic / Narrative Review Article

registered with the Ministry of Health for food and animal ETHICAL APPROVAL
practice, the majority of these antibiotics are not advisable This review article does not contain any studies related to
for veterinary purposes by WHO. It was suggested that the human participants or animals performed by any of the
growth of promoter agents that are not used for human authors.
therapeutic reasons should be used in livestock farming

REFERENCES
instead of antibiotics used in human therapy.

Malaysian Action Plan on Antimicrobial Resistance 1. Ehrlich P. Über den jetzigen stand der chemotherapie. Berichte
The Malaysian government has revised several strategies to Der Deutschen Chemischen Gesellschaft 1909; 42:17-47.
curb the spread of fatal diseases and minimize the threat of 2. World Health Organisation (WHO). Antimicrobial resistance
factsheet; [cited Dec 2019]. Available from:
antimicrobial resistance. The action plan on antimicrobial
http://www.who.int/mediacentre/factsheets/fs194/en/.
resistance (MyAP-AMR) is structured based on four key areas: 3. Van Boeckel T, Gandra S, Ashok A, Caudron Q, Grenfell B, Levin
(1) public awareness and education, (2) surveillance and S, Laxminarayan R. Global antibiotic consumption from 2000 to
research, (3) infection prevention and control, and (4) 2010: an analysis of national pharmaceutical sales data. Lancet
appropriate use of antimicrobials. Infect Dis 2014; 14:742-50.
4. World Health Organization. Antibiotic resistance. Available
Significant measures have been developed to slow down the from: https://www.who.int/news-room/fact-
emergence of antimicrobial resistance and to avert its spread. sheets/detail/antibiotic-resistance.
5. World Health Organization. Situational analysis on
This includes increasing public awareness and understanding
antimicrobial resistance in the south-east Asia region; [cited Dec
regarding antimicrobial resistance, particularly among 2019]. Available from:
healthcare workers, those under nursing care, in food and https://apps.who.int/iris/rest/bitstreams/1171693/retrieve.
livestock production, and aquaculture. It is important to 6. Holt E. ‘Anti-microbial resistance on the rise’. New Straits Times;
comprehend the emergence of antimicrobial resistance [cited Dec 2019]. Available from:
through surveillance, monitoring and research thus, https://www.nst.com.my/opinion/columnists/2018/12/438444/a
providing information on antimicrobial issues and the nti-microbial-resistance-rise.
proposed risk of antimicrobial resistance. The government is 7. Hryniewicz K. Antibiotic susceptibility of bacterial strains isolated
from urinary tract infections in Poland. J Antimicrobial
also focused on infection prevention and control through
Chemother 2001; 47:773-80.
enforcement of appropriate antimicrobial uses to reduce 8. Frederick A. Escherichia coli, its prevalence and antibiotic
antibiotic-resistant bacteria.40 resistant in Malaysia: a mini review. Microbiol 2011; 1:47-53.
9. The Center for Disease, Dynamics Economics & Policy Resistance
Research findings have suggested that more educational Map: Antibiotic resistance. Available from:
campaigns need to be organized to improve public awareness https://resistancemap.cddep.org/AntibioticResistance.php.
and promote the rational use of antibiotics as many 10. Lim K, Yasin R, Yeo C, Puthucheary S, Thong K. Characterization
Malaysians were found to have inadequate knowledge and of multidrug resistant ESBL-producing Escherichia coli isolates
from hospitals in Malaysia. J Biomed Biotechnol 2009; 165637.
attitudes concerning both antibiotic use and antibiotic
11. Ibrahim N, Wajidi MF, Yusof MY, Tay, ST. The integron
resistance. Aside from that, antimicrobial stewardship and prevalence of extended-spectrum beta lactamase producing
infection control programs have been designed to optimize enterobacterial isolates in a Malaysian teaching hospital. Trop
the appropriate use of antimicrobials by ensuring that every Biomed 2011; 28(3): 668-71.
patient receives an antibiotic only when one is needed, with 12. Mustafa M, Balingi J. Urinary tract infections in a Sabah general
the right dose and within the exact duration. This is to hospital. J Pharm Biol Sci 2012; 1(6): 44-8.
optimize clinical outcomes and minimize unintended 13. Ministry of Health Malaysia. National Surveillance of
consequences of antimicrobial use. Antimicrobial Resistance. Available
from:https://www.imr.gov.my/images/uploads/NSAR/NSAR_201
5 / e d i t e d _ 2 5 1 6 1 6 _ N S A R _ A n t i b i o t i c _

CONCLUSION
Resistance_Surveillance_data_2015.pdf.
14. Mohsen SMY, Hamzah HA, Al-Deen MMI, Baharudin R.

Escherichia coli with extended-spectrum β-lactamase associated

Antimicrobial resistance is a serious threat to human health Antimicrobial susceptibility of Klebsiella pneumoniae and
and this review has revealed the trends of antibiotic
resistance in Malaysia over the years. Major drivers of genes in Hospital Tengku Ampuan Afzan, Kuantan, Pahang.
antimicrobial resistance include inappropriate uses of Malays J Med Sci 2016; 23(2):14-20.
antibiotics in healthcare practices as well as in animal 15. Fazlul MKK, Farzana Y, Najnin A, Rashid MA, Nazmul MHM.
production. A continuous effort from the related agencies to Detection of CTX-M-type ESBLs from Escherichia coli Clinical
Isolates from a Tertiary Hospital, Malaysia. Baghdad Sci J 2019;
combat antimicrobial resistance in every aspect is essential to 16(3): 682-8.
prevent bacteria from becoming resistant, henceforth causing 16. Institute for Medical Research, National Antibiotic Resistance
severe impacts on human health and the future economy. Surveillance Report 2018. Institute for Medical Research, 2020.
17. Doi Y, Murray GL, Peleg AY. Acinetobacter baumannii: evolution

FUNDING
of antimicrobial resistance-treatment options. Semin Respir Crit
Care Med 2015; 36(1): 85-98.
None to declare. 18. Misbah S, Abu Bakar S, Hassan H, Hanifah YA, Yusof MY.
Antibiotic susceptibility and REP-PCR fingerprints of
Acinetobacter spp. isolated from a hospital ten years apart. J
CONFLICTS OF INTEREST
Hosp Infect 2004; 58(4): 254-61.
19. Loh LC, Yii CTJ, Lai KK, Seevaunnamtum SP, Pushparasah G,
None to declare. Tong JMG. Acinetobacter baumannii respiratory isolates in
ventilated patients are associated with prolonged hospital stay.
Clin Microbiol Infect 2006; 12(6): 597-8.

704 Med J Malaysia Vol 76 No 5 September 2021

14-Trends00102_3-PRIMARY.qxd 9/3/21 4:08 PM Page 705

Trends in antimicrobial resistance in Malaysia

20. Dhabaan GN, Abu Bakar S, Shorman MA, Hassan H. In vitro 32. Sit P, Teh C, Idris N, Ponnampalavanar S. Methicillin-resistant
activity of tigecycline against Acinetobacter baumannii isolates Staphylococcus aureus (MRSA) bacteremia: correlations between
from a teaching hospital in Malaysia. J Chemother 2012; 24(2): clinical, phenotypic, genotypic characteristics and mortality in a
87-92. tertiary teaching hospital in Malaysia. Infect Genet Evol 2018;
21. Deris ZZ, Harun A, Omar M, Johari, MR. The prevalence and risk 59: 132-41.
factors of nosocomial Acinetobacter blood stream infections in 33. Bariman MH, Mustafa-Mahmoud MIA, Hamzah HA. Phenotypic
tertiary teaching hospital in north-eastern Malaysia. Trop and genotypic characterization, and detection of PVL encoding
Biomed 2009; 26(2): 123-9. gene in methicillin resistant Staphylococcus aureus strains
22. Biglari S, Hanafiah A, Mohd Puzi S, Ramli R, Rahman M, Lopes isolated from patients admitted to a tertiary hospital in Kuantan,
BS. Antimicrobial resistance mechanisms and genetic diversity of Malaysia. IIUM Med J Malaysia 2019; 18: 2.
multidrug-resistant Acinetobacter baumannii isolated from a 34. Weng PL, Hamat RA, Cheah YK, Zainol N, Aziz MN, Shamsudin
teaching hospital in Malaysia. Microb Drug Resist 2017; 23(5): MN. Vancomycin-resistant Enterococcus faecium of multi locus
545-55. sequence type 18 in Malaysia. Med J Malaysia 2012; 67(6): 639-
23. Nor FM, Shahari AS, Palaniasamy NK, Mohd Rustam FR, M-Zain 40.
Z, Lee BPK, Soh T. Multidrug resistant (MDR) Acinetobacter 35. Weng PL, Ramli R, Shamsudin MN, Cheah YK, Hamat RA. High
baumannii: rate of occurrence from a tertiary hospital, Malaysia. genetic diversity of Enterococcus faecium and Enterococcus
Int J Infect Dis 2019; 79: 46-7. faecalis clinical isolates by pulsed-field gel electrophoresis and
24. Hamzan N, Yean C, Rahman R, Hasan H, Rahman Z. Detection multilocus sequence typing from a hospital in Malaysia. Biomed
of blaIMP4 and blaNDM1 harboring Klebsiella pneumoniae Res Int 2013; 2013: 938937.
isolates in a university hospital in Malaysia. Emerg Health 36. Moussa AA, Md Nordin AF, Hamat RA, Jasni AS. High level
Threats J 2015; 8(1): 26011. aminoglycoside resistance and distribution of the resistance
25. Al-Marzooq F, Mohd Yusof MY, Tay ST. Molecular analysis of genes in Enterococcus faecalis and Enterococcus faecium from
antibiotic resistance determinants and plasmids in Malaysian teaching hospital in Malaysia. Infect Drug Resist 2019; 12: 3269-
isolates of multidrug resistant Klebsiella pneumoniae. PLoS One 74.
2015; 10(7): e0133654. 37. Ab Rahman N, Teng CL, Sivasampu S. Antibiotic prescribing in
26. Kaur D, Chate S. Study of antibiotic resistance pattern in public and private practice: a cross-sectional study in primary
methicillin resistant Staphylococcus aureus with special reference care clinics in Malaysia. BMC Infect Dis 2016; 16: 1.
to newer antibiotic. J Glob Infect Dis 2015; 7: 78. 38. Adzitey F, Rahmat Ali GR, Huda N, Cogan T, Corry J. Prevalence,
27. Wielders CLC, Fluit AC, Brisse S, Verhoef J, Schmitz FJ. MecA gene antibiotic resistance and genetic diversity of Listeria
is widely disseminated in Staphylococcus aureus population. J monocytogenes isolated from ducks, their rearing and processing
Clin Microbiol 2002; 40: 3970-5. environments in Penang, Malaysia. Food Control 2013; 32(1):
28. Cheong I, Tan SC, Wong YH, Zainudin BM, Rahman MZ. 607-14.
Methicillin-resistant Staphylococcus aureus (MRSA) in a 39. Chong ES, Bidin ZF, Abu Bakar NF, Zulfakar SS. Bacterial
Malaysian hospital. Med J Malaysia 1994; 49: 24-8. contamination on beef carcass at selected abattoirs located in
29. Al-Talib H, Chan YY, Al-Jashamy K, Hasan H. Methicillin- Selangor, Malaysia. Malays Appl Biol 2017; 46(1): 37-43.
resistant Staphylococcus aureus nosocomial infection trends in 40. Ministry of Health Malaysia. Malaysian Action Plan on
Hospital Universiti Sains Malaysia during 2002–2007. Ann Saudi Antimicrobial Resistance (MyAP-AMR) 2017–2021. Ministry of
Med 2010; 30: 358–63. Health Malaysia: 2017.
30. Neela V, Sasikumar M, Ghaznavi G, Sekawi Z, Mariana S. In
vitro activities of 28 antimicrobial agents against methicillin-
resistant Staphylococcus aureus (MRSA) from a clinical setting in
Malaysia. SE Asian J Trop Med 2008; 39(5): 85-92.
31. Ho W, Choo Q, Chew C. Predominance of three closely related
methicillin-resistant Staphylococcus aureus clones carrying a
unique ccrC-positive SCCmec type III and the emergence of spa
t304 and t690 SCCmec type IV pvl+ MRSA isolates in Kinta
Valley, Malaysia. Microb Drug Resist 2017; 23(2): 215-23.

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