A visualized hybrid PCR-LAMP assay for the detection of human Plasmodium species

Combining the advantages of PCR and LAMP, we described a new technique, namely PCR-LAMP, for malaria diagnosis. The whole process of DNA amplification can be completed in 35 min. This hybrid amplification technique markedly improved the sensitivity of detection compared to the classic single PCR or LAMP assay alone. PCR-LAMP assay had a detection limit of 1 copy/µL for P. knowlesi and P. ovale, 0.1 copy/µL for P. vivax, P. falciparum and P. malariae, respectively. To facilitate the endpoint detection, xylenol orange was added. Positive samples were indicated in orange while negative reactions were violet. The inclusion of xylenol orange into the LAMP reaction mix significantly reduces the post-amplification workload. Without relying on the use of specific instruments, the color changes of the amplicons could be visualized directly through the naked eye. In conclusion, PCR-LAMP poses the potential to be developed as a new malaria molecular diagnosis tool.

ACORN (A Clinically-Oriented Antimicrobial Resistance Surveillance Network) II: protocol for case based antimicrobial resistance surveillance

Background: Antimicrobial resistance surveillance is essential for empiric antibiotic prescribing, infection prevention and control policies and to drive novel antibiotic discovery. However, most existing surveillance systems are isolate-based without supporting patient-based clinical data, and not widely implemented especially in low- and middle-income countries (LMICs). Methods: A Clinically-Oriented Antimicrobial Resistance Surveillance Network (ACORN) II is a large-scale multicentre protocol which builds on the WHO Global Antimicrobial Resistance and Use Surveillance System to estimate syndromic and pathogen outcomes along with associated health economic costs. ACORN-healthcare associated infection (ACORN-HAI) is an extension study which focuses on healthcare-associated bloodstream infections and ventilator-associated pneumonia. Our main aim is to implement an efficient clinically-oriented antimicrobial resistance surveillance system, which can be incorporated as part of routine workflow in hospitals in LMICs. These surveillance systems include hospitalised patients of any age with clinically compatible acute community-acquired or healthcare-associated bacterial infection syndromes, and who were prescribed parenteral antibiotics. Diagnostic stewardship activities will be implemented to optimise microbiology culture specimen collection practices. Basic patient characteristics, clinician diagnosis, empiric treatment, infection severity and risk factors for HAI are recorded on enrolment and during 28-day follow-up. An R Shiny application can be used offline and online for merging clinical and microbiology data, and generating collated reports to inform local antibiotic stewardship and infection control policies. Discussion: ACORN II is a comprehensive antimicrobial resistance surveillance activity which advocates pragmatic implementation and prioritises improving local diagnostic and antibiotic prescribing practices through patient-centred data collection. These data can be rapidly communicated to local physicians and infection prevention and control teams. Relative ease of data collection promotes sustainability and maximises participation and scalability. With ACORN-HAI as an example, ACORN II has the capacity to accommodate extensions to investigate further specific questions of interest.

Socio-Demographic Factors and Public Knowledge of Antibiotic Resistance

(1) Background: Antibiotic resistance is a serious health issue, and raising public awareness of it is crucial to combating it. This study aimed to assess the socio-demographic factors associated with knowledge of antibiotics and antibiotic resistance in Malaysia. (2) Methods: A cross-sectional study was carried out between April 2022 and March 2023. Malaysian adults aged ≥18 years old and able to understand English or Malay were recruited. During data collection, the WHO questionnaire "Antibiotic Resistance, Multi-Country Public Awareness Survey" was used. Data were collected across 14 states in Malaysia. (3) Results: A total of 517 participants completed the questionnaire. Most participants were females (67.9%), aged 30-49 (46%), and from central Malaysia (69.8%). Most participants (98.5%) reported taking antibiotics. A misconception presented was that sore throats, fevers, colds, and flu can be treated with antibiotics. A total of 58.8% of participants had high knowledge of antibiotic usage (scores 12-15), while 64% had high knowledge of antibiotic resistance (scores 9-14). Findings indicate that increasing age, income, and education were associated with higher knowledge. (4) Conclusions: This study highlights the knowledge deficiency of antibiotic resistance among Malaysians. Educational programs should engage a younger and lower socio-economic population to increase awareness.

Evaluation of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia: Epidemiology, clinical characteristics, and outcomes in the older patients in a tertiary teaching hospital in Malaysia

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is a major concern in the global healthcare system. However, data from Asian regions dealing with the singularity of this infection in older persons is lacking. We aimed to identify the differences in the clinical characteristics and outcomes of MRSA bacteremia between adults aged 18-64 and ≥ 65 years.

METHODS

A retrospective study cohort was conducted at the University Malaya Medical Centre (UMMC) on cases of MRSA bacteremia from 2012 to 2016. Patient demographic and clinical data were collected for risk factors analyses.

RESULTS

New cases of MRSA bacteremia showed a trend of increase from 0.12 to 100 admissions in 2012 to 0.17 per 100 admissions in 2016 but a drop was observed in 2014 (0.07 per 100 admissions). Out of the 275 patients with MRSA bacteremia, 139 (50.5%) patients were aged ≥ 65 years old. Co-morbidities and severity at presentation were significantly higher among older adults, including diabetes mellitus (p = 0.035), hypertension (p = 0.001), and ischemic heart disease (p < 0.001), as well as higher Charlson Comorbidity Index (p < 0.001) and Pitt bacteremia scores (p = 0.016). Central line-associated bloodstream infections were more common among younger patients (37.5% vs. 17.3% in older patients, p < 0.001), while skin and soft tissue infections are more frequent among older adults (20.9% vs. 10.3% in younger patients, p = 0.016). All-cause mortality and in-hospital mortality were significantly higher in older patients (82.7% and 56.1% vs. 63.2% and 28.7% in younger patients, p < 0.001). Multivariate analysis revealed age ≥ 65 years (adjusted odds ratio: 3.36; 95% confidence interval: 1.24-9.13), Pitt score ≥ 3 (2.15; 1.54-3.01), hospital (6.12; 1.81-20.72) and healthcare (3.19; 1.30-7.81) acquisition of MRSA, indwelling urinary catheters (5.43; 1.39-21.23), inappropriate targeted treatment (8.08; 1.15-56.86), lack of infectious disease team consultation (2.90; 1.04-8.11) and hypoalbuminemia (3.31; 1.25-8.79), were significant risk factors for 30-day mortality.

CONCLUSION

Older patients' risk of mortality from MRSA bacteremia was three times higher than younger patients. Our data will contribute to developing and validating a robust scoring system for risk-stratifying patients to achieve better management and improved clinical outcomes.

Factors Associated With Nosocomial COVID-19 Infection Among Health Care Workers in an Urban-Setting Malaysia Hospital

This single-center study aimed to explore the factors associated with coronavirus disease (COVID-19) transmission in a hospital. All laboratory-confirmed COVID-19 cases among health care workers (HCWs) in a tertiary hospital in Malaysia were analyzed cross-sectionally from January 25, 2020, to September 10, 2021. A total of 897 HCWs in the hospital had laboratory-confirmed COVID-19 infection during the study period. Around 37.4% of HCWs were suspected to acquire COVID-19 infection from the hospital workplace. Factors associated with lower odds of workplace COVID-19 transmission were being females, ≥30 years old, fully vaccinated, and working as clinical support staff. Involvement in COVID-19 patient care was significantly associated with higher odds (adjusted odds ratio = 3.53, 95% confidence interval: [2.42, 5.12]) of workplace COVID-19 transmission as compared with non-workplace transmission. Most HCWs in the tertiary hospital acquired COVID-19 infection from non-workplace settings. During a pandemic, it is important to communicate with HCWs about the risk of both workplace and non-workplace COVID-19 transmission and to implement measures to reduce both workplace and non-workplace COVID-19 transmission.

Physician's Perspectives on Factors Influencing Antibiotic Resistance: A Qualitative Study in Vietnam

(1) Background: The antibiotic resistance (ABR) rates are escalating to seriously high levels worldwide. This study was conducted to determine physicians' perspectives on factors influencing ABR in Vietnam. (2) Methods: Focus group discussion (FGD) was conducted through in-depth interviews on ABR perspectives with 5-6 physicians from different geographical locations and hospitals in Vietnam between March and June 2020. The research questions were focused on three main themes of (a) knowledge deficiency on ABR and hospital-acquired infection, (b) antibiotic prescribing practice among clinicians in the healthcare setting, and (c) regulations and hospital policies on antibiotic use. The descriptive analysis was performed using QRS NVivo software. (3) Results: A total of six FGDs were conducted among 34 physicians (18 males, 16 females) aged 26-53 years old from six public and six private hospitals in Vietnam. Most of the participants were attending physicians (85.3%) and had 5-10 years of experience in surgical wards (55.9%). For theme (a), a majority of participants agreed that they had adequate information updates on how ABR develops in their clinical setting; and were well aware of hospital-acquired infections. For theme (b), the participants agreed that WHO guidelines and Vietnam national guidelines were two important reference documents in guiding physicians in antibiotic use. For theme (c), the FGD study revealed awareness of ABR, hospital antibiotic policies, and procedures for administrators on antibiotic use that were updated and complied with. (4) Conclusions: While different levels of control measures against ABR are ongoing in Vietnam, several weaknesses in the current antibiotic prescribing strategies in the hospital and clinical setting management policies have been identified in the healthcare system. The research findings will be helpful for policymakers to have better plans of action against ABR in Vietnam.

OUP accepted manuscript

The National Antimicrobial Prescribing Survey (NAPS) is a web-based qualitative auditing platform that provides a standardized and validated tool to assist hospitals in assessing the appropriateness of antimicrobial prescribing practices. Since its release in 2013, the NAPS has been adopted by all hospital types within Australia, including public and private facilities, and supports them in meeting the national standards for accreditation. Hospitals can generate real-time reports to assist with local antimicrobial stewardship (AMS) activities and interventions. De-identified aggregate data from the NAPS are also submitted to the Antimicrobial Use and Resistance in Australia surveillance system, for national reporting purposes, and to strengthen national AMS strategies. With the successful implementation of the programme within Australia, the NAPS has now been adopted by countries with both well-resourced and resource-limited healthcare systems. We provide here a narrative review describing the experience of users utilizing the NAPS programme in Canada, Malaysia and Bhutan. We highlight the key barriers and facilitators to implementation and demonstrate that the NAPS methodology is feasible, generalizable and translatable to various settings and able to assist in initiatives to optimize the use of antimicrobials.

Factors influencing inappropriate use of antibiotics: Findings from a nationwide survey of the general public in Malaysia

Antibiotic resistance is one of the biggest threats to global public health. Misuse of antibiotics has never been investigated on a nationwide scale among the general public in Malaysia. This study aimed to identify sociodemographic and knowledge factors associated with inappropriate use of antibiotics in the Malaysian context to inform the development of interventions to mitigate inappropriate antibiotic use. We conducted computer-assisted telephone interviews (CATI) between June 2019 and December 2019. The telephone numbers were randomly generated from the electronic residential telephone directory of all 13 states and 3 Federal Territories in Malaysia. The survey consisted of questions on demographics, knowledge about antibiotics and antibiotic resistance (53 items), and practices of antibiotic use (16 questions). A total of 864 complete responses were received. Pronounced erroneous beliefs that antibiotics are effective against infections caused by viruses and that antibiotics can speed up recovery from coughs and colds were evident. The proportions that were aware of the terms ‘drug resistance’, ‘antimicrobial resistance’, and ‘superbugs’ were low. The mean and standard deviation (SD) for the antibiotic knowledge score was 23.7 (SD ±9.25; range 0 to 50) out of a possible score of 52. Regarding antibiotic practices, a considerable proportion reported non-adherence to recommended doses. The mean and SD for the antibiotic practices score was 37.9 (SD ± 6.5; range 17 to 47) out of a possible score of 48. Participants who earned an average monthly household income of MYR1001-3000 (OR 1.61, 95% CI 1.04–2.50) were more likely to report higher antibiotic practice scores than those with <MYR1000. Participants with tertiary education attainment reported higher antibiotic practice scores (OR 1.99; 95%CI 1.02–3.91) than those with primary school and below. High antibiotic knowledge scores (OR 3.94; 95% CI 2.71–5.73) were associated with higher antibiotic practice scores. Inappropriate antibiotic use is influenced by demographics and antibiotic knowledge. This study calls for education interventions focused on the lower socio-economic status population to increase awareness and to promote appropriate antibiotic use.

Utility and applicability of rapid diagnostic testing in antimicrobial stewardship in Asia Pacific: A Delphi consensus

Rapid diagnostic tests (RDTs) facilitate fast and accurate identification of infectious disease microorganisms and are a valuable component of multimodal antimicrobial stewardship (AMS) programs but are currently underutilized in the Asia-Pacific region. An experienced group of infectious diseases clinicians, clinical microbiologists, and a clinical pharmacist used a modified Delphi consensus approach to construct 10 statements, aiming to optimize the utility and applicability of infection-related RDTs for AMS in the Asia-Pacific region. They provide guidance on definition, types, optimal deployment, measuring effectiveness, and overcoming key challenges. The Grading of Recommendations Assessment, Development, and Evaluation system was applied to indicate the strength of the recommendation and the quality of the underlying evidence. Given the diversity of the Asia-Pacific region, the trajectory of RDT development will vary widely; the collection of local data should be prioritized to allow realization and optimization of the full benefits of RDTs in AMS.

Investigation of biofilm formation in methicillin-resistant Staphylococcus aureus associated with bacteraemia in a tertiary hospital

Biofilm formation is an important physiological process in Staphylococcus aureus (S. aureus) that can cause infections in humans. In this study, the ability of 36 methicillin-resistant S. aureus (MRSA) clinical isolates to form biofilm was studied based on genotypic and phenotypic approaches. These isolates were genotyped based on the microbial surface components recognizing adhesive matrix molecules (MSCRAMMs) and biofilm-associated genes (icaAD) via polymerase chain reactions. Phenotyping was performed based on the determination of the strength of biofilm formation of MRSA isolates in vitro. The most prevalent MSCRAMMs and biofilm-associated genes were clfA, eno, and icaD, followed by clfB. The fnbB (38.9%) and ebpS (11.1%) occurred less frequently among the MRSA isolates, while bbp and fnbA genes were absent from all isolates. The MRSA isolates were mostly moderate to strong biofilm formers, despite the heterogeneity of the MSCRAMM profiles. MRSA isolates from different infection sources (primary, catheter-related bloodstream, or secondary infections) were capable of forming strong biofilms. However, persistent bacteraemia was observed only in 19.4% of the MRSA-infected individuals. This study suggested that persistent MRSA bacteraemia in patients might not be associated with the biofilm-forming ability of the isolates.

Genetic mechanisms and correlated risk factors of antimicrobial-resistant ESKAPEE pathogens isolated in a tertiary hospital in Malaysia

BACKGROUND

Knowledge on the epidemiology, genotypic and phenotypic features of antimicrobial-resistant (AMR) ESKAPEE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter spp., and Escherichia coli) and their association with hospital-acquired infections (HAIs) are limited in Malaysia. Therefore, we evaluated the AMR features and resistance mechanisms of the ESKAPEE pathogens collected in a tertiary hospital located in the capital of Malaysia.

METHODS

A total of 378 AMR-ESKAPEE strains were obtained based on convenience sampling over a nine-month study period (2019-2020). All strains were subjected to disk diffusion and broth microdilution assays to determine the antimicrobial susceptibility profiles. Polymerase chain reaction (PCR) and DNA sequence analyses were performed to determine the AMR genes profiles of the non-susceptible strains. Chi-square test and logistic regression analyses were used to correlate the AMR profiles and clinical data to determine the risk factors associated with HAIs.

RESULTS

High rates of multidrug resistance (MDR) were observed in A. baumannii, K. pneumoniae, E. coli, and S. aureus (69-89%). All organisms except E. coli were frequently associated with HAIs (61-94%). Non-susceptibility to the last-resort drugs vancomycin (in Enterococcus spp. and S. aureus), carbapenems (in A. baumannii, P. aeruginosa, and Enterobacteriaceae), and colistin (in Enterobacteriaceae) were observed. Both A. baumannii and K. pneumoniae harbored a wide array of extended-spectrum β-lactamase genes (blaTEM, blaSHV, blaCTX-M, blaOXA). Metallo-β-lactamase genes (blaVEB, blaVIM, blaNDM) were detected in carbapenem-resistant strains, at a higher frequency compared to other local reports. We detected two novel mutations in the quinolone-resistant determining region of the gyrA in fluoroquinolone-resistant E. coli (Leu-102-Ala; Gly-105-Val). Microbial resistance to ampicillin, methicillin, and cephalosporins was identified as important risk factors associated with HAIs in the hospital.

CONCLUSION

Overall, our findings may provide valuable insight into the microbial resistance pattern and the risk factors of ESKAPEE-associated HAIs in a tertiary hospital located in central Peninsular Malaysia. The data obtained in this study may contribute to informing better hospital infection control in this region.

Methicillin-resistant Staphylococcus aureus bacteraemia, 2003-2015: Comparative evaluation of changing trends in molecular epidemiology and clinical outcomes of infections

Methicillin-resistant Staphylococcus aureus (MRSA) is a prominent pathogen causing invasive infections such as bacteraemia. The continued excessive use of antibiotics to treat MRSA infections has resulted in the evolution of antimicrobial resistant of S. aureus. This study aims to perform a comparative evaluation of changing trends in molecular epidemiology of MRSA and clinical characteristics of patients. This study shows that ST22-MRSA-IV has gradually replaced ST239-MRSA-III as the predominant MRSA clone in the tertiary teaching hospital studied. Independent predictors of mortality among patients included devices in situ at the time of infection, pre-exposure to macrolides, catheter-related bloodstream infection and mono-microbial infection. Hence, our study affirmed community-associated MRSA, which was previously identified from individuals without any exposure to healthcare settings, has now emerged in healthcare settings, causing healthcare-associated MRSA infections.

Antibiotics in surgical wards: use or misuse? A newly industrialized country’s perspective

Introduction: Studies exploring the appropriateness of therapeutic antibiotic use among surgical patients are limited, particularly in developing countries. Therefore, the aim of our study was to determine the appropriateness of antibiotics prescribed in a surgical setting in Malaysia. Methodology: A prospective observational study was conducted in two surgical wards at a tertiary hospital in Malaysia from November 2012-July 2013. Data was collected using a case report form. The appropriateness of antibiotic therapy was based on compliance with either the Malaysian National Antibiotic Guidelines 2008 or International Clinical Practice Guidelines and determined by an expert panel (consisting of two infectious disease consultants and a pharmacist). Results: Over the study period, a total of 593 antibiotic courses were prescribed for 129 patients (4.6±3.4 antibiotics/patient). Only 34 (26.4%) patients received appropriate antibiotic therapy, whilst 95 (73.6%) patients received at least one course of inappropriate antibiotic therapy. The prevalence of inappropriate antibiotic use was 214 (66.3%) and 55 (42.0%) for prophylactic and therapeutic purposes, respectively. The most common causes of inappropriate prophylactic antibiotics were inappropriate timing 20 (36.4%) and inappropriate duration of prophylaxis 19 (34.5%). In cases of inappropriate timing, 9 (45%) were administered too late while 6 (30%) were too early. . In contrast, inappropriate choice of antibiotics (42.1%) and inappropriate indication (40.7%) were the most common reasons encountered for inappropriate therapeutic antibiotics. Conclusion: Our study suggests considerable inappropriate use of both prophylactic and therapeutic antibiotics in the surgical wards; highlighting an urgent need for antibiotic stewardship initiatives in this setting.

Cohorting Dengue Patients Improves the Quality of Care and Clinical Outcome

Introduction

The increasing incidence of dengue among adults in Malaysia and other countries has important implications for health services. Before 2004, in order to cope with the surge in adult dengue admissions, each of the six medical wards in a university hospital took turns daily to admit and manage patients with dengue. Despite regular in-house training, the implementation of the WHO 1997 dengue case management guidelines by the multiple medical teams was piecemeal and resulted in high variability of care. A restructuring of adult dengue inpatient service in 2004 resulted in all patients being admitted to one ward under the care of the infectious disease unit. Hospital and Intensive Care Unit admission criteria, discharge criteria and clinical laboratory testing were maintained unchanged throughout the study period.

Objectives

To evaluate the impact of cohorting adult dengue patients on the quality of care and the clinical outcome in a university hospital in Malaysia.

Methods

A pre (2003) and post-intervention (2005–6) retrospective study was undertaken.

Intervention

Cohorting all dengue patients under the care of the Infectious Disease team in a designated ward in 2004.

Results

The number of patients enrolled was 352 in 2003, 785 in 2005 and 1158 in 2006. The evaluation and detection of haemorrhage remained high (>90%) and unchanged throughout the study period. The evaluation of plasma leakage increased from 35.4% pre-intervention to 78.8% post-intervention (p = <0.001) while its detection increased from 11.4% to 41.6% (p = <0.001). Examination for peripheral perfusion was undertaken in only 13.1% of patients pre-intervention, with a significant increase post-intervention, 18.6% and 34.2% respectively, p = <0.001. Pre-intervention, more patients had hypotension (21.5%) than detected peripheral hypoperfusion (11.4%), indicating that clinicians recognised shock only when patients developed hypotension. In contrast, post-intervention, clinicians recognised peripheral hypoperfusion as an early sign of shock. The highest haematocrit was significantly higher post-intervention but the lowest total white cell counts and platelet counts remained unchanged. A significant and progressive reduction in the use of platelet transfusions occurred, from 21.7% pre-intervention to 14.6% in 2005 and 5.2% in 2006 post-intervention, p<0.001. Likewise, the use of plasma transfusion decreased significantly from 6.1% pre-intervention to 4.0% and 1.6% in the post-intervention years of 2005 and 2006 respectively, p<0.001. The duration of intravenous fluid therapy decreased from 3 days pre-intervention to 2.5 days (p<0.001) post-intervention; the length of hospital stay reduced from 4 days pre- to 3 days (p<0.001) post-intervention and the rate of intensive care admission from 5.8% pre to 2.6% and 2.5% post-intervention, p = 0.005.

Conclusion

Cohorting adult dengue patients under a dedicated and trained team of doctors and nurses led to a substantial improvement in quality of care and clinical outcome.

The epidemiology of dengue disease in the tropical regions is characterized by a rapid increase in the number of reported cases, and in some Asian countries, a shift in the age range predominance from children toward adults. This has important implications for health services, resources, and training, provision of treatment and care and ultimately clinical outcome of dengue. There is no literature on the impact of this shift in the epidemiological pattern of dengue on healthcare delivery and the clinical outcome of adult dengue patients. Before 2004, each of the 6 general medical wards in a university hospital took turns daily to admit and manage patients with dengue. Despite regular in-house training, the implementation of the WHO 1997 dengue case management guidelines by the multiple teams was piecemeal with high variability in clinical practice. In 2004 all dengue patients were admitted to one ward under the care of the infectious disease unit. In this pre (2003) and post-intervention (2005–6) retrospective study we demonstrated that cohorting dengue patients under a specific team enhances the experiential knowledge of clinicians in managing dengue patients from the perspective of clinical evaluation and detection of increased vascular permeability and the ensuing hypovolemic shock with improvement in clinical outcomes.

Molecular diversity of HIV-1 and surveillance of transmitted drug resistance variants among treatment Naïve patients, 5 years after active introduction of HAART in Kuala Lumpur, Malaysia

Expansion of antiretroviral treatment programs have led to the growing concern for the development of antiretroviral drug resistance. The aims were to assess the prevalence of drug resistant HIV-1 variants and to identify circulating subtypes among HAART-naïve patients. Plasma specimens from N = 100 HIV+ HAART-naïve adult were collected between March 2008 and August 2010 and viral RNA were extracted for nested PCR and sequenced. PR-RT sequences were protein aligned and checked for transmitted drug resistance mutations. Phylogenetic reconstruction and recombination analysis were performed to determine the genotypes. Based on the WHO consensus guidelines, none of the recruited patients had any transmitted drug resistance mutations. When analyzed against the Stanford guidelines, 35% of patients had at least one reported mutation that may reduce drug susceptibility to PI (24%), NRTI (5%), and NNRTI (14%). The commonly detected mutation that may affect current first line therapy was V179D (3%), which may lead to reduced susceptibility to NNRTI. The predominant circulating HIV-1 genotypes were CRF01_AE (51%) and CRF33_01B (17%). The prevalence of unique recombinant forms (URF) was 7%; five distinct recombinant structures involving CRF01_AE and subtype B' were observed, among them a cluster of three isolates that could form a novel circulating recombinant form (CRF) candidate. Transmitted drug resistance prevalence among HAART-naïve patients was low in this cohort of patients in Kuala Lumpur despite introduction of HAART 5 years ago. Owing to the high genetic diversity, continued molecular surveillance can identify the persistent emergence of HIV-1 URF and novel CRF with significant epidemiological impact.