Background: Nonalcoholic fatty liver disease (NAFLD) is one of the common causes of chronic liver disease globally. Obesity, metabolic diseases, and exposure to some environmental agents contribute to NAFLD. NAFLD is commonly considered a precursor for some types of cancers. Since the leading causes of death in people with NAFLD are cardiovascular disease and extrahepatic cancers, it is important to understand the mechanisms of the progression of NAFLD to control its progression and identify its association with extrahepatic cancers. Thus, this review aims to estimate the global prevalence of NAFLD in association with the risk of extrahepatic cancers. Objective: We aimed to determine the prevalence of various cancers in NAFLD patients and the association between NAFLD and cancer. Methods: We searched PubMed, ProQuest, Scopus, and Web of Science from database inception to March 2022 to identify eligible studies reporting the prevalence of NAFLD and the risk of incident cancers among adult individuals (aged ≥18 years). Data from selected studies were extracted, and meta-analysis was performed using random effects models to obtain the pooled prevalence with the 95% CI. The quality of the evidence was assessed with the Newcastle-Ottawa Scale. Results: We identified 11 studies that met our inclusion criteria, involving 222,523 adults and 3 types of cancer: hepatocellular carcinoma (HCC), breast cancer, and other types of extrahepatic cancer. The overall pooled prevalence of NAFLD and cancer was 26% (95% CI 16%-35%), while 25% of people had NAFLD and HCC (95% CI 7%-42%). NAFLD and breast cancer had the highest prevalence out of the 3 forms of cancer at 30% (95% CI 14%-45%), while the pooled prevalence for NAFLD and other cancers was 21% (95% CI 12%-31%). Conclusions: The review suggests that people with NAFLD may be at an increased risk of cancer that might not affect not only the liver but also other organs, such as the breast and bile duct. The findings serve as important evidence for policymakers to evaluate and recommend measures to reduce the prevalence of NAFLD through lifestyle and environmental preventive approaches. Trial Registration: PROSPERO CRD42022321946; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=321946

Background: Antimicrobial resistance (AMR) has emerged as a major global public health challenge due to the overuse and misuse of antibiotics for humans and animals. Hospitals are among the major users of antibiotics, thereby having a large contribution to AMR. Objective: The aim of this study is to determine the prevalence of antibiotic-resistant pathogenic bacteria and the level of antibiotic residues in the hospital effluents in Selangor, Malaysia. Methods: A cross-sectional study will be performed in the state of Selangor, Malaysia. Tertiary hospitals will be identified based on the inclusion and exclusion criteria. The methods are divided into three phases: sample collection, microbiological analysis, and chemical analysis. Microbiological analyses will include the isolation of bacteria from hospital effluents by culturing on selective media. Antibiotic sensitivity testing will be performed on the isolated bacteria against ceftriaxone, ciprofloxacin, meropenem, vancomycin, colistin, and piperacillin/tazobactam. The identification of bacteria will be confirmed using 16S RNA polymerase chain reaction (PCR) and multiplex PCR will be performed to detect resistance genes (ermB, mecA, blaNDM-L, blaCTX-M, blaOXA-48, blaSHV, VanA, VanB, VanC1, mcr-1, mcr-2, mcr-3, Intl1, Intl2, and qnrA). Finally, the level of antibiotic residues will be measured using ultrahigh-performance liquid chromatography. Results: The expected outcomes will be the prevalence of antibiotic-resistant Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter (ESKAPE) bacterial species from the hospital effluents, the occurrence of antibiotic resistance genes (ARGs) from the isolated ESKAPE bacteria, and the level of antibiotic residues that may be detected from the effluent. Sampling has been conducted in three hospitals. Data analysis from one hospital showed that as of July 2022, 80% (8/10) of E. faecium isolates were resistant to vancomycin and 10% (1/10) were resistant to ciprofloxacin. Further analysis will be conducted to determine if the isolates harbor any ARGs and effluent samples are being analyzed to detect antibiotic residues. Sampling activities will be resumed after being suspended due to the COVID-19 pandemic and are scheduled to end by December 2022. Conclusions: This study will provide the first baseline information to elucidate the current status of AMR of highly pathogenic bacteria present in hospital effluents in Malaysia. International Registered Report Identifier (IRRID): DERR1-10.2196/39022

Background: Antimicrobial resistance is a known global public health threat. In addition, it brings serious economic consequences to agriculture. Antibiotic resistance in humans, animals, and environment is interconnected, as proposed in the tricycle surveillance by the World Health Organization. In Malaysia, research and surveillance of antimicrobial resistance are mainly performed in clinical samples, agricultural settings, and surface waters, but no surveillance of the drinking water systems has been performed yet. Hence, this policy-driven study is a combined effort of microbiologists and engineers to provide baseline data on the magnitude of antimicrobial resistance in the drinking water systems of Malaysia.Objective: The aim of this study was to study the baseline level of antibiotic-resistant bacteria in the drinking water distribution systems of Malaysia by collecting samples from the pretreatment and posttreatment outlets of water treatment plants in a selected state of Malaysia. We aimed to determine the prevalence of antibiotic-resistant bacteria, the occurrence of antibiotic-resistant genes, and the level of antibiotics present in the drinking water systems.Methods: This is a laboratory-based, cross-sectional study in a selected state of Malaysia. Water samples from 6 drinking water treatment plants were collected. Samples were collected at 3 sampling points, that is, the intake sampling station, service reservoir outlet station, and the distribution system sampling station. These were tested against 7 types of antibiotics in triplicates. Samples were screened for antibiotic-resistant bacteria and antibiotic-resistant genes and quantified for the level of antibiotics present in the drinking water treatment plants.Results: We will show the descriptive statistics of the number of bacterial colonies harvested from water samples grown on Reasoner’s 2A agar with or without antibiotics, the occurrence of antibiotic-resistant genes, and the level of antibiotics detected in the water samples. The sampling frame was scheduled to start from November 2021 and continue until December 2022. Data analysis is expected to be completed by early 2023, and the results are expected to be published in mid-2023.Conclusions: This study provides baseline information on the status of the antimicrobial-resistant bacteria, the presence of resistance genes as contaminants, and the level of antibiotics present in the drinking water systems of Malaysia, with the aim of demonstrating to policymakers the need to consider antimicrobial resistance as a parameter in drinking water surveillance.International Registered Report Identifier (IRRID): DERR1-10.2196/37663

Background/Objectives: Hospital wastewater has become a major hotspot for the spread of antimicrobial resistance and the accumulation of antibiotic-resistant genes. We focused on ESKAPE pathogens isolated from hospital wastewater and their antibiotic profiles, which are known to cause nosocomial infections in hospitals. Screening for antibiotic resistant genes in isolates and quantifying antibiotic residues in hospital wastewaters, which may reflect the amount of usage of antibiotics in Klang Valley city hospitals in Malaysia. Methods: Hospital wastewater treatment plants from Klang Valley city were selected based on the study criteria. ESKAPE pathogens were isolated and identified using 16S rRNA PCR, and antibiotic sensitivity testing was performed. Antibiotic resistant gene screenings were performed using quantitative PCR, and quantification of antibiotic residues in the effluent samples was performed using liquid chromatography-mass spectrometry (LC-MS). Results: Klebsiella pneumoniae with Multiple Antibiotics Resistance Index (MARi) ranging from low (0.29) to very high resistance (0.71) dominantly isolated among ESKAPE pathogens followed by Enterococcus faecium ranging from low (0.29) to critical resistance (1.0) from hospital wastewater in Klang Valley city. The ermB gene was the predominant antibiotic resistance gene identified in Klang Valley city hospitals and suburban hospitals, representing 45.5% of isolated E. faecium from suburban hospitals and 69% from city hospitals. Although the detection of antibiotic residues was minimal, vancomycin and ciprofloxacin were detected from the wastewater. Conclusions: These findings call for improved wastewater management and antibiotic stewardship to mitigate the spread of resistant pathogens from healthcare facilities into the environment.

Antimicrobial resistance (AMR) is a major global health threat, reducing the effectiveness of antibacterial treatments. Understanding its spread across different environments is crucial for improving surveillance and guiding policies. Wastewater is an often overlooked but significant contributor to the AMR crisis. It collects bacteria from human, industrial, and agricultural sources, making it both a potential mitigator through treatment and a pathway for antimicrobial-resistant bacteria (ARB) and antimicrobial-resistant genes (ARGs) if not properly managed. The improper handling of wastewater leads to the environmental dissemination of AMR, exacerbating its spread. In many low- and middle-income countries (LMICs), wastewater treatment facilities are either non-existent or incapable of effectively removing ARB, ARGs, and antibiotic residues. The role of wastewater in the development and dissemination of AMR has been significantly underestimated in both scientific research and policy discussions because AMR research has primarily concentrated on clinical settings and agricultural practices. A major challenge in addressing AMR in wastewater systems is the lack of global monitoring and policy frameworks, which limits coordinated efforts. Additionally, wastewater surveillance remains an underutilized tool for tracking AMR trends, missing a critical opportunity for early intervention. Raising awareness about the role of wastewater in AMR is essential for safeguarding global health. Strengthening wastewater treatment practices, implementing standardized monitoring systems, and integrating wastewater-based AMR surveillance into public health strategies can help mitigate the crisis.

The water environment plays a prominent role in the spread of antimicrobial resistance (AMR). Water discharges from hospitals and animal farms are hotspots harbouring antibiotic-resistant bacteria (ARB) and antibiotic-resistant genes (ARGs). From this discharge, ARB can be further transmitted via water bodies, including river used for drinking, hygiene, and recreational activities, posing risks to the community. Although AMR surveillance primarily focuses on clinical and agricultural settings, monitoring drinking water system has been neglected. Studies worldwide have shown the presence of ARB in drinking water supplies. However, AMR has not yet been recognised as parameter for drinking water quality. Research on AMR in drinking water systems is still lacking in many countries, highlighting the urgent need for public health action and the importance of guiding policymakers towards achieving Sustainable Development Goals (SDGs), particularly SDG 6: “Clean water & Sanitation” and SDG 3: “Good health and wellbeing”. Therefore, it is crucial to address this gap by providing more evidence AMR in the drinking water systems, worldwide. Here, we discussed challenges and implications of AMR, emphasising the occurrence of ARB, ARGs and antibiotics residues in drinking water system, as well as recommendations for policy and management to reduce the risks.