Abstract

Methicillin-Resistant Staphylococcus aureus (MRSA) and Vancomycin-Resistant Enterococcus (VRE) are major contributors to healthcare-associated infection, yet data from primary care clinics remain limited. This study assessed environmental contamination in eight clinics in the Klang Valley, Malaysia, and evaluated associated environmental factors. Samples were collected from environmental surfaces and equipment in Medical Officer and Patient Treatment Rooms, then cultured and tested for antimicrobial susceptibility. Environmental parameters, including temperature, relative humidity, air movement, and room density, were measured. Data were analyzed using Kruskal–Wallis, Mann–Whitney, and multiple linear regression analyses. MRSA was detected on 19.8% of environmental surfaces (patient treatment beds (47.3%) and side tables (31.6%)), and 2.1% of equipment surfaces. No VRE was detected; however, Vancomycin-Sensitive Enterococcus was identified in several samples. Significant variation in MRSA contamination across sampling sites was observed (χ² = 25.664, p-value = 0.007). Regression analysis showed that room density (β = −3.285, p-value = 0.006) and temperature (β = −7.922, p-value = 0.012) were significant predictors of aerobic colony counts (R² = 0.157). The detection of MRSA on high-touch surfaces highlights occupational exposure risks in PHC. Strengthened infection prevention and control measures, targeted cleaning strategies, and improved spatial management are urgently required to mitigate environmental transmission.

References

1. Lucian-Daniel P, Andreea-Eliza Z, Nicoleta-Maricica M, et al. Methicillin-Resistant Staphylococcus aureus (MRSA) and Vancomycin-Resistant Enterococci (VRE) in Nosocomial Infections: A Systematic Review of Resistance, Pathogenesis, and Clinical Management. Microorganisms. 2026; 14 (2): 428. DOI: 10.3390/microorganisms14020428.

2. Shoaib M, Aqib AI, Muzammil I, et al. MRSA compendium of epidemiology, transmission, pathophysiology, treatment, and prevention within one health framework. Front Microbiol. 2023; 13: 1067284. DOI: 10.3389/fmicb.2022.1067284.

3. Tang YF, Lin YS, Su LH, et al. Increasing trend of healthcare-associated infections due to vancomycin-resistant Enterococcus faecium (VRE-fm) paralleling escalating community-acquired VRE-fm infections in a medical center implementing strict contact precautions: An epidemiologic and pathogenic genotype analysis and its implications. J Microbiol Immunol Infect. 2023; 56 (5): 1045-1053. DOI: 10.1016/j.jmii.2023.07.015.

4. McCarthy S, Motala A, Shekelle PG. Prevention in adults of transmission of infection with multidrug-resistant organisms: An updated systematic review from Making Healthcare Safer IV. BMJ Qual Saf. 2025; 34: 244–256. DOI:10.1136/bmjqs-2024-017545.

5. Goh LPW, Marbawi H, Goh SM, et al. The prevalence of hospital-acquired infections in Southeast Asia (1990-2022). J Infect Dev Ctries. 2023; 17 (2): 139-146. DOI: 10.3855/jidc.17135.

6. Pal M, Rebuma T, Regassa T, et al. Methicillin-Resistant Staphylococcus Aureus (Mrsa) Remains a Major Threat to Public Health. Am J Public Health Res. 2024; 12 (3): 48–53. DOI: 10.12691/ajphr-12-3-2.

7. Ministry of Health Malaysia. Guidelines on Healthcare-Associated Infections (HCAI). Putrajaya: Infection Control Unit, Ministry of Health; 2017.

8. Subramaniam K, Khaithir TMN, Ding CH, et al. Epidemiology of bloodstream infections in the paediatric population in a Malaysian general hospital over a 2-year period. Malays J Pathol. 2021; 43 (2): 291-301.

9. Syed Abdul Fatah SUZ, Hashim R, Mohd Hafiz Ngoo SK, et al. A Five-Year Antibiotic Susceptibility Trends and Vancomycin-resistant Genotype Distribution Among Enterococcus Faecium/Faecalis in Malaysia. Int J Infect Dis. 2023; 130 (Suppl 2): S58-S59. DOI: 10.1016/j.ijid.2023.04.147.

10. Radford-Smith DE, Anthony DC. Vancomycin-Resistant E. faecium: Addressing Global and Clinical Challenges. Antibiotics. 2025; 14 (5): 522. DOI: 10.3390/antibiotics-14050522.

11. The National Institute for Occupational Safety and Health. Work-Related Risks and Hazards: Biological Hazards. Atlanta, GA: Centers for Disease Control and Prevention; 2025.

12. Cruz-López F, Martínez-Meléndez A, Garza-González E. How Does Hospital Microbiota Contribute to Healthcare-Associated Infections? Microorganisms. 2023; 11 (1). DOI: 10.3390/microorganisms11010192.

13. Adhikari S, Adhikaree N, Paudel KP, et al. Bacterial Assessment of Stethoscopes Used by Healthcare Workers at a Tertiary Care Government Hospital in Bharatpur, Nepal. Diseases. 2023, 11 (2): 55. DOI: 10.3390/diseases11020055.

14. McKinnell JA, Miller LG, Singh RD, et al. High Prevalence of Multidrug-Resistant Organism Colonization in 28 Nursing Homes: An “Iceberg Effect”. J Am Med Direct Assoc. 2020; 21 (12): 1937-1943.e2. DOI: 10.1016/j.jamda.2020.04.007.

15. Perez LG, Ramanantsoa C, Beaudron A, et al. Efficacy of an Ethanol-Based Hand Sanitizer for the Disinfection of Blood Pressure Cuffs. Int J Environ Res Public Health. 2019; 16 (22): 4342. DOI: 10.3390/ijerph16224342.

16. Mody L, Gibson KE, Cassone M, et al. Epidemiology and transmission dynamics of multidrug-resistant organisms in nursing homes within the United States. Nature Comm. 2025; 16: 2487. DOI: 10.1038/s41467-025-57566-3.

17. Lima LB, Freitas AAS, Nunes FVA, et al. Faucets and keyboards as a major reservoir of Gram-negative bacilli in a regional hospital in Northeast Brazil. Rev Fac Ciênc Méd Sorocaba. 2024; 26: e65617. DOI: 10.23925/1984-4840.2024v26a23.

18. Price JR, Cole K, Bexley A, et al. Transmission of Staphylococcus aureus between health-care workers, the environment, and patients in an intensive care unit: A longitudinal cohort study based on whole-genome sequencing. Lancet Infect Dis. 2017; 17 (2): 207–214. DOI: 10.1016/S1473-3099(16)30413-3.

19. Yu CH, Shen S, Huang KYA, et al. The trend of environmental and clinical methicillin-resistant Staphylococcus aureus in a hospital in Taiwan: Impact of USA300. J Microbiol Immunol Infect. 2022; 55: 241-248. DOI: 10.1016/j.jmii.2021.03.020.

20. Yuen JWM, Chung TWK, Loke AY. Methicillin-Resistant Staphylococcus aureus (MRSA) Contamination in Bedside Surfaces of a Hospital Ward and the Potential Effectiveness of Enhanced Disinfection with an Antimicrobial Polymer Surfactant. Int J Environ Res Public Health. 2025; 12 (3): 3026-3041. DOI: 10.3390/ijerph120303026.

21. Macesic N, Cottingham H, Wisniewski JA, et al. Hospital Enterococcus faecium demonstrates distinct environmental and patient reservoirs: A genomic point prevalence survey. Infect Control Hosp Epidemiol. 2025; 46 (5): 540–543. DOI: 10.101/ice.2025.27.

22. Duin DV, Paterson DL. Multidrug Resistant Bacteria in the Community: An Update. Infect Dis Clin North Am. 2020, 34 (4): 709–722. DOI: 10.1016/j.idc.2020.08.002.

23. Jansson L, Akel Y, Eriksson R, et al. Impact of swab material on microbial surface sampling. J Microbiol Methods. 2020; 176: 106006. DOI: 10.1016/j.mimet.2020.106006.

24. Hussein HAM, Mohamed MA, Raway M, et al. Prevalence and antimicrobial susceptibility profile of methicillin-resistant Staphylococcus aureus among patients in various intensive care units. Egypt J Botany. 2025; 65 (2): 259-267. DOI: 10.21608/ejbo.2024.136101.1974.

25. Devhare DP, Pol SS, Pendse V. Utility of bile esculin azide agar for screening of stool samples for vancomycin resistant enterococci from patients with gut colonization. Int J Res Med Sci. 2021; 9 (12): 3633-3636. DOI: 10.18203/2320-6012.ijrms20214713.

26. Nai GA, Martelli CAT, Medina DAL, et al. Fractal dimension analysis: A new tool for analyzing colony-forming units. MethodsX. 2021; 8: 101228. DOI: 10.1016/j.mex.2021.101228.

27. Odoyo E, Matano D, Georges M, et al. Ten Thousand-Fold Higher than Acceptable Bacterial Loads Detected in Kenyan Hospital Environments: Targeted Approaches to Reduce Contamination Levels. Int J Environ Res Public Health. 2021; 18 (13): 6810. DOI: 10.3390/ijerph18136810.

28. Thunyaharn S, Boonsiri T, Visawapoka U, et al. Prevalence of Methicillin-Resistant Staphylococcus aureus and Other Staphylococcal Nasal arriages Among Healthcare Workers Phramongkutklao Hospital. J Southeast Asian Med Red. 2022; 6: e0122. DOI: 10.55374/jseamed.v6i0.122.

29. Salam MA, Al-Amin MY, Pawar JS, et al. Conventional methods and future trends in antimicrobial susceptibility testing. Saudi J Bio Sci. 2023; 30 (3): 103582. DOI: 10.1016/j.sjbs.2023.103582.

30. Department of Occupational Safety and Health. Industry Code of Practice on Indoor Air Quality 2010. Putrajaya: Ministry of Human Resources, Malaysia; 2010.

31. International Code Council. International Building Code (IBC) 2021. Washington, DC: International Code Council; 2021.

32. Yomi DMN, Esemu SN, Kfusi JA, et al. Prevalence and Antibiotic-Resistance Profile of MRSA and MSSA on High-Touch Hospital Surfaces in the Buea Health District, Cameroon. BioMed Res Int. 2025; 1825277. DOI: 10.1155/bmri/1825277.

33. Al-Fawares O, Bashabsheha RHF, Natshehb LY, et al. Molecular investigation of Staphylococcus aureus isolated from inanimate surfaces in Jordanian hospitals. Brazilian J Bio. 2024; 84: e285397. DOI: 10.1590/1519-6984.285397.

34. Osman AH, Darkwah S, Kotey FCN, et al. Reservoirs of Nosocomial Pathogens in Intensive Care Units: A Systematic Review. Environ Health Insights. 2024, 18: 11786302241243239. DOI: 10.1177/11786302241243239.

35. Ashuro Z, Diriba K, Afework A, et al. Assessment of Microbiological Quality of Indoor Air at Different Hospital Sites of Dilla University: A Cross-Sectional Study. Environ Health Insights. 2022; 16: 11786302221100047. DOI: 10.1177/11786302221100047.

36. Onmek N, Kongcharoen J, Singtong A, et al. Environmental Factors and Ventilation Affect Concentrations of Microorganisms in Hospital Wards of Southern Thailand. J Environ Public Health. 2020; 7292198. DOI: 10.1155/2020/7292198.

37. Qiu Y, Zhou Y, Chang Y, et al. The Effects of Ventilation, Humidity, and Temperature on Bacterial Growth and Bacterial Genera Distribution. Int J Environ Res Public Health. 2022; 19 (22): 15345. DOI: 10.3390/ijerph192215345.

38. Mitchell AE, Patel AP, DiCandilo J, et al. Culture harder: Use more specimen to increase methicillin-resistant Staphylococcus aureus culture yield relative to PCR. Access Microbiol. 2025; 7 (6): 000918. DOI: 10.1099/acmi.0.000918.v4.

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