Background: Antimicrobial Stewardship Program (ASP) is a global issue. World Health Organization (WHO) stated, there are 3 categories of antimicrobial: ACCESS, WATCH, and RESERVE. e-RASPRO as a digital ASP may alter antibiotic prescribing pattern by prioritizing ACCESS category as suggested by WHO. Methods: This manuscript was a ward retrospective survey data of 9 months Define Daily Dose (DDD) average before-after implementing the electronic-RASPRO (e-RASPRO) on ACCESS & WATCH antibiotic. Results: Number of inpatients 9 months before-after e-RASPRO implementation were 7,754 and 6,794. Within 9 months after implementing e-RASPRO there was a trend of antibiotic prescription shifting from WATCH category antibiotic to ACCESS category antibiotic. There was a trend of reduced Define Daily Dose (DDD) average of WATCH category antibiotic. 24.82% of 3rd generation Cephalosporin, 33.20% of Quinolones, 14.76% of Carbapenems and 100% of Piperacillin Tazobactam DDD average were reduced. While, in ACCESS Category Antibiotic, there were an elevation of Penicillin and Aminoglycosides DDD average up to 528.66% and 137.66%. Conclusion: T here are trend changing of DDD average from WATCH to ACCESS category antibiotic following the 9 months implementation of e-RASPRO. We need further study to judge the effectiveness of e- RASPRO as a digital ASP tools.

The nexus of artificial intelligence (AI) and memory is typically theorized as a ‘hybrid’ or ‘symbiosis’ between humans and machines. The dangers related to this nexus are subsequently imagined as tilting the power balance between its two components, such that humanity loses control over its perception of the past to the machines. In this article, I propose a new interpretation: AI, I posit, is not merely a non-human agency that changes mnemonic processes, but rather a window through which the past itself gains agency and extends into the present. This interpretation holds two advantages. First, it reveals the full scope of the AI–memory nexus. If AI is an interactive extension of the past, rather than a technology acting upon it, every application of it constitutes an act of memory. Second, rather than locating AI’s power along familiar axes – between humans and machines, or among competing social groups – it reveals a temporal axis of power: between the present and the past. In the article’s final section, I illustrate the utility of this approach by applying it to the legal system’s increasing dependence on machines, which, I claim, represents not just a technical but a mnemonic shift, where the present is increasingly falling under the dominion of the past – embodied by AI.

Recently, several philosophers and physicists have increasingly noticed the hegemony of unitarity in the discourse on black hole information loss and are challenging its legitimacy in the face of the measurement problem. They proclaim that embracing non-unitarity solves two paradoxes for the price of one. Although I share their distaste regarding the philosophical bias, I disagree with their strategy of still privileging certain interpretations of quantum theory. I argue that information-restoring solutions can be interpretation-neutral because the manifestation of non-unitarity in Hawking’s original derivation is unrelated to what’s found in collapse theories or generalized stochastic approaches, thereby decoupling the two puzzles.

Judges’ role in adjudicating constitutional human rights is frequently criticised as undemocratic, fuelled by recent United States Supreme Court judgements on abortion, gun rights and the environment. But human rights of those without political power are insufficiently protected by decision-makers accountable only to majorities. This paper develops a model of human rights adjudication which enhances democracy rather than detracting from it. Human rights disputes should not be determined through bargaining, which reflects the power of different interests, but through ‘value-oriented’ reasoning, where parties adduce reasons aiming to convince others, while remaining open to persuasion. This is the essence of deliberative democracy. However, this is not open-ended deliberation. Although human rights are abstract, requiring further interpretation in particular contexts, they establish a ‘realm of meaning’ setting the boundaries within which deliberation can occur. This is bounded deliberation. Courts should enhance deliberative democracy by requiring decision-makers to demonstrate that they have addressed human rights questions in a value-oriented manner, rather than reflecting political, numerical or economic power. This includes ensuring a variety of perspectives and that marginalised voices are taken seriously. The paper uses examples from different jurisdictions, including India, South Africa and the US, to demonstrate the possibility of this model.

Objective: To describe a collaboration effort between gynae-oncology and infection control unit in a sustainable surgical side infection prevention program Methods: In January 2023, gynae-oncologist noted a surge in surgical side infection (SSI) in gynae-oncology unit in Sabah Women and Children’s Hospital (SWACH), Kota Kinabalu, Sabah, Malaysia. The increasing trend of SSI was further confirmed by active surveillance started in January and February 2023. The SSI rate was found to be up to 46.2% (6 out of 13) in the elective gynae-oncology cases and 5 out of 15ases (31.2%) in February 2023.

Outbreak interventions taken place. A combined continuous medical education of the latest SSI guidelines was carried out in the gynae-oncology unit including clinical nurses, clinicians and infection control team (ICT).

Ward clinical nurses and infection control nurses developed SSI prevention program based on the latest SSI guideline and started ward clinical nurse education. An active SSI surveillance team was formed consisting ward sister and one clinical nurse, chief clinicians and infection control nurse to collect SSI cases. Results: SSI rate had reduced and maintained since March 2023. The SSI rate was maintained at zero except June and August with one superficial SSI respectively. Since September until December 2023 there was no SSI detected in active surveillance. Conclusions: Collaborative effort and understanding between clinical services and infection control unit are important in creating an effective and sustainable infection prevention program. Effective infection prevention program is not necessarily expensive. In fact, a highly motivated team, simple and practical approach can have amazing results.

Introduction: Infection by Extended Spectrum Beta-Lactamase (ESBL)-producing bacteria in Intensive Care Unit (ICU) is associated with treatment failure, prolonged hospital stay, increased costs and patient mortality. The factors of infection by ESBL-producing bacteria are important to figure out so that prevention and control efforts can be made. The aim of the study is to understand the risk factors associated with ESBL- producing bacteria infections in ICU of Jogja Hospital. Method: This case control study included ICU’s patients who have an infection with confirmed E. coli or K. pneumoniae based on microbiological examination from January-December 2023. The patient’s data were obtained from the medical record to find the risks factors. Cases were defined as E. coli or K. pneumoniae ESBL, while controls were defined as non ESBL E. coli or K. pneumoniae. Bivariate analysis was carried out on independent variables (sex, age, length of hospitalization, comorbidity, history of cephalosporin, duration of antibiotic, utilization of urinary catheter and central venous catheter, exposure to mechanical ventilation, and presence of open wounds). Risk factors with P values <0.25 on bivariate analysis were included in multivariate logistic regression analysis. Two- sided P values less than 0,05 were considered statistically significant. Result: There were 30 patients with ESBL-producing E. coli or K. pneumoniae (cases) and 32 patients with non ESBL-producing E. coli or K. pneumoniae (controls). Based on multivariate analysis, the presence of open wounds has statistical significance, OR 6.52 (IK 95% p = 0.011). Conclusion: The presence of open wounds is associated with the occurrence ESBL-producing E. coli or K. pneumoniae infection in ICU of Jogja Hospital.

Objectives: Hand hygiene is the cornerstone of infection prevention and control. Factors associated with hand hygiene compliance continues to be a key focus of research today. Choosing the ‘right’ alcohol-based hand rub (ABHR) is pivotal in mitigating ICD (irritant contact dermatitis) caused or aggravated by repetitive use of ABHRs. 31% of our healthcare workers (HCW)s reported worsening of their underlying eczema from repetitive use of the incumbent ABHR, whilst 74% experienced either dryness or ICD. In this study, we aim to evaluate two ethanol-based hand rubs against the incumbent hand rub (ethanol and n-propanol mix) to determine if skin tolerability and incidence of ICD can be improved. Methods: 500 HCWs from three departments were invited to participate in a survey to evaluate skin tolerability and user’s acceptability of the 1) incumbent ABHR (i-ABHR) (176 responded) and (2) New ABHR 1 (n-ABHR-1) (147 responded), whilst 190 HCWs from one department were invited to trial 3) New ABHR 2 (n-ABHR-2) (87 responded) using the WHO protocol 1 for handrub evaluation over the course of two weeks for each product respectively. Results: For skin tolerability assessment, only n-ABHR-2 achieved the product acceptability criteria of ≥75% of the participants choosing scale 5 or higher, whereas the other two ABHRs did not. Only 47.7% felt that i-ABHR provided acceptable moisture content. Product acceptability wise, only n-ABHR-2 achieved the acceptable criteria for all measurements. For n-ABHR-1, 45% experienced ICD or dryness, whilst 9% reported worsening of underlying eczema. For n-ABHR 2, 23% reported ICD whilst 1% experienced worsening of underlying eczema. Conclusion: In conclusion, n-ABHR-2 was a more suitable alternative compared to i-ABHR and n-ABHR-1 in terms of acceptability and skin tolerability, particularly for those with underlying eczema. Further investigation is warranted to determine if the low ICD rate could be maintained longer-term to ensure hand hygiene compliance.

Background: Enhancing environmental hygiene resulted in a reduction of multidrug-resistant microorganisms colonization and healthcare-associated infections. There has been less studies to compare the effects of practice observation with other methods. This study aimed to compare correlations between visual inspection, practice observation and aerobic colony count (ACC) and verify the effectiveness. Methods: A prospective study was conducted in a medical intensive care unit from May 2021 to November 2022. High-touch surfaces were assessed by visual inspection (clean or not clean) and practice observation (compliant or not compliant) to compare the correlations by using ACC with the cut-off point of 2.5 CFU/cm2 as a golden standard. Results: Among 569 samples, the pass rate by ACC was 90.5%, the clean rate by visual inspection was 73.3%, and the compliant rate by practice observation was 47.1%. The concordance was 245 surfaces (43.1%) of the three methods. There was no correlation between visual inspection and ACC (p<0.001, φ=0.184). The correlations were weak positive between visual inspection and practice observation and between practice observation and ACC (p<0.001, φ=0.212, 0.233). The median aerobic colony count of “compliant” group (0.00 CFU/cm2) was significantly lower than “not compliant” (0.40 CFU/cm2) (p<0.001). The median aerobic colony count of “clean” groups (0.08 CFU/cm2) was also significantly lower than “not clean” groups (0.20 CFU/cm2) (p<0.001). Conclusion: Practice observation is more reliable than visual inspection. Therefore, visual inspection can be used for low risk area to maintain visibly clean. In high risk area, an integrated program is critical to combine practice observation with other methods to monitor cleanliness.

Drought-tolerant (DT) corn (Zea mays L.) hybrids are developed to provide crop protection from plant water stress in areas prone to drought like the Intermountain West. These regions also face challenges from weeds because of the wide range of developmental and physiological mechanisms possessed by weeds that give an ecological advantage under increased temperature and water stress. Many weeds have developed resistance to some herbicides; therefore, understanding weed interactions with DT corn is important in developing sustainable strategies for management in water-stressed environments. A two-season field experiment was conducted to evaluate the critical period of weed control (CPWC) in DT versus drought-susceptible (DS) corn hybrids exposed to optimal and reduced irrigation in Utah. Treatment combinations of the two corn hybrids, two irrigation levels, and time of weed removal were arranged in a split-split plot design with each treatment replicated four times. Exponential decay and asymptotic regression models were used to determine the CPWC based on an estimated 5% relative yield loss in corn. Up to 5% and 42% yield differences were observed between weed-free and weedy plots throughout the 2021 and 2022 field seasons, respectively. The beginning and end of CPWC differed between the two corn hybrids as well as between the two irrigation levels in both seasons. CPWC was 19.5 and 28 d for DT corn under optimal irrigation in 2021 and 2022, respectively. CPWC was increased for DS corn with optimal irrigation to 52 and 35 d in 2021 and 2022, respectively. A similar result was observed with reduced irrigation for each hybrid (5 and 48.5 d for DT corn and 35 and 50 d for DS corn in 2021 and 2022, respectively). The results suggest that use of DT corn may help reduce the need for more intensive weed management because it reduces the CPWC.

Objectives: A multi-center study aimed to determine the outcome of using oral care sets for cleaning the oral cavity of the patients admitted to the Intensive Care Units (ICU). Methods: Oral care sets which are single-use sets consisting of two toothbrushes with toothpaste, six 0.12% chlorhexidine swabs, and an oral moisturizer swab were developed. The ICUs of fourteen tertiary care hospitals participated in the study. All ICU nurses were asked to brush the patient’s teeth twice and clean the patient’s oral cavity with antiseptic six times daily. One thousand four hundred and two patients were recruited. The oral care sets were used with each patient on the first day they received mechanical ventilation until weaning. VAP surveillance was conducted to compare the VAP rate before and after the ICU used the oral care set. Results: Two hundred and sixty-six VAPs developed with an overall 34,731 ventilator days in the participating ICUs in 2022, before ICUs used oral care sets. The VAP rate was 7.66 per 1,000 ventilator days. The cost of antibiotic treatment was 5,134,621.74 Thai Bath. In 2023, after the ICUs used the oral care sets, 182 VAPs were developed. The overall ventilator day was 34,309. The VAP rate was reduced to 5.30 per 1,000 ventilator days. The cost of antibiotic treatment was reduced to 2,101,939.70 Thai Bath. One hundred and eighty-seven ICU nurses evaluated the benefit of the oral care set. Ninety-six-point eight percent of them agreed and strongly agreed that the single-use oral care set could prevent hospital- associated infections. Ninety-two-point five percent agreed and strongly agreed that only one nurse could clean the patient’s oral cavity, the oral care set helped reduce VAP occurrence (92%), the patient’s teeth and oral cavity were clean (92%), and ICU nurses could work conveniently (91.4%). Conclusion: The single-use oral care set can help reduce the VAP occurrence among patients admitted to the ICU.

Background: Negative-pressure isolation room was considered the standard for Tuberculosis (TB) isolation ward, but it tends to be high in cost and maintenance. Alternatively natural ventilation with the combination of mechanical ventilation (exhaust fan) room were more commonly used in resource-limited settings. However, its efficacy to prevent TB to the medical staffs are unknown. Objective: To compare the prevalence of latent TB among medical staffs that works in negative-pressure isolation ward against natural ventilation isolation ward at Kandou General Hospital Manado. Methods: An cross-sectional study involving 20 medical personnel that have worked for more than 6 months in negative -pressure isolation ward and natural ventilation isolation ward at Kandou General Hospital Manado, North Celebes, Indonesia. Exclusion criteria were history of TB disease or TB latent, immunodeficiency and long term steroid uses. Fischer exact test and regression analysis was used to evaluate the differences between variables. Results : There were 7 medical personnel (35%) from the negative-pressure isolation ward compared to 11 medical personnel (55%) in natural ventilation isolation ward that were positive for Interferon Gamma Release Assay (IGRA). There were no significance differences between the type of isolation room and the prevalence of latent tuberculosis (p= 0.341). There were also no significant correlations between room type (p = 0.633), work duration (p = 0.181), and the prevalence of latent TB (R2 = 0.06). Conclusion : There is no significant difference between latent TB prevalence among medical presonnel in negative- pressure isolation room and natural ventilation isolation room. Natural ventilation room could be used as an alternative to negative-pressure isolation room.

Background: Prevention of Healthcare-Associated Infections (HCAIs) is an essential component of patient’s safety in every healthcare setting and serve as an indicator for a good healthcare practice. Surveillance for HCAIs is important to measure their burden, identify high-risk patients and procedures, and guide efforts to reduce HCAI incidence. The aim of current study is to determine the prevalence of HCAI Hospital Universiti Sains Malaysia (Hospital USM), Kelantan, Malaysia. Methods: A one-day point prevalence survey (PPS) was conducted between 1st October 2023 to 15th October 2023 on all patients admitted to 15 selected wards at Hospital USM. The PPS was performed strictly following the “Manual for point prevalence survey for healthcare associated infection” by Ministry of Health Malaysia. Data were collected by a team of trained infection control practitioners, compiled, and analysed accordingly. Results: The surveyed hospital is a tertiary care teaching hospital contained 829 beds, has 11 certified infection control nurses, has 50 isolation rooms and 4 negative pressure rooms. During the surveyed period, there were 121 patients on continuous bladder catheterization, 63 patients had central venous catheter in situ and 107 patients were on mechanical ventilation.

Of the 588 patients surveyed, 14 (2.4%) had an active HCAI. Identified predisposing factors associated with the occurrence of HCAI were underlying medical illness (40.7%), prolonged hospitalization (25.9%), prematurity (11.1%), history of surgery (11.7%), immunosuppressive therapy (7.4%) and others (3.7%). The most frequent types of HCAI were pneumonia, followed by blood stream infection, clinical sepsis, surgical site infection and urinary tract infection. Conclusions: The survey reports an overall prevalence of 2.4% of HCAI in Hospital USM. A yearly PPS is very useful tool to measure the overall prevalence of HCAI, highlighting the areas with prevalence that require special attention and allowing planning for improvement actions.

Background: Irrational use of antibiotics will trigger anti-microbial resistance which is a threat to health problems now and in the future. The use of meropenem is often the last choice in using antibiotics without undergoing microbiological examination (culture). The rational use of meropenem is expected to reduce resistant microbes as well as reducing hospital costs. Anti-microbial stewardship at Prof Ngoerah General Hospital began to be implemented at the end of 2020, and evaluation of the implementation of antimicrobial stewardship is required. Objective: The aim of this study was to determine the effect of meropenem stewardship on the prevalence of Carbapenem-resistant Acinetobacter Baumannii, Carbapenem-resistant Pseudomonas Aeruginosa and evaluate meropenem cost of purcashing. Retrospective cohort study from medical records, pharmacy records and microbiology data from microbiology from 2020 to 2023 was taken. Data is presented in the form of tables and graphs. Results: Before antimicrobial stewardship was implemented, in 2020 the prevalence of Carbapenem-resistant Acinetobacter Baumannii reached 69.1% and began to decline in 2021 by 52.35%, in 2022 it became 43.8% and 44.3% in 2023, respectively. The prevalence of Carbapenem-resistant Pseudomonas Aeruginosa also decreased, in 2020 was 31.6% to 27.3% in 2021, in 2022 it fell again to 24.8% and in 2023 only 18.4%. The cost of purchasing meropenem at Prof Ngoerah hospital before implementing antimicobial stewardship in 2020 was IDR 229,905,300,- decreasing to IDR 94,156,920,- in 2021, IDR 98,025,255 in 2022 and in 2023 IDR. 97,147,335,-, respectively. Conclusions: Meropenem stewardship at Prof. Ngoerah Hospital reduces the prevalence of Carbapenem-resistant Acinetobacter Baumannii and Carbapenem-resistant Pseudomonas Aeruginosa. Meropenem stewardship also reduces hospital costs in purchasing antibiotics.

Objective: Antimicrobial resistance will become one of the most lethal conditions, which will raise burdens in many sectors across the One Health spectrum. The irrational use of antibiotics without proper monitoring is one of the causes of antimicrobial resistance. The quality of antimicrobial usage could be evaluated quantitatively using the Defined Daily Dose (DDD) method and qualitatively using the Gyssens method. This study aims to evaluate the antimicrobial usage qualitatively. Method: This is a retrospective study using data from the electronic medical record of Adam Malik Hospital within the period of July 2022–December 2023. All adult patients (>18 years old) in the internal medicine ward with a history of antimicrobial prescriptions were included in this study. The quality evaluation was carried out by the researchers, of whom three of them are members of the hospital’s antimicrobial stewardship program (PPRA) team. Result: There are 293 cases of antimicrobial use included in this study. Most of the population in this study was female (51.9%), in the 18–59 year group (74.1%), and respiratory tract infection was mostly diagnosed in this study (31.2%). Based on the Gyssens analysis, only 33% of cases of antimicrobial usage were appropriate (category 0). It means more than half of the antimicrobial use in internal medicine wards were irrational. Conclusion: The rationality of antimicrobial use is one of the most important ways to reduce the rate of antimicrobial resistance. This study shows only 33% of cases of appropriate antimicrobial usage, which is relatively low. Because irrational antimicrobial use can lead to antimicrobial resistance, prolonged length of stay and mortality, efforts need to be taken to improve the quality of antimicrobial use.

Introduction: Catheter Related Bloodstream Infection (CRBSI) continues to be a major healthcare associated infection in Intensive Care Units. The necessity of Central Venous Catheters (CVC) for critically ill patients creates a significant challenge in reducing the CRBSI rates. This challenge is further amplified by the extended duration of CVC use required for many of our patients due to complex treatment regimens, hemodynamic monitoring needs, and the presence of high comorbidity factors. The purpose of this study was to review the impact of a 12-month comprehensive CRBSI reduction program and a new Central Line Maintenance Bundle (CLMB) on reducing CRBSI rate in a cardiothoracic surgical ICU. Case Presentation: Observational study carried out and yearly CRBSI rate compared before and after implementation of the program. The program consists of one-month hand hygiene campaign conducted every quarterly throughout 2021, application of disinfectant cap (Curos) for all long staying patients, application of Chlorhexidine tegaderm for newly inserted central line, application of no sting barrier film at CVL sites and Adenosine triphosphate test on random surfaces for cleanliness. Besides, the existing CRBSI Bundle was separated into CRBSI Insertion and Maintenance Bundle. The new CRBSI Maintenance Bundle consists of HH, hub care, site care, tubing care and daily review. Infection control link nurses were appointed every shift to ensure adherence to the infection control protocol. The CRBSI rate before and after the program was compared. Discussion: At the beginning of the study, the CRBSI rate was 4.8 per 1000 catheter days. The CRBSI rate reduced to 3.3 per 1000 catheter days, at the end of the study. The overall reduction of CRBSI rate was 31%. Conclusion Implementing a comprehensive CRBSI reduction program and a new Central Line Maintenance Bundle was able to significantly reduce catheter related blood stream infection in ICU.

Acknowledgments: Department of Nursing, National Heart Institute, Dato Dr.Suneta Sulaiman, Intensive Care Unit Director.

Objectives: The COVID-19 pandemic has become a serious threat to global health. Current research shows that COVID-19 causes an increase in the incidence of multidrug-resistant organisms (MDRO) due to excessive use of antibiotics during COVID-19 [1,2]. Extended-spectrum β lactamase-producing Enterobacterales (ESBL-PE), especially Escherichia coli-producing ESBL (Eco-ESBL) and Klebsiella pneumoniae-producing ESBL (Kp-ESBL) are pathogens of current concern due to their potential for rapid spread in communities and healthcare [3]. Based on antibiogram data from Dr. M. Djamil General Hospital Padang in 2022, the incidence of MDRO in the inpatient, outpatient, and intensive care units was mostly caused by Kp-ESBL (12,7%), followed by Eco-ESBL (11,9%) [4]. This study aims to compare the incidence of MDRO caused by Eco-ESBL and Kp-ESBL before, during, and after COVID- 19. Methods: This research constitutes a retrospective descriptive study conducted at Dr. M. Djamil General Hospital Padang during three distinct periods: before, during, and after the COVID-19 pandemic. The population of this study was the results of all cultures from all specimen examinations that produced ESBL. Two thousand and seventeen samples were taken from the population that met the inclusion and exclusion criteria using the total sampling technique. Results: Comparison of the incidence showed that Eco-ESBL has an increased risk of incidents after the pandemic by 1.41 times compared to before the pandemic, while the risk of incidence during the pandemic does not show a significant relationship (p=0.63, p>0.05). In contrast to Kp-ESBL, there is a decrease in the risk of incidence after the pandemic by 0.62 times compared to before the pandemic (p<0.05), while the risk of incidence during the pandemic also does not show a significant relationship (p=0.63, p>0.05). Conclusion: There is a significant risk of incidence of MDRO caused by Eco-ESBL and Kp-ESBL after the pandemic compared to before the pandemic COVID-19.