JAC-Antimicrobial Resistance

The inappropriate use of antimicrobials enhances antimicrobial resistance (AMR). Antimicrobial stewardship (AMS) is a coordinated effort of prescribers, pharmacists, and nurses. Still, local data regarding AMS-related knowledge, attitudes, and practices (KAP) are scarce in many low and middle-income countries. We evaluated KAP regarding AMS among the healthcare providers at Komfo Anokye Teaching Hospital (KATH), Ghana, and found the related factors. A cross-sectional survey in the form of a descriptive survey was conducted among medical doctors, pharmacists, and nurses at KATH. Knowledge, attitude, and practice were evaluated using a structured questionnaire. The scores were converted into percentages and classified as good (>=60%) or poor (<60%). Chi-square tests were used to test associations, and logistic regression to predict good KAP (p<0.05). A total of 349 healthcare professionals participated, which comprised: 91 medical doctors (26.1%), 101 pharmacists (28.9%), and 157 nurses (45.0%). The majority of the respondents had formal AMS/AMR training (69.6%), and 37.0% had updated training the previous year. Only 18.6% demonstrated good AMS-related knowledge, although attitudes were largely positive (95.7% good) and reported practices were mostly appropriate (77.4% good). In multivariable models, greater years of practice (5-9 years: adjusted odds ratio [AOR] 2.32; >=15 years: AOR 2.77) and formal training (AOR 2.94) were associated with good knowledge. Formal training was also associated with good attitudes (AOR 5.19). Compared with medical doctors, nurses had lower odds of good practice (AOR 0.29), while pharmacists had higher odds (AOR 1.41). Participants with 10-14 years of experience had higher odds of good practice (AOR 3.18). This study revealed that marked knowledge deficits exist, despite favourable attitudes and generally good self-reported AMS practices. Role-tailored, competency-based AMS training with regular updates and reinforcement through practical stewardship tools is needed to translate positive attitudes into evidence-based prescribing and administration behaviours.

Background : Antimicrobial resistance (AMR) is a major public health threat globally, with a disproportionate burden in sub-Saharan Africa. Faith-based health facilities provide essential healthcare services to underserved populations, yet data on antimicrobial use in these settings remain limited. Aim : To assess antimicrobial use in Christian Health Association of Malawi health facilities using the World Health Organisation core medicine use indicators. Materials and Methods : A multicentre cross-sectional study was conducted in 29 CHAM health facilities across Malawi between January 2024 and June 2025. Data were collected from facility personnel, inpatient prescriptions, and patient interviews and analysed using descriptive and inferential statistics. Results : Average availability of key antimicrobials was 33.1% (95% CI: 29.7-36.4), while customised formularies were available in 64.3% of health facilities. Among 660 prescriptions analysed, 90.3% contained an antimicrobial agent, but only 33.2% adhered to standard treatment guidelines and 43.6% were prescribed using full generic names. Facilities with pharmacy professionals were more likely to have a facility-specific formulary (84.6% vs. 46.7%, p = 0.037). Conclusion : Antimicrobial stewardship gaps remain substantial in faith-based health facilities in Malawi and across sub-Saharan Africa, highlighting the need for targeted stewardship programmes in faith-based health facilities.

Background: Rising antibiotic resistance challenges empirical therapies for urinary tract infections (UTIs). This study evaluated the microbial etiology, susceptibility profiles, and multidrug resistance (MDR) patterns of uropathogens among outpatients at the Berekum Holy Family Hospital, Ghana. Methods: This cross-sectional study (February to August 2021) screened 263 symptomatic outpatients. Mid-stream urine samples underwent quantitative culture, biochemical identification, and antimicrobial susceptibility testing via the Kirby-Bauer disc diffusion method following the 2021 CLSI guidelines. Results: Significant bacteriuria prevalence was 22.8% (60/263). UTIs predominated in females (78.3%, 47/60; p = 0.1501) and individuals [&ge;]45 years (33.3%, 20/60). Gram-negative rods accounted for 90.0% of isolates, primarily Escherichia coli (26.7%), Citrobacter spp. (25.0%), and Enterobacter spp. (21.7%); Staphylococcus aureus (10.0%) was the only Gram-positive pathogen. Extreme phenotypic resistance was observed against piperacillin/tazobactam (98.3%), cefotaxime (93.3%), tetracycline (88.3%), and cefoperazone (85.0%). Conversely, highest therapeutic susceptibilities were retained by amikacin (78.3%), levofloxacin (61.7%), and gentamicin (58.3%). Conclusion: The high prevalence of MDR uropathogens against advanced beta-lactamase inhibitor combinations and cephalosporins necessitates an immediate re-evaluation of regional empirical protocols. Amikacin, levofloxacin, and gentamicin remain viable options prior to culture confirmation. These findings establish a crucial phenotypic baseline to guide localized prescribing policies and regional antimicrobial resistance tracking strategies.

Background Antimicrobial stewardship (AMS) and infection prevention and control (IPC) are complementary strategies to improve patient safety and address antimicrobial resistance (AMR). In low- and middle-income countries (LMICs), they are often implemented separately, reducing effectiveness. Evidence on integrating AMS and IPC in routine hospital practice remains limited. Objective To evaluate the feasibility of an integrated AMS-IPC improvement approach and describe changes in implementation in Vietnamese hospitals. Methods We conducted a multisite quality improvement initiative in four hospitals within the national AMR surveillance network in Viet Nam (March-September 2025). We used US-CDC tools to guide the implementation, including the Global Antibiotic Stewardship Evaluation Tool (G-ASET) and the Infection Control Assessment and Response (ICAR) tool. Baseline assessments were followed by feedback, multidisciplinary action planning, and targeted capacity building. Follow-up occurred 2-5 months later. Changes were analysed descriptively using quantitative scores and qualitative synthesis, and reported following the SQUIRE 2.0 guidelines. Results All hospitals had established IPC programmes at baseline, while AMS maturity varied. G-ASET scores improved across all sites, with greater gains in hospitals starting from lower baselines. Key improvements included leadership and governance, education and training, stewardship actions, and monitoring and reporting. IPC practices aligned with AMS priorities also improved, particularly transmission-based precautions, environmental cleaning, and cross-team coordination. Infrastructure-dependent areas, such as water safety, showed limited short-term progress. Conclusions An integrated AMS-IPC approach using repeated assessment and feedback is feasible and associated with meaningful improvements. This model offers a scalable strategy for strengthening hospital responses to AMR in LMICs and informs national programmes.

BackgroundThe rise of antimicrobial resistance (AMR) in the Lake Chad Basin poses a significant threat to global health. While Escherichia coli and Klebsiella pneumoniae are primary concerns for the WHO, Proteus species have emerged as important clinical pathogens and potential reservoirs for genetic resistance. This study aimed to analyze the molecular diversity and horizontal gene transfer (HGT) potential of ESBL-producing Proteus species in the region. MethodsA regional surveillance was conducted with 1,500 clinical samples from Borno, Adamawa, Bauchi, Gombe, Taraba, and Yobe states. Proteus isolates were identified biochemically, and antibiotic susceptibility was assessed using the Kirby-Bauer method. Resistance genes (blaTEM, blaSHV, blaCTX-M) were identified via PCR, and HGT was evaluated through conjugation assays. ResultsA total of 144 Proteus isolates were identified, with a prevalence of 9.6%. P. mirabilis was the dominant species (90.97%). Phenotypic screening indicated that 69.44% produced extended-spectrum beta-lactamases (ESBL), with high resistance rates observed for Cefotaxime (80.56%) and Ampicillin (84.72%). Alarmingly, resistance to Ertapenem reached 54.86%. Molecular analysis showed blaTEM as the predominant gene (81.69%), and the conjugation assay revealed a high HGT rate of 76.92%, confirming blaTEM acquisition by E. coli. ConclusionThese results indicate that Proteus species in North-Eastern Nigeria are significant reservoirs for genetic resistance, facilitating the spread of ESBL markers. The high frequency of HGT raises concerns about the effectiveness of beta-lactam therapies in sub-Saharan Africa, underscoring the need to include Proteus in the GLASS framework and promote regional antimicrobial stewardship efforts. Current UnderstandingAntimicrobial resistance (AMR) in Enterobacteriaceae, particularly with Escherichia coli and Klebsiella pneumoniae, is a significant global issue highlighted by the World Health Organizations Global Antimicrobial Resistance and Use Surveillance System (WHO GLASS). While Proteus species are recognized as opportunistic pathogens, their role as genetic reservoirs in sub-Saharan Africa, especially in the Lake Chad Basin, remains inadequately defined in surveillance data. Study ContributionThis study identifies Proteus species as a critical "Genetic Hub" for the transmission of extended-spectrum beta-lactamases (ESBL) in North-Eastern Nigeria, revealing a high horizontal gene transfer (HGT) rate of 76.92% for the blaTEM genotype to E. coli. It also shows a concerning 54.86% resistance rate to Ertapenem, underscoring the urgent need to include Proteus in regional stewardship and global surveillance efforts.

In low-income countries, ESBL-producing Escherichia coli (ESBL-EC) is frequently detected in humans, animals and household environments, indicating widespread exposure to antimicrobial resistance (AMR). Established risk factors such as antibiotic use do not explain the high community carriage of AMR in all settings; identifying the dominant exposure pathways can inform interventions against AMR. We aimed to investigate (i) animal-human-environment sharing of AMR by assessing associations between the abundance of ESBL-EC in the household environment, domestic animal feces and young children's stool and (ii) household factors associated with ESBL-EC abundance in these reservoirs. We enrolled 112 households from the CRADLE trial in rural Bangladesh. We enumerated ESBL-EC in drinking water, food, child hand rinses, outdoor soil, indoor floor swabs, chicken and cow feces, and stool from children aged 6 months. We recorded indicators of sanitation, animal ownership/management, human and animal antibiotic use, and child exposure behaviors using structured questionnaires and spot checks. The highest prevalence of ESBL-EC was in child stool (95.6%) and animal feces (82.3-96.9%), followed by soil (48.2%) and floors (36.6%); < 10% of food, child hands and drinking water harbored ESBL-EC. The abundance of ESBL-EC in child stool was not associated with its abundance in any sampled matrix; the abundance in chicken but not cow feces showed positive correlations with soil, floors, child hands, and drinking water (correlation coefficients: 0.19-0.39, p-values < 0.05). Higher-quality latrines (improved, pour-flush, with slab) were associated with lower ESBL-EC abundance across matrices; unsafe animal management (animals roaming or spending the night inside the home) was associated with higher abundance. Child antibiotic use and exposure behaviors (soil ingestion, time spent on floor) were not associated with ESBL-EC abundance in child stool. We observed high AMR colonization among young children and domestic animals in rural Bangladesh not explained by traditional fecal-oral exposure pathways. Future studies should explore additional pathways and assess whether sanitation and animal management improvements can reduce AMR.

Background and objectives Spontaneous bacterial peritonitis (SBP) is a life-threatening complication of cirrhosis with ascites, carrying one- and two-year mortality rates exceeding 70% and 80%, respectively. Fluoroquinolone prophylaxis is the cornerstone of SBP prevention. Real-world longitudinal data on prescribing practices and clinical outcomes from Indian tertiary care centers are sparse. We aimed to evaluate fluoroquinolone prescribing patterns, guideline adherence, and six-month clinical outcomes in SBP patients at a tertiary academic center in North India. Methods This was a pre-specified sub-analysis of a 15-month analytical longitudinal study at AIIMS Rishikesh. Adults (age >/=18 years) admitted with SBP and initiated on fluoroquinolone prophylaxis were enrolled consecutively and followed for six months. Prescribing practices were compared against EASL and AASLD recommendations. The primary outcome was the rate of guideline-directed prescribing. Secondary outcomes included clinical cure at discharge, six-month cure, relapse, regimen modification, adverse drug reactions, and treatment compliance. Categorical variables were compared by Fisher's exact test or chi-squared test (SPSS). Results Forty-eight SBP patients were included (mean age 44.75 +/- 11.94 years; 85.4% male). Guideline-directed fluoroquinolone prophylaxis was prescribed to all patients (100%). Norfloxacin 400 mg once daily was predominant (85.4%), followed by levofloxacin (10.4%) and moxifloxacin (4.2%). Cure at discharge was 85.4%. At six months, 64.6% maintained sustained cure and 22.9% relapsed. Regimen modification occurred in 22.9%, most commonly antimicrobial substitution. Nausea was the only adverse drug reaction (4.8%). Treatment compliance was 73.8%. No patient underwent therapeutic drug monitoring. Conclusions Fluoroquinolone prescribing for SBP prophylaxis at AIIMS Rishikesh was fully concordant with standard guidelines. Despite complete adherence, a relapse rate of 22.9% and frequent regimen modification underscore the limitations of long-term fluoroquinolone prophylaxis, likely reflecting emerging quinolone resistance. Strengthening antimicrobial stewardship is essential to sustain prophylaxis effectiveness in Indian tertiary care settings.

Bacterial contamination of Surgical sites could lead to Surgical Site infections (SSI) which may prolong hospital stay, increased treatment costs and increased mortality. This study determined the prevalence of bacterial contamination of surgical sites among post-operative wounds and theatre surfaces together with their resistance to commonly prescribed antibiotics. A cross-sectional study design was used where a total of 290 and 74 swabs were collected from patients and theatre surfaces respectively. Swabs were cultured on duplicate plates of Blood Agar, Chocolate Agar and MacConkey Agar. Gram-staining and Biochemical tests were performed to identify the isolates. Resistance to commonly prescribed antibiotics was determined using the Kirby Bauer (KB) method. Data were analyzed using SPSS version 23, and descriptive statistics, Chi square and student T- tests were used to describe the results. The prevalence of bacterial contamination in wounds was 30.7% and was significantly higher in women of child bearing age ({chi}2= 10.79, df=1, P=0.0010). Microbial growth increased with an increase in duration of antibiotic therapy ({chi}2=12.73, df=2, P=0.007). E. coli was responsible for the highest cases of wound contamination (34.9%). All microorganisms isolated from post-operative wounds showed considerable resistance to antimicrobials. All isolates from wounds were resitant to Trimethoprin Sulfamexathone and 76.9% showed resistance to Ciprofloxacin. Other than E.coli and Acinetobacter, the rest of the isolates were susceptible to imipinem. Fourty nine gram positive isolates were grown from theatre surfaces and a significant majority (86%) were from air. There was high resistance to Erythromycin in Coagulase Negative Staphylococcus (CNS) isolates (56.0%). Overall, our study demonstrated that wound contamination at the Hoima Regional Referral Hospital is high but not associated with theatre surface contamination.

SynopsisO_ST_ABSBackgroundC_ST_ABSTime kill curve (TKC) assessments are an essential step in the study of an antimicrobials pharmacodynamic characteristics. Surprisingly TKCs have not be formally standardised, therefore there remain concerns that different testing centres/methodologies may produce different results. Six centres participating in Gram-negative-Antibiotics NOW (GNA-NOW) consortium measured a series of TKCs with meropenem against E. coli to establish: Same-day (SD) vs different-day (DD) replication per centre (intra-site), and centre to centre (inter-site) correlations. MethodsMeropenem was tested against three strains of E. coli (ATCC 25922; ESBL producer C1.55; OXA-48 producer C1.62). An inoculum of 1.5x106 CFU was specified with meropenem concentrations of x0, x1 to x16 MIC; and sampling assessment of bacterial density was determined at 0-24h. Experiments were performed in triplicate, aerobically at 37{degrees}C. Centre-specific methodology was collected. Meropenem, media, bacterial strains, were shipped from one central laboratory to participating laboratories. ANOVA and Friedman tests were used to assess SD, DD and between centre replications. ResultsAssessment of the methodologies between centres revealed many differences, including bacterial inoculum, meropenem preparation, volume of TKC vessel, vessel materials, agitation vs static cultures and sampling volumes. Intra-centre SD and DD analysis for all strains were generally associated with P>0.05 suggesting consistency. Inter-centre SD and DD comparisons resulted in P<0.05, indicating variable total bacterial load measurement between centres. ConclusionsTKC methodologies varied between different centres, and while intra-centre comparison of SD and DD were generally consistent, inter-centre comparisons were not. Standardisation of TKC methodologies is required.

Background: Antimicrobial resistance is the world's silent pandemic. The public knowledge, attitudes, and practices (KAP) about antibiotic usage are strongly related to the growing problem in Nepal. Methods: A cross-sectional descriptive survey was done to 263 respondents. Information on KAP regarding antibiotics, primary healthcare sources, and demography was collected through a questionnaire. To identify health literacy gaps and characteristics that contribute to improper antibiotic use, this study assessed these variables across an age group from 18 to 60 years. Descriptive statistics analysis was performed to analyze the data. Results: The majority of respondents were between the ages of 18 and 39 (85.1%), female (63.1%), and had at least a bachelor's degree (67.8%). Significant misunderstandings about antibiotics remained, even though 77.6% of respondents correctly recognized antibiotics as effective against bacteria; 44.1% incorrectly believed that antibiotics cure viral diseases, and 87.8% felt that antibiotics should be stopped right away if adverse effects develop. In practice, 52.9% acknowledged quitting antibiotics as soon as symptoms improved, despite 89.4% consulting doctors. Additionally, 43% of respondents said they have taken antibiotics without a prescription, frequently due to pharmacist recommendations (21.67%) and financial or geographical constraints. The main sources of information were doctors (11.07%) and pharmacist-doctor combinations (14.88%), yet 81.8% of respondents said they had never heard of the phrase antimicrobial resistance. Conclusion: There is a significant lack between theoretical understanding and practical application, despite the high levels of fundamental knowledge toward the prohibition of non-prescription sales. Self-medication and early withdrawal are still common inappropriate practices. It is crucial to implement focused teaching initiatives that highlight the differences between bacterial and viral diseases as well as the risks associated with leftover medicine. It is advised to use digital platforms for younger demographics and to strengthen the role of pharmacists in order to reduce AMR.

SynopsisO_ST_ABSBackgroundC_ST_ABSThe main advantages of Time Kill Curves (TKCs) in antimicrobial drug development are the ability to track bacterial kill and regrowth over time and with varying drug concentrations. Whilst there are guideline documents in place, such as M26-A in CLSI, there remains scope for individual laboratory differences in practice. Here we evaluated several factors which potentially influenced data generated in TKCs. MethodsFirstly, E. coli ATCC 25922 was used to determine optimum sampling volume, culture vessel volume, CFU enumeration variance factors and static versus agitated cultures in a single laboratory. Secondly, a ring test comprising of TKCs was performed by six laboratories focusing on: standardised inoculum, static culture and two culture vessel sizes 10 mL and 200 {micro}L. Data analysis was performed to determine consistency within centres and between them. ResultsConsistently accurate inocula could be achieved by use of: larger sampling volumes between 100 {micro}L > 20 mL; larger culture vessels volumes (10 mL > 100 {micro}L) and higher inocula (10 8 > 1.5x10 5 CFU). Culture agitation during the TKC experiment resulted in reduced killing compared to static cultures. Reproducibility of TKCs was best between centres when they were performed in 10 mL culture vessels. There was more variability per site when performing TKC in 96 well trays. ConclusionsTechnical factors such as preparation of inocula, agitation, vessel size and enumeration of cultures are important variables in performing TKCs that need to be standardised in drug development programmes involving multiple laboratory centres.

The Burkholderia cepacia complex (BCC) is comprised of 24 species of Gram-negative bacteria that cause opportunistic infections. While antimicrobial susceptibility testing (AST) has historically been used to guide treatment for BCC infections, recent work highlighting problems with AST for these organisms led the Clinical and Laboratory Sciences Institute (CLSI) to remove disk diffusion (DD) and minimal inhibitory concentration (MIC) breakpoints for BCC from its M100 standards document. Epidemiological cut-off values (ECVs) may be helpful to clinicians in the absence of breakpoints, as they may be used to determine whether an isolate has a wild-type or non-wild-type phenotype. Here we present an analysis of BCC ECVs for ceftazidime (CAZ), levofloxacin (LVX), meropenem (MEM), minocycline (MIN), and trimethoprim-sulfamethoxazole (TMP-SMX). ECVs were calculated using MIC data from 3 previous studies and 3 independent laboratories for 1,896 BCC isolates. ECVs were 16 g/ml for CAZ, 8 g/ml for LVX, 16 g/ml for MEM, and 8 g/ml for MIN. The ECV for TMP-SMX varied depending on the analysis from 2 g/ml, 8 g/ml, and 16 g/ml and therefore could not be reliably established. Challenges with establishing ECVs for BCC include limitations with the pooled MIC dataset, broad MIC distributions, and high ECVs that are above the obsolete susceptible MIC breakpoints. These challenges limit the clinical utility of ECVs for these organisms and supported removal of ECVs from the CLSI M100 standards document. IMPORTANCEThe Burkholderia cepacia complex is a group of bacterial species that cause difficult-to-treat opportunistic infections. Recently, clinical breakpoints, which are used to determine whether organisms are susceptible to certain antimicrobials, were removed from Clinical and Laboratory Standards Institute (CLSI) standards for these organisms due to problems with antimicrobial susceptibility testing performance. Clinicians are now faced with the challenge of how to treat these complex infections without clinical breakpoints. Here we determine epidemiological cut-off values (ECVs) for relevant antimicrobials for the B. cepacia complex. While we established ECVs for four antimicrobials, we encountered significant challenges in our analyses, including limitations with data for these organisms and high ECVs that are not clinically useful. These challenges limit the practical use of these ECVs in helping guide clinicians on treatment and supported the eventual removal of ECVs from the CLSI M100 standards document.

The incidence of vancomycin-resistant Enterococcus (VRE) is rising in hospitals in Canada, and resistance to last-resort antimicrobials including linezolid complicates treatment options for multidrug-resistant isolates. Recent reports from around the globe indicate that both linezolid and vancomycin resistance genes can be co-carried and mobilized by linear plasmids (named pELF) in Enterococcus species, often on the same backbone. We aimed to investigate linezolid resistance and linear plasmid prevalence in VRE bloodstream infection isolates collected by the Canadian Nosocomial Infection Surveillance Program from 2009 to 2024. We found that screening for pELF linear plasmid ends in short reads was a reliable way to predict linear plasmid presence in large-scale surveillance data (100 % accuracy on 85 reference samples). Almost half of the isolates in our collection were predicted to carry pELF plasmids (45.4 %, 941/2071) and we found that this proportion has increased from 2018 (32.2 %, 59/183) to 72 % of isolates between 2021 and 2024 (2021: 68.5 % (115/168); 2022: 71.6 % (146/204); 2023: 72.8 % (166/228); 2024: 71.6 % (235/328)). This trend of increasing linear plasmid carriage is evident from 2018 to 2024 across the dominant emerging sequence types (ST80, ST17, ST117). Linezolid resistance based on phenotypic antimicrobial susceptibility testing was low (1.0 %, 21/2071). Using long read sequencing, we characterized the linezolid resistant isolates and confirmed pELF plasmid presence in 13/21 (61.9 %) isolates. Six isolates harboured pELF plasmids encoding linezolid resistance genes (optrA, cfr(D), poxtA) and five of these also encoded vancomycin resistance genes (vanA). We compared these six plasmids to 39 public plasmid sequences and clustered them using MOB-suite and pling. Overall, this study provides further examples of the co-carriage of vancomycin and linezolid resistance genes on mobile linear plasmids and shows that linear plasmid prevalence is detectable and increasing across VRE in Canada. IMPACT STATEMENTGiven the increasing prevalence of multidrug-resistant hospital-acquired pathogens, resistance to last-resort antibiotics is a global public health threat. Linezolid is a last-resort antibiotic used to treat vancomycin-resistant Enterococcus isolates, and the dissemination of linezolid resistance genes is significantly facilitated by mobile elements that can transfer between unrelated strains and species. Linezolid resistance genes have recently been described on linear plasmids and are often co-localized with other resistance genes on the same plasmid backbone. Consequently, understanding the features and distribution of linear plasmids and those harbouring linezolid resistance genes is crucial for pathogen surveillance and mitigation of resistance. In this work, we used long-read and short-read sequencing to characterize genomic epidemiology of linear plasmids across 16 years of Enterococcus surveillance data in Canada. This study furthers knowledge of linear plasmids by demonstrating that they are relatively common across vancomycin-resistant Enterococcus blood isolates and by providing more examples of co-localized vancomycin and linezolid resistance genes on the same linear plasmid backbone. DATA SUMMARYSequencing data and genome sequences were deposited in National Centre for Biotechnology BioProject PRJNA1279082, and accessions are listed in Table S1. Supplementary materials for this study are available at the Figshare portal through DOI: XXX.

Carbapenemase-producing Enterobacterales represent a growing global threat due to their extensive antimicrobial resistance and rapid dissemination. This study characterized the phenotypic and genomic features of Escherichia coli and Klebsiella pneumoniae isolates collected between 2020 and 2022 from four healthcare institutions in Lima, Peru. A total of 320 non-redundant isolates (61 E. coli and 259 K. pneumoniae) were analyzed through antimicrobial susceptibility testing, polymerase chain reaction, and whole-genome sequencing. The most frequent carbapenemase gene was blaNDM (69%), followed by blaKPC (16.9%) and blaOXA-48-like (4.6%). Eleven K. pneumoniae isolates co-produced NDM and KPC, and one E. coli isolate co-harbored NDM and OXA-48-like. All isolates were multidrug resistant, and 5% were pandrug resistant. Novel {beta}-lactam/{beta}-lactamase inhibitor combinations such as aztreonam/avibactam and cefiderocol showed complete activity against all classes of carbapenemases. Genomic analysis revealed predominant E. coli sequence types ST167 and ST410 and K. pneumoniae lineages ST147, ST15, ST45, and ST273. The blaNDM-5 allele was detected for the first time in Peru, mostly in E. coli ST167, carried on multireplicon IncF-type plasmids. In K. pneumoniae, ST147 was identified as a dominant clone associated with blaNDM-1, indicating sustained local dissemination of high-risk clonal groups. The coexistence of multiple carbapenemases and plasmid backbones highlights the ongoing evolution of resistance mechanisms. These findings provide actionable evidence to guide treatment strategies in settings with high prevalence of metallo-{beta}-lactamases and underscores the need for continuous genomic surveillance and antimicrobial stewardship to mitigate their clinical and epidemiological impact.

BackgroundUnderstanding antimicrobial use and factors driving it in communities is essential to devise its stewardship and reduce emergence of antimicrobial resistance. ObjectivesTo study the intersectional influence of socioeconomic status, migration and place of treatment on antimicrobial use in a semi urban area in Tamil Nadu, India. MethodsWe conducted a cross-sectional survey among systematically sampled 525 adult men and women from three villages in a semi-urban area in Tiruvallur district. We collected data through structured interviews on incidence of infections in the past 3 months, treatment seeking behaviour, and audited the antimicrobial prescription or empty packs of medicines used. We analyzed the data using R statistical software and performed a multilevel analysis of individual heterogeneity and discriminatory accuracy to study intersectional effects. ResultsWe found that the incidence of infection syndrome was 37% with a majority of them being acute respiratory infections. 143 of them sought treatment, with 40% going to a private general practitioner. People belonging to middle class had a 3.7 times greater odds of going to private sector compared to lower class. Twenty eight (19.6%) of those who sought treatment received an antimicrobial prescription. Sixty percent of them belonged to Access group, 35.7% Watch and 3.6% Restrict group. There was a significant intersectional effect showing middle class- non migrant - private care seekers having 22% probability of antimicrobial use versus lower class - migrant - government care seekers having 16% probability. The variance partition coefficient was 2.6% showing a small by significant portion of the variance contributed by intersectional identities. ConclusionAntimicrobial use in the community is significantly shaped by the intersection of socioeconomic status, migrant status and place of seeking care for the infection. Regulation of private sector prescription patterns and improving access to health care for migrants are key policy interventions.

Background: Antimicrobial resistance (AMR) is a global public health problem. Infections caused by extended-spectrum beta-lactamase (ESBL) and carbapenemase (CP) -producing Enterobacterales (E) threaten individuals and healthcare systems worldwide. Symptomatic infection caused by Enterobacterales is typically preceded by asymptomatic colonisation and often occurs in the most vulnerable individuals, thus interrupting asymptomatic transmission is desirable. The dominant transmission routes across the healthcare continuum including hospitals, intermediate care, and long-term care facilities are not well understood. Methods: Here we present a protocol describing a genomic surveillance framework developed for the Tracking Antimicrobial Resistance Across Care Settings (TRACS) Liverpool programme, which aims to identify critical ESBL-E transmission points in hospitals and care homes in Liverpool, UK. Our study integrates individual participant and healthcare facility data, validated standard operating procedures for taking and culturing stool, rectal, environmental, and staff samples, and genomic sequencing of ESBL-E, and statistical modelling approaches into a research framework for ESBL-E genomic surveillance. Discussion: There is a need for improved epidemiological and laboratory approaches to studying bacterial transmission. Drug-resistant enteric bacteria are a highly tractable marker of the movement of all enteric bacteria, and interventions designed to interrupt transmission of drug-resistant bacteria are expected to have a broader healthcare impact. This protocol provides a standardised, reproducible approach for identifying ESBL-E, tracking acquisition events, and linking clinical and environmental isolates through whole-genome sequencing.

BackgroundRapid identification of pathogens and antimicrobial resistance (AMR) in bloodstream infections (BSIs) is critical for timely clinical management. Although blood culture is the reference standard, it is limited by turnaround time and incomplete resolution of resistance mechanisms. We evaluated metagenomic next-generation sequencing (mNGS) applied to flagged positive blood culture bottles to enhance diagnostic resolution and inform targeted molecular approaches. MethodsFifty-five flagged positive blood culture bottles from a tertiary care hospital in Bengaluru, India, were analyzed. Shotgun mNGS was performed directly on blood culture broth and compared with routine phenotypic identification and antimicrobial susceptibility testing (AST) from corresponding isolates. Antimicrobial resistance genes (ARGs) and plasmid replicons were profiled. ResultsmNGS showed high concordance with routine culture for pathogen identification (54/55; 98.2%) and improved species-level resolution across bacterial and fungal pathogens. Genotypic resistance profiles were consistent with phenotypic AST, identifying {beta}-lactamases, efflux-associated determinants, and target modification mechanisms. Diverse ARGs and plasmid replicons (Inc-, Col-, and rep-family) were detected, providing genomic context for resistance. Sequencing predominantly reflected the cultured organism, supporting high specificity in flagged blood culture material. ConclusionsmNGS applied to flagged blood culture bottles enables high-resolution characterization of pathogens and resistance determinants at a clinically actionable stage. The genomic insights generated provide a framework for developing targeted multiplex PCR assays that can reduce turnaround time and improve affordability compared with sequencing-based approaches. This strategy supports the use of mNGS as an adjunct to conventional diagnostics and as a bridge toward scalable, rapid, and cost-effective solutions for BSI diagnosis and AMR surveillance.

Background: Antimicrobial resistance (AMR) disproportionately affects low- and middle-income countries (LMICs) such as Pakistan, where obstetric and gynaecological (OBGYN) patients carry high antibiotic exposure. Specialty-specific drug utilization data with concurrent stewardship audit remain scarce. This study evaluated antibiotic prescribing patterns, consumption metrics, and antimicrobial stewardship program (AMS) compliance in OBGYN inpatients at a public sector tertiary care hospital. Methods: A prospective cross-sectional study was conducted in OBGYN wards of Dow University Hospital, Karachi, from 1 September to 31 October 2025. Women receiving [&ge;]1 systemic antibiotic were included. Daily AMS rounds were conducted by an Infectious Diseases physician and pharmacist. Antibiotic consumption was measured as Defined Daily Doses (DDD) and Days of Therapy (DOT) per 1,000 patient-days (total = 821). Antibiotics were classified by WHO AWaRe (2023) framework. Results: Of 812 total admissions, 278 patients (34.2%) received [&ge;]1 antibiotic and were enrolled (205 obstetric, 73 gynaecological), generating 636 prescriptions (mean 2.29/patient). Surgical prophylaxis was the predominant documented indication (213, 33.5%); 65.1% carried no documented indication. By AWaRe classification, 53.6% were Access-group and 46.1% Watch-group. Ceftriaxone (38.4%) and metronidazole (36.8%) together represented 75.2% of prescriptions. Combined DDD/1,000 patient-days was 1,758.6 and DOT/1,000 patient-days was 1,852.7. AMS compliance was 0%. Conclusions: This study documents high antibiotic prescribing burden, near-universal documentation failure, and zero AMS compliance in OBGYN inpatients at a Pakistani public sector hospital. The predominance of Watch-group antibiotics and undocumented surgical prophylaxis highlights structural stewardship gaps. Findings support urgent need for institutional OBGYN antibiotic guidelines and structured pharmacist-led AMS programs.

Acinetobacter spp. represents critical opportunistic pathogens driving severe bloodstream infections (BSIs) in intensive care unit (ICU) and neonatal intensive care unit (NICU) settings. The convergence of carbapenem resistance and emerging biocide tolerance, often mediated by mobile genetic elements, has intensified concerns regarding co-selection and persistence in clinical environments. A total of 90 molecularly confirmed Acinetobacter isolates (ICU = 44; NICU = 46) from bloodstream infections were analyzed. Antimicrobial susceptibility was determined using the Kirby-Bauer disk diffusion method in accordance with CLSI M100 (2024) guidelines and extended-spectrum {beta}-lactamase production was assessed by combined disc diffusion. Polymerase chain reaction (PCR) was employed to detect carbapenemase genes (blaVIM, blaNDM, blaIMP, blaOXA-23, blaOXA-58), biocide resistance determinants (qacE, qac{Delta}E1), and the class 1 integron-integrase gene (intI1). Multidrug-resistant (MDR) and extensively drug-resistant (XDR) phenotypes were identified in 71.1% (64/90) and 22.2% (20/90) of isolates, respectively. High resistance (>71%) was observed against meropenem and cephalosporins, whereas colistin (51.1%, 46/90) and amikacin (47.8%, 43/90) showed moderate susceptibility. The most prevalent genotypes were qac{Delta}E1 (76.6%, 69/90) and blaVIM (56.6%, 51/90). Statistical and network analyses revealed significant correlations between biocide and carbapenemase genes, identifying IntI1 as a primary driver of co-resistance. The findings demonstrate that integron-mediated co-carriage of carbapenemase and biocide resistance genes is a major driver of MDR and XDR phenotypes in Acinetobacter BSIs. This co-selection dynamic highlights the urgent need to reassess disinfection strategies alongside antimicrobial stewardship to curb the persistence and spread of highly resistant strains in critical care settings.

Antimicrobial resistance (AMR) exacerbates bacteraemia in cancer patients, particularly in low-resource settings. At the Uganda Cancer Institute, high rates of Enterobacterales producing extended-spectrum {beta}-lactamases (ESBLs) have been reported, with DNA-based detection of bla genes limited to PCR. This study aimed to determine whether bacterial genomic DNA shipped at ambient temperature from Uganda to the UK retained sufficient quality for whole-genome sequencing (WGS), to allow in-depth genomic analyses of isolates. Genomic DNA was extracted from Gram-negative bloodstream isolates (n=77) in Uganda and shipped to the UK at ambient temperature. rpoB gene (77/77, 100%) and WGS data (72/77, 93.5%) were generated for isolates, with 66/72 (91.7%) genomes of high-quality (Escherichia coli n=34; Klebsiella spp. n=32). Bioinformatic analyses included species identification, sequence typing, SNP analysis, AMR and virulence gene profiling, and comparison with publicly available genomes of Ugandan isolates. Phenotypic-genotypic concordance was generally high: 7/77 (9.1%) isolates were misidentified by phenotypic testing, and two showed unexplained carbapenem resistance. E. coli isolates showed diverse sequence types, with high prevalence of blaCTX-M (91.2%) and blaOXA-1 (47.1%); carbapenemase genes were rare. Klebsiella isolates lacked hypermucoidy loci and displayed diverse capsule types, with a high prevalence of ESBLs. Genomic clustering suggested limited within-hospital transmission of strains. Genomic data can provide important insights into the dissemination of bacterial subclades of global concern. The widespread AMR genotypes reported here highlight the need for improved diagnostics and updated treatment guidelines for bacteraemia in Ugandan cancer patients.