Extensive outbreak of colistin resistant, carbapenemase (blaOXA-48, blaNDM) producing Klebsiella pneumoniae in a large tertiary care hospital, India

A nosocomial outbreak of colistin and carbapenem-resistant hypervirulent Klebsiella pneumoniae in a large teaching hospital

Recently, colistin and carbapenem-resistant hypervirulent Klebsiella pneumoniae (CCR-hvKP) has been observed sporadically. The aim of this study was to report a nosocomial outbreak due to CCR-hvKP, so as to control the transmission of CCR-hvKP and prevent future outbreaks. The clinical characteristics of five involved cases were analyzed and infection prevention and control measures were documented. Five CCR-hvKP isolates were discovered from the five involved cases. Molecular features of the isolates including sequence type, capsule locus, antimicrobial resistance genes, virulence factors and phylogenetic relationship were analyzed by whole-genome sequencing. Validation of the role of the deleterious amino acid mutations to colistin resistance was examined by complementation assays. PCR was performed to identify insertion sequences within the mgrB gene. Mouse intraperitoneal infection models were used to assess virulence phenotype. Five cases infected with CCR-hvKP were identified with a high attributable mortality rate of 60% in the patients. The five outbreak isolates belonged to the high-risk ST11-KL64 clone and were closely clustered. They were highly resistant to commonly used antibiotics and showed hypervirulent in vivo. WGS revealed multiple antimicrobial resistance genes such as blaKPC-2 and blaCTX-M-65 and important virulence factors. Concerning colistin resistance, amino acid mutations G53S in pmrA gene, and T157P, T246A and R256G in pmrB gene were indentified. Among them, the deleterious mutation T157P in pmrB gene was validated to be responsible for the resistance phenotype of isolate KP01, KP03 and KP05. In addition, disruption of mgrB gene by insertion sequences of ISKpn26 and IS903B was indentified in isolate KP02 and KP04, respectively. This is the first report of an outbreak caused by CCR-hvKP. The study highlights infection prevention and control measures are key to successfully fight against CCR-hvKP dissemination and nosocomial infections. Continuous surveillance should be performed to limit the spread of these isolates.

Comparison of two commercial broth microdilution panels for multidrug-resistant Gram-negative bacteria: Thermo Scientific™ Sensititre DKMGN vs. Beckman Coulter MicroScan NMDRM1

Introduction

Antimicrobial susceptibility testing (AST) using broth microdilution (BMD) is usually the reference method to obtain accurate minimum inhibitory concentrations and optimally manage infections with resistant organisms. Several commercial dry BMD are available for AST in clinical laboratories.

Materials and methods

Two commercial BMD panels for testing of multidrug-resistant Gram-negative bacteria were compared: the Thermo Scientific™ Sensititre DKMGN and the Beckman Coulter NMDRM1, for 17 antimicrobial agents.

Results

A total of 207 isolates were tested: three ATCC strains and one NCTC strain, six quality control strains from the Belgian National Antimicrobial Committee, and 197 clinical isolates, including carbapenem-resistant Enterobacterales, Pseudomonas aeruginosa, and Acinetobacter baumannii. The European Committee on Antimicrobial Susceptibility Testing (EUCAST) 2023 breakpoints version 13.1 were used to assign susceptibility categories.

Discussion

Overall, the categorical agreement (CA) and essential agreement (EA) were both above 90%, but several useful antibiotics for the treatment of multi-resistant organisms showed CA and EA under 90%, that is, meropenem, imipenem, and colistin for Enterobacterales and meropenem and colistin for P. aeruginosa. For Enterobacterales, the NMDRM1 panel showed a significantly higher resistance rate for meropenem, imipenem, amikacin, and colistin. For carbapenems, the minimal inhibitory concentrations (MICs) were underestimated by the DKMGN panel, as already pointed out by a warning on the EUCAST website. To better assess carbapenem susceptibility in carbapenem-resistant organisms, the DKMGN panel now requires the use of a higher inoculum in the insert kit. However, for a given isolate whose susceptibility to carbapenems is not known, there is a risk of underestimating the MIC values. Our results show that colistin testing remains a challenge, highlighting the urgent need for the development of more accurate commercial methods. The use of a single commercial method cannot guarantee good precision in the determination of the MIC value for colistin.

Characterization of colistin-resistant carbapenemase producing Klebsiella pneumoniae in a river receiving wastewater treatment plant effluent

Genes conferring antibiotic resistance phenotype, particularly to last resort antibiotics, pose a significant concern globally. Wastewater treatment plant (WWTP) effluent substantially contributes to antibiotic resistance in receiving rivers, threatening human health. Globally, colistin- and carbapenem-resistant Klebsiella pneumoniae infections cause high morbidity and mortality. We investigated colistin-resistant carbapenemase-producing K. pneumoniae (Co-CRKP) isolates in Kathajodi river receiving WWTP effluent, their resistance genes, and pathogenic potential. Four isolates (Co-CRKP-7, Co-CRKP-8, Co-CRKP-10, and Co-CRKP-15) exhibited extensively drug-resistant (XDR) phenotype, harbouring blaTEM-1, blaCTX-M-15, blaNDM-5, and blaOXA-48 genes. Colistin resistance was attributed to mutations in the pmrA and pmrB genes. Virulence genes (fimH, mrkD, entB, iucA, iutA, and irp1), capsular serotypes (K1, K2) and biofilm formation in the isolates explicated their pathogenicity. Furthermore, Inc plasmid replicons (Y, FrepB, P, K/B, L/M, N, FIA, A/C, and FIB) indicated the dissemination potential of the resistance genes in Co-CRKP isolates. The multi-locus sequence typing showed that Co-CRKP-7 and Co-CRKP-8 belonged to ST42, while Co-CRKP-10 and Co-CRKP-15 were ST16 and ST231, respectively. These high-risk clones carrying multidrug resistance and virulence genes, implicated in numerous outbreaks, have spread worldwide. Our findings emphasize the necessity for effective treatment of hospital wastes to restrict the spread of clinical isolates into aquatic environments.

Predominance of blaNDM- and blaIMP-Harboring Escherichia coli Belonging to Clonal Complexes 131 and 23 in a Major University Hospital

Background and Objectives: Carbapenem resistance is a growing global challenge for healthcare, and, therefore, monitoring its prevalence and patterns is crucial for implementing targeted interventions to mitigate its impact on patient outcomes and public health. This study aimed to determine the prevalence of carbapenem resistance among Escherichia coli (E. coli) strains in the largest tertiary care hospital of the capital territory of Pakistan and to characterize the isolates for the presence of antimicrobial resistance genes. Additionally, the most prevalent sequence types were analyzed. Materials and Methods: A total of 15,467 clinical samples were collected from November 2020 to May 2022, underwent antimicrobial susceptibility testing, and were analyzed for antimicrobial resistance genes through conventional PCR and sequence typing using MLST. Results: In carbapenem-resistant E. coli (CR-EC), 74.19% of isolates harbored the blaNDM gene, with blaNDM-1 (66.96%), blaNDM-5 (12.17%), and blaNDM-7 (20.87%) variants detected. Additionally, blaIMP was found in 25.81% and blaOXA-48 in 35.48% of isolates. The presence of blaCTX-M15 and blaTEM was identified in 83.87% and 73.55% of CR-EC isolates, respectively, while armA and rmtB were detected in 40% and 65.16% of isolates, respectively. Colistin and tigecycline were the most effective drugs against CR-EC isolates, with both showing an MIC50 of 0.5 µg/mL. The MIC90 for colistin was 1 µg/mL, while for tigecycline, it was 2 µg/mL. MLST analysis revealed that the CR-EC isolates belonged to ST131 (24.52%), ST2279 (23.87%), ST3499 (16.13%), ST8051 (15.48%), ST8900 (9.68%), ST3329 (7.10%), ST88 (1.94%), and ST6293 (1.29%). The ST131 complex (70.97%) was the most prevalent, harboring 95.65% of the blaNDM gene, while the ST23 complex (18.06%) harbored 62.50% of the blaIMP gene. Conclusions: Implementing large-scale surveillance studies to monitor the spread of specific pathogens, along with active infection control policies, is crucial for the effective containment and prevention of future epidemics.

Association between indoor environmental risk factors and pneumonia among preschool children in Urumqi：A case-control study

Background

Pediatric pneumonia presents a significant global health challenge, particularly in low- and middle-income countries. This study aimed to investigate the incidence of pneumonia in preschool children in Urumqi and its association with indoor environmental factors.

Methods

This case-control study collected data from December 2018 to December 2019 on 1522 preschool children in Urumqi (779 boys and 743 girls) who were diagnosed with pneumonia by a physician. A control group of children who had never had pneumonia was matched in a 1:1 ratio based on gender, age, and ethnicity. Using questionnaires, data were collected on children's general characteristics, passive smoking, types of housing, flooring materials, and indoor dampness, analyzing potential factors associated with the incidence of pediatric pneumonia.

Results

Multivariate analysis revealed that cesarean birth (odds ratio [OR] = 1.27; 95 % confidence interval [95%CI] = 1.08-1.48), being an only child (OR = 1.32; 95%CI = 1.13-1.55), antibiotic treatment during the first year of life (OR = 2.51; 95%CI = 1.98-3.19), passive smoking during the mother's pregnancy (OR = 1.62; 95%CI = 1.24-2.13), living in multi-family apartment housing (OR = 1.64; 95%CI = 1.28-2.10) and other types of housing (OR = 1.47; 95%CI = 1.09-1.99), laminate flooring (OR = 1.31; 95%CI = 1.01-1.72), and tile/stone/cement flooring flooring (OR = 1.31; 95%CI = 1.06-1.61), and dampness in dwelling (during first year of mother's pregnancy) (OR = 1.30; 95%CI = 1.04-1.63) were risk factors for pediatric pneumonia. The use of fresh air filtration systems in children's residences (OR = 0.66; 95%CI = 0.50-0.86) was identified as a protective factor.

Conclusion

This study underscores the importance of indoor environmental factors in the prevention of pediatric pneumonia. Public health strategies should consider these factors to reduce the incidence of pneumonia in children. Future research needs to be conducted over a broader geographical range and consider a more comprehensive range of factors influencing pediatric pneumonia.

Characterization of blaOXA-232 carrying carbapenem-resistant Klebsiella pneumoniae (CRKP) & their expression profiles under selective carbapenem pressure: An in-depth study from India

Background & objectives OXA-232 is a five amino acid substitution variant of OXA-48 and is reported in carbapenem-resistant Klebsiella pneumoniae (CRKP), which is associated with nosocomial infections among immunocompromised patients in the intensive care unit. This study aimed to characterise blaOXA-232 in CRKP of clinical origin and investigate its transcriptional response against sub-inhibitory levels of carbapenems. Methods CRKP was isolated from blood (pathogens) and stool cultures (colonisers) of neonates and was characterized for blaOXA-232. Co-existing resistance determinants were investigated in blaOXA-232 positive isolates, followed by horizontal gene transferability assay and PCR-based replicon typing (PBRT). Cloning of blaOXA-232 was performed, and expression of blaOXA-232 in the isolates and their clones under sub-inhibitory concentrations of carbapenems was checked via RT-PCR. Mobile genetic elements associated with blaOXA-232 were investigated, followed by DNA fingerprinting through enterobacterial repetitive intergenic consensus (ERIC) PCR. Results blaOXA-232 with co-carriage of extended-spectrum beta-lactamases (ESBLs), sulphonamides and quinolones were identified in seven CRPK isolates recovered from blood samples of neonates. Transformation and cloning of blaOXA-232 was successful. The sub-inhibitory concentration of carbapenems induces elevated expression of this resistant determinant. ISEcp1 was associated with blaOXA-232 in the upstream region within two haplotypes of CRKP isolates of clinical origin. Interpretation & conclusions Selective carbapenem pressure resulted in higher expression of this gene, which could account for treatment failure. With frequent reports of occurrence among clinical isolates, monitoring and further investigation of this novel variant are necessary to understand its transmission dynamics and to thwart its further dissemination.

Antimicrobial resistance trends in clinical Escherichia coli and Klebsiella pneumoniae in Ethiopia

Background

Clinicians rely on local antimicrobial resistance pattern data to guide empiric treatment for seriously ill patients when culture and antimicrobial susceptibility testing results are not immediately available.

Objective

This study aimed to analyse 5-year trends in antimicrobial resistance profiles of Escherichia coli and Klebsiella pneumoniae isolates.

Methods

Bacteriology reports from 2017 to 2021 at the Ethiopian Public Health Institute were analysed retrospectively. Isolates were identified using either the VITEK 2 Compact system, the BD Phoenix M50 instrument, or conventional biochemical tests. Antimicrobial susceptibility testing was conducted using either the Kirby-Bauer disk diffusion method or the VITEK 2 Compact system and BD Phoenix M50 systems available at the time of testing. The Cochran Armitage trend test was employed to test the significance of antimicrobial resistance trends over time. P-values less than 0.05 were considered statistically significant.

Results

Of the 5382 bacteriology reports examined, 458 (9%) were on E. coli and 266 (5%) were on K. pneumoniae. Both K. pneumoniae (88%) and E. coli (65%) demonstrated high resistance to extended-spectrum cephalosporins. However, both K. pneumoniae (14%) and E. coli (5%) showed lower rates of resistance to carbapenems compared to other antimicrobials. In K. pneumoniae, resistance to carbapenems (from 0% to 38%; p < 0.001) and ciprofloxacin (from 41% to 90%; p < 0.001) increased significantly between 2017 and 2021.

Conclusion

Both organisms showed very high resistance to broad-spectrum antibiotics. Additionally, K. pneumoniae demonstrated a statistically significant rise in ciprofloxacin and carbapenem resistance.

What this study adds

This study emphasises the significance of regular reporting of local antimicrobial resistance patterns as this information can guide appropriate empiric therapy and efforts to address antimicrobial resistance issues.

Antimicrobial resistance burden pre and post-COVID-19 pandemic with mapping the multidrug resistance in Egypt: a comparative cross-sectional study

Overuse of antibiotics during coronavirus disease 2019 (COVID-19) in an attempt to reduce COVID-19 mortality in the short term may have contributed to long-term mortality from antimicrobial resistance (AMR). The aim of this study was to evaluate the impact of the COVID-19 pandemic on AMR in Egypt and map the distribution of multidrug-resistant (MDR) and extensive drug-resistant (XDR) across Egypt. Through a multicenter cross-sectional study 2430 culture results were collected in 2019 and 2022 pre and post-COVID-19 pandemic in Egypt, including 400 Klebsiella pneumoniae, 760 Escherichia coli, 650 Acinetobacter baumannii, and 620 Methicillin-resistant staphylococcus aureus (MRSA) culture results. MDR and XDR culture results distribution across Egypt was highlighted through the geographic information system. Mixed effect logistic regression models and sub-group analysis were performed according to the type of specimens to test the impact of COVID-19 on resistance. Adjusted analysis demonstrated K. pneumoniae resistance has increased against quinolones and carbapenems (P < 0.001). Resistance of E. coli has increased significantly against imipenem and meropenem. While E.coli susceptibility has increased to cefoxitin, levofloxacin, and ciprofloxacin. A. baumannii resistance has increased more than double against ceftazidime, cefepime, and piperacillin-tazobactam (P < 0.001). MRSA reserved its susceptibility to vancomycin and linezolid. MDR K. pneumoniae and A. baumannii have increased post-COVID-19 from 67% to 94% and from 79% to 98%, respectively (P < 0.001). XDR K. pneumoniae and A. baumannii have increased from 6% to 46%, and from 47% to 69%, respectively (P < 0.001). COVID-19 has changed the profile of AMR in Egypt so that urgent action is required to mitigate this threat and preserve our capacity to face infections in future decades.

A review on antimicrobial strategies in mitigating biofilm-associated infections on medical implants

Biomedical implants are crucial in providing support and functionality to patients with missing or defective body parts. However, implants carry an inherent risk of bacterial infections that are biofilm-associated and lead to significant complications. These infections often result in implant failure, requiring replacement by surgical restoration. Given these complications, it is crucial to study the biofilm formation mechanism on various biomedical implants that will help prevent implant failures. Therefore, this comprehensive review explores various types of implants (e.g., dental implant, orthopedic implant, tracheal stent, breast implant, central venous catheter, cochlear implant, urinary catheter, intraocular lens, and heart valve) and medical devices (hemodialyzer and pacemaker) in use. In addition, the mechanism of biofilm formation on those implants, and their pathogenesis were discussed. Furthermore, this article critically reviews various approaches in combating implant-associated infections, with a special emphasis on novel non-antibiotic alternatives to mitigate biofilm infections.

Nosocomial outbreak of colistin-resistant, carbapenemase-producing Klebsiella pneumoniae ST11 in a medical intensive care unit

OBJECTIVES

Klebsiella pneumoniae is an important opportunistic Gram-negative pathogen. This study describes an outbreak due to colistin-resistant and carbapenem-resistant Klebsiella pneumoniae (ColR-CRKP) in a tertiary hospital related to six patients successively admitted to the department of medical intensive care unit (MICU) between March 11 and April 29, 2021.

METHODS

Phenotypic characterization was conducted on 16 ColR-CRKP strains obtained from six infected patients and five ColR-CRKP strains isolated from 48 environmental samples, followed by whole-genome sequencing (WGS) and polymerase chain reaction (PCR) analysis.

RESULTS

All ColR-CRKP strains showed resistance to commonly used antibiotics. Whole-genome sequencing revealed a variety of resistance genes such as blaKPC-2, blaCTX-M-65, and blaTEM-4 present in all strains, which is consistent with their antimicrobial resistance profile. All isolates were identified as the high-risk sequence type 11 (ST11) clonal lineage by multilocus sequencing typing (MLST) and subsequently clustered into a single clonal type by core genome MLST (cgMLST). IS5-like element ISKpn26 family transposase insertion mutations at positions 74 nucleotides in the mgrB gene were the main cause of colistin resistance in these ColR-CRKP. The variations of genes were verified by PCR. SCOTTI analysis demonstrated the transmission pathway of the ColR-CRKP between the patients.

CONCLUSION

Our study highlights the importance of coordinated efforts between clinical microbiologists and infection control teams to implement aggressive surveillance cultures and proper bacterial genotyping to diagnose nosocomial infections and take control measures. Routine surveillance and the use of advanced sequencing technologies should be implemented to enhance nosocomial infection control and prevention measures.

Effectiveness of Ceftazidime-Avibactam in Gram-Negative Nosocomial Pneumonia: A Real-World Study in India

BACKGROUND AND OBJECTIVE

The incidences of nosocomial pneumonia in intensive care units (ICUs) in India have been reported to range from 9% to 58% and are associated with a mortality rate of 30-70%. Ceftazidime-avibactam has activity against OXA-48-like carbapenem-resistant Enterobacterales (CRE) and has a safer adverse effect profile as compared to the nephrotoxic colistin. The current study aimed to assess the effectiveness and usage pattern of ceftazidime-avibactam in gram-negative hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) in real-world settings in India.

METHODS

Electronic medical records of hospitalized patients in three prominent medical centers in India (Fortis Memorial Research Centre, Gurugram, S L Raheja Hospital, Mumbai, and Fortis Hospital, Anandapur, Kolkata) with nosocomial pneumonia and documented gram-negative Klebsiella pneumoniae (KP)-confirmed infection were collected. This study assessed the effectiveness, usage pattern of ceftazidime-avibactam, and clinical and microbiological cure rates.

RESULTS

Among the 116 patients included, 78.45% (91/116) showed clinical cure. Microbiological cure was observed in nine out of 13 (69.23%) patients. In the subset analysis, a clinical cure rate of 84.85% (28/33) and microbiological recovery rate of 62.50% (5/8) were observed when ceftazidime-avibactam was initiated within 72 hours of diagnosis. Ceftazidime-avibactam was administered for a mean (±SD) duration of 7.79 ± 4.43 days, with improvement in signs and symptoms reported among 91.38% (106/116). Ceftazidime-avibactam showed a susceptibility of 56% (28/56) in the study.

CONCLUSION

The current study showed a better clinical and microbiological cure rate with a safer tolerability profile of ceftazidime-avibactam in carbapenem-resistant KP nosocomial pneumonia and VAP. This study has further demonstrated that ceftazidime-avibactam may be used as one of the viable treatment choices in carbapenem-resistant KP with favorable clinical outcomes.

Perspectives on Assessing the Flexibility of Hospitals for Crisis Mode Operations: Lessons From the COVID-19 Pandemic in the Netherlands

BACKGROUND

The COVID-19 pandemic placed healthcare design at the heart of the crisis. Hospitals faced challenges such as rapidly increasing their intensive care unit capacity, enabling physical distancing measures, quickly converting to telehealth and telework practices, and above all, keeping patients and staff safe. Improving flexibility in hospital facility design and adaptability of hospital operations to function in "crisis mode" can be seen as ways of future-proofing for pandemics. In a design brief, flexibility is typically mentioned as an important target. Meanwhile, robustness of technical infrastructure is called for, and standardization at unit level with single-occupancy inpatient accommodation may be considered a way to enhance flexibility and adaptability in dealing with a surge in infectious patients.

AIM

To future-proof facility design with pandemic preparedness and resilience in mind, this study evaluated what kinds of interventions were taken in Dutch hospital facilities and what perspectives need to be considered when hospitals operate in crisis mode.

METHODS

We have collected data from facility and estate professionals from 30 Dutch hospitals. Using a practice-based approach, in-depth interviewing helped uncover and compare successful operational strategies and design elements that provided the flexibility needed in the early stages of the recent crisis.

RESULTS

As we looked at existing facilities and alterations made to allow hospitals to operate during the COVID-19 pandemic, we discovered that staff availability and adaptability were deemed crucial.

CONCLUSION

We add the perspective of staff as an essential factor to be considered when future-proofing hospital facility desigr crisis mode operation.

Roles of crrAB two-component regulatory system in Klebsiella pneumoniae: growth yield, survival in initial colistin treatment stage, and virulence

OBJECTIVES

Alternation of the colistin resistance-regulating two-component regulatory system (crrAB) is a colistin-resistance mechanism in Klebsiella pneumoniae (K. pneumoniae), but its role in bacteria is not fully understood.

METHODS

Twelve colistin-susceptible K. pneumoniae clinical isolates were included in this study: six crrAB-positive and six crrAB-negative. We deleted the crrAB genes from two crrAB-positive isolates and complemented them. We measured the growth yields by determining growth curves in lysogeny broth and minimal media with or without Fe2+. In vitro selection rates for colistin resistance were determined by exposure to colistin, and survival rates against high concentrations of colistin (20 mg/L) at the early stage of growth (20 min) were investigated. Virulence was determined using a serum bactericidal assay and Galleria mellonella larval infection.

RESULTS

The presence of crrAB was not associated with colistin resistance and did not increase the in vitro selection rate of colistin resistance after exposure. The growth yield of crrAB-positive isolates was higher in lysogeny broth media and increased when Fe2+ was added to minimal media. The crrAB-positive isolates showed higher survival rates in the early stages of exposure to high colistin concentrations. Decreased serum resistance was identified in the crrAB-deleted mutants. More G. mellonella larvae survived when infected by crrAB-deleted mutants, and higher survival rates of bacteria were identified within the larvae infected with wild-type than crrAB-deletant isolates.

CONCLUSION

Through rapid response to external signals, crrAB would provide advantages for K. pneumoniae survival by increasing the final growth yield and initial survival against colistin treatment. This may partly contribute to the bacterial virulence.

Health care utilisation in Cox's Bazar district, Bangladesh, during the first year of the COVID-19 pandemic: A mixed-methods study among host communities

To respond to the COVID-19 pandemic, countries introduced public health and social measures that had indirect societal, economic consequences. Concerns during epidemics include continuity of routine health services. We investigate how healthcare utilisation and healthcare seeking behaviour changed during the first year of the COVID-19 pandemic among host communities in Cox's Bazar, Bangladesh. This mixed-methods study combines quantitative analyses of routine health data and population-based findings about healthcare seeking behaviours. Trends in consultations changed according to facility level (higher-level facilities included Upazila Health Complexes and District Hospitals; lower-level facilities included Community Clinics and Union Health and Family Welfare Centers). At the pandemic's beginning, drops were seen at higher-level health facilities for outpatient department (OPD) consultations, respiratory infections, and antenatal care. Minor reductions or increases were seen at lower-level facilities for the same services. Half of the subdistricts reported a cumulative increase in OPD and respiratory tract infection consultations. Most subdistricts reported a cumulative decrease in antenatal care. Child vaccinations dropped in all subdistricts, half of which did not catch-up, resulting in a cumulative decrease of delivered doses. Fear of contracting COVID-19 and financial constraints were the main reasons for decreased access. Drivers of healthcare seeking behaviours should be better understood to guide preparedness and service delivery modalities at primary and secondary levels.

Risk factor and resistance profile of colistin resistant Acinetobacter baumannii and Klebsiellapneumoniae

PURPOSE

Antimicrobial resistance is one of the major global health concerns, which is relentless despite multipronged measures. Carbapenems and colistin, drug of choice for multi drug resistant Klebsiella pneumoniae and Acinetobacter species, have also been rendered of less use. This underlines the need to decipher prevalence of colistin resistance comprehensively for formulation of hospital and country-wise antibiogram. We conducted this study to decipher the prevalence of colistin resistance in our tertiary care centre of North India.

MATERIALS AND METHODS

This was a prospective, case control study conducted over a period of one and half years. All carbapenem resistant Klebsiella pneumoniae and Acinetobacter isolates were included. Kirby-Bauer method of disc diffusion was used for all antibiotics, except colistin for which broth microdilution was performed and interpreted using CLSI guidelines. Demographic details, risk factors and outcome details were recorded. Genotypic characterization was performed using representative strains, for blaNDM, blaKPC and blaOXA-48.

RESULTS

Of 103 carbapenem resistant isolates, 7 were found to be colistin resistant. Median age was 43 years, with male:female ratio of 1.1:1. 35% isolates were from pus samples, followed by endotracheal aspirate. Colistin resistance was more in ICUs than wards. Presence of indwelling devices was noted as the most common risk factor, followed by previous antibiotic exposure and use of steroids/immunosuppressants. Indwelling devices, steroids/immunosuppressants usage, length of hospital stay, COPD, prior usage of carbapenems, piperacillin-tazobactam and colistin, usage of ampicillin-sulbactam during hospital stay, were statistically significant. Mortality was noted in 4 cases, with statistical difference between control and case arm. The blaNDM and blaOXA-48 were noted in 3 and 2 isolates respectively, with absence of blaKPC.

CONCLUSION

The present study unravels incidence, risk factors and resistance encoding genes at our centre. This is of immense help in formulation of antibiotic policies and guidance for infection control measures.

Multidrug-resistant and carbapenemase-producing critical gram-negative bacteria isolated from the intensive care unit environment in Amhara region, Ethiopia

BACKGROUND

Intensive care units are units where healthcare-associated infections (HAIs) are common and antimicrobial resistance rates are increasing. Microbial contamination in hospital environment plays an important role in the development of HAIs. Intervention-based improvements in infection prevention and control at national and facility level are critical for the containment of antimicrobial resistance and prevention of HAIs.

OBJECTIVES

This study aimed to determine the distribution of multidrug-resistant and carbapenemase-producing critical gram negative bacteria (Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa and Acinetobacter species) and their antibiotic resistance in intensive care unit environmental surfaces at the University of Gondar and Felege Hiwot Comprehensive Specialized Hospitals.

METHODS

This was multicenter hospital-based cross sectional study. Environmental samples were swabbed from all intensive care units using a normal saline moistened-sterile cotton tip stick. Bacteria culturing and antibiotic susceptibility testing were performed following standard microbiological techniques. Selected meropenem-resistant isolates were phenotypically assessed for carbapenemase production using modified and simplified carbapenem inactivation methods.

RESULTS

From a total of 384 environmental samples analyzed, 126 (32.8%) showed growth and 162 isolates were identified. K. pneumoniae (79/162, 48.8%) was the commonest isolate followed by Acinetobacter species (51/162, 31.5%), E. coli (19/162, 11.7%) and P. aeruginosa (13/162, 8.0%). Multidrug-resistant and carbapenemase-producing isolates were detected on most hospital environment surface types, especially from the baby bed sets and incubators. The most common multidrug-resistant and principal carbapenemase producer was K. pneumoniae, with rates of 71(89.9%) and 24(85.7%), respectively.

CONCLUSION

This study revealed the distribution of multidrug-resistant and carbapenemase-producing critical gram negative bacteria in the environment of intensive care unit. Higher detection rate of multidrug-resistant and carbapenemase-producing K. pneumoniae on most environmental surfaces calls for urgent control action and further attention.

Multidrug-resistant Escherichia coli isolated from patients and surrounding hospital environments in Bangladesh: A molecular approach for the determination of pathogenicity and resistance

Extended spectrum β-lactamase producing Escherichia coli (ESBL E. coli) is a primary concern for hospital and community healthcare settings, often linked to an increased incidence of nosocomial infections. This study investigated the characteristics of ESBL E. coli isolated from hospital environments and clinical samples. In total, 117 ESBL E. coli isolates were obtained. The isolates were subjected to molecular analysis for the presence of resistance and virulence genes, antibiotic susceptibility testing, quantitative adherence assay, ERIC-PCR for phylogenetic analysis and whole genome sequencing of four highly drug resistant isolates. Out of the 117 isolates, 68.4% were positive for blaCTX-M, 39.3% for blaTEM, 30.8% for blaNDM-1, 13.7% for blaOXA and 1.7% for blaSHV gene. Upon screening for diarrheagenic genes, no isolates were found to harbour any of the tested genes. In the case of extraintestinal pathogenic E. coli (ExPEC) virulence factors, 7.6%, 11%, 5.9%, 4.3% and 21.2% of isolates harbored the focG, kpsMII, sfaS, afa and iutA genes, respectively. At a temperature of 25°C, 14.5% of isolates exhibited strong biofilm formation with 21.4% and 28.2% exhibiting moderate and weak biofilm formation respectively, whereas 35.9% were non-biofilm formers. On the other hand at 37°C, 2.6% of isolates showed strong biofilm formation with 3.4% and 31.6% showing moderate and weak biofilm formation respectively, whereas, 62.4% were non-biofilm formers. Regarding antibiotic susceptibility testing, all isolates were found to be multidrug-resistant (MDR), with 30 isolates being highly drug resistant. ERIC-PCR resulted in 12 clusters, with cluster E-10 containing the maximum number of isolates. Hierarchical clustering and correlation analysis revealed associations between environmental and clinical isolates, indicating likely transmission and dissemination from the hospital environment to the patients. The whole genome sequencing of four highly drug resistant ExPEC isolates showed the presence of various antimicrobial resistance genes, virulence factors and mobile genetic elements, with isolates harbouring the plasmid incompatibility group IncF (FII, FIB, FIA). The sequenced isolates were identified as human pathogens with a 93.3% average score. This study suggests that ESBL producing E. coli are prevalent in the healthcare settings of Bangladesh, acting as a potential reservoir for AMR bacteria. This information may have a profound effect on treatment, and improvements in public healthcare policies are a necessity to combat the increased incidences of hospital-acquired infections in the country.

The Etiological and Drug Resistance Characteristics of Multidrug-Resistant Pathogens in Patients Requiring Extracorporeal Membrane Oxygenation: A Retrospective Cohort Study

Purpose

Infections induced by multidrug-resistant (MDR) pathogens are one of the most common and serious complications in extracorporeal membrane oxygenation (ECMO) patients. However, there is currently little research about "ECMO and MDR bacteria". The purpose of our study was to clarify the epidemiological characteristics of MDR bacteria and provide references for empiric antibiotic treatments according to the drug susceptibility tests for ECMO patients.

Patients and Methods

There were 104 patients admitted to our department and receiving ECMO treatments between January 2014 and December 2022. Altogether, 61 veno-arterial ECMO (VA-ECMO) and 29 veno-venous ECMO (VV-ECMO) patients enrolled. The data on other intensive care unit (ICU) patients in our department in the same period are summarized.

Results

A total of 82 MDR bacteria were detected from ECMO patients, and most of these were MDR Gram-negative bacteria (MDR-GNB). There were also 5559 MDR-GNB collected from other patients in our department in the same period. We found that the distribution of MDR-GNB in ECMO patients was different from other critical patients. The proportion of Klebsiella pneumoniae (MDR-KP) in VV-ECMO patients was higher than other critical patients (35.1% and 21.3%, respectively). Moreover, the proportions of MDR Acinetobacter baumannii (MDR-AB) of VA-ECMO and VV-ECMO were higher than other critical patients (54.6%, 43.2% and 30.5%, respectively). In addition, MDR-AB and MDR-KP in ECMO patients exhibited higher percentages of drug resistance to possibly appropriate antibiotics for other critical patients, but showed better sensitivity to colistin.

Conclusion

Infections induced by MDR-GNB in ECMO patients were serious and exhibited higher degrees of drug resistance compared with other ICU patients. Colistin might be an option to consider if there is no medical contraindication. However, widespread use of broad spectrum antibiotics is something that should be discouraged, and alternative options are being explored.

Effects of implementation of healthcare associated infection surveillance and interventional measures in the neonatal intensive care unit: Small steps matter

PURPOSE

Neonatal sepsis has been a global concern considering the mortality and morbidity. This study was undertaken to determine the effects of implementation of interventions namely healthcare associated infection (HAI) surveillance and hand hygiene (HH) monitoring in the neonatal intensive care unit (NICU).

MATERIALS AND METHODS

The cohort study was conducted in the NICU of a tertiary care hospital over a period of June-September 2021 (pre-intervention) to October-March 2022 (post-intervention). HAI surveillance of primary bloodstream infections (BSI) and HH monitoring was initiated as interventions post outbreak due to non-albicans Candida (NAC). The primary outcome of the interventions was to record any improvement in HH rates or any change in HAI rates in the 6 months intervention period. Characteristics of the pre- and post-intervention period were compared by Fisher exact test.

RESULTS

There was significant reduction in BSI cases in the post-intervention period (p ​< ​0.05). Mortality and BSI due to NAC were significantly more in the pre-intervention period even though low birth weight neonates (<2500 ​g) were significantly more in the post-intervention period (p ​< ​0.05). The HAI rate for primary BSI in the NICU was 10.82 per 1000 patient days. The overall adherence rate to HH was 10.68% (complete) and 73.35% (partial). HAI rates were seen to change reciprocally with changes in HH rates.

CONCLUSIONS

HAI rates of primary BSI in the NICU could be regulated by the effective implementation of HAI surveillance, HH monitoring, feedback meetings with the NICU staff and other simple interventional measures even in resource-limited setups.

Microbiologic Cure with a Simplified Dosage of Intravenous Colistin in Adults: A Retrospective Cohort Study

Purpose

Colistin's FDA weight-based dosing (WBD) and frequency are both expressed in a broad range. Therefore, a simplified fixed-dose regimen (SFDR) of intravenous colistin based on three body-weight segments has been established for adults. The SFDR falls within the WBD range of each body-weight segment and accounts for the pharmacokinetic features. This study compared microbiologic cure with colistin SFDR to WBD in critically ill adults.

Patients and Methods

A retrospective cohort study was conducted for colistin orders from January 2014 to February 2022. The study included ICU patients who received intravenous colistin for carbapenem-non-susceptible, colistin-intermediate Gram-negative bacilli infections. Patients received the SFDR after the protocol was implemented, as the WBD was previously used. The primary endpoint was microbiologic cure. Secondary endpoints were 30-day infection recurrence and acute kidney injury (AKI).

Results

Of the 228 screened patients, 84 fulfilled the inclusion and matching criteria (42 in each group). The microbiologic cure rate was 69% with the SFDR and 36% with the WBD [p=0.002]. Infection recurred in four of the 29 patients who had a microbiologic cure with the SFDR (14%), and in six of the 15 patients with WBD (40%); [p=0.049]. AKI occurred in seven of the 36 SFDR patients who were not on hemodialysis (19%) and 15 of the 33 WBD patients (46%); [p=0.021].

Conclusion

In this study, colistin SFDR was associated with a higher microbiologic cure in carbapenem-non-susceptible, colistin-intermediate Gram-negative bacilli infections and with a lower incidence of AKI in critically ill adults compared to WBD.

Prevalence and clonal diversity of carbapenem-resistant Klebsiella pneumoniae causing neonatal infections: A systematic review of 128 articles across 30 countries

BACKGROUND

Klebsiella pneumoniae is the most common pathogen causing neonatal infections, leading to high mortality worldwide. Along with increasing antimicrobial use in neonates, carbapenem-resistant K. pneumoniae (CRKP) has emerged as a severe challenge for infection control and treatment. However, no comprehensive systematic review is available to describe the global epidemiology of neonatal CRKP infections. We therefore performed a systematic review of available data worldwide and combined a genome-based analysis to address the prevalence, clonal diversity, and carbapenem resistance genes of CRKP causing neonatal infections.

METHODS AND FINDINGS

We performed a systematic review of studies reporting population-based neonatal infections caused by CRKP in combination with a genome-based analysis of all publicly available CRKP genomes with neonatal origins. We searched multiple databases (PubMed, Web of Science, Embase, Ovid MEDLINE, Cochrane, bioRxiv, and medRxiv) to identify studies that have reported data of neonatal CRKP infections up to June 30, 2022. We included studies addressing the prevalence of CRKP infections and colonization in neonates but excluded studies lacking the numbers of neonates, the geographical location, or independent data on Klebsiella or CRKP isolates. We used narrative synthesis for pooling data with JMP statistical software. We identified 8,558 articles and excluding those that did not meet inclusion criteria. We included 128 studies, none of which were preprints, comprising 127,583 neonates in 30 countries including 21 low- and middle-income countries (LMICs) for analysis. We found that bloodstream infection is the most common infection type in reported data. We estimated that the pooled global prevalence of CRKP infections in hospitalized neonates was 0.3% (95% confidence interval [CI], 0.2% to 0.3%). Based on 21 studies reporting patient outcomes, we found that the pooled mortality of neonatal CRKP infections was 22.9% (95% CI, 13.0% to 32.9%). A total of 535 neonatal CRKP genomes were identified from GenBank including Sequence Read Archive, of which 204 were not linked to any publications. We incorporated the 204 genomes with a literature review for understanding the species distribution, clonal diversity, and carbapenemase types. We identified 146 sequence types (STs) for neonatal CRKP strains and found that ST17, ST11, and ST15 were the 3 most common lineages. In particular, ST17 CRKP has been seen in neonates in 8 countries across 4 continents. The vast majority (75.3%) of the 1,592 neonatal CRKP strains available for analyzing carbapenemase have genes encoding metallo-β-lactamases and NDM (New Delhi metallo-β-lactamase) appeared to be the most common carbapenemase (64.3%). The main limitation of this study is the absence or scarcity of data from North America, South America, and Oceania.

CONCLUSIONS

CRKP contributes to a considerable number of neonatal infections and leads to significant neonatal mortality. Neonatal CRKP strains are highly diverse, while ST17 is globally prevalent and merits early detection for treatment and prevention. The dominance of blaNDM carbapenemase genes imposes challenges on therapeutic options in neonates and supports the continued inhibitor-related drug discovery.

Phages for treatment of Klebsiella pneumoniae infections

Klebsiella pneumoniae is an opportunistic pathogen involved in both hospital- and community-acquired infections. K. pneumoniae is associated with various infections, including pneumonia, septicemia, meningitis, urinary tract infection, and surgical wound infection. K. pneumoniae possesses serious virulence, biofilm formation ability, and severe resistance to many antibiotics especially hospital-acquired strains, due to excessive use in healthcare systems. This limits the available effective antibiotics that can be used for patients suffering from K. pneumoniae infections; therefore, alternative treatments are urgently needed. Bacteriophages (for short, phages) are prokaryotic viruses capable of infecting, replicating, and then lysing (lytic phages) the bacterial host. Phage therapy exhibited great potential for treating multidrug-resistant bacterial infections comprising K. pneumoniae. Hence, this chapter emphasizes and summarizes the research articles in the PubMed database from 1948 until the 15th of December 2022, addressing phage therapy against K. pneumoniae. The chapter provides an overview of K. pneumoniae phages covering different aspects, including phage isolation, different morphotypes of isolated phages, in vitro characterization, anti-biofilm activity, various therapeutic forms, in vivo research and clinical studies.

Metagenomic Insight into Microbiome and Antibiotic Resistance Genes of High Clinical Concern in Urban and Rural Hospital Wastewater of Northern India Origin: a Major Reservoir of Antimicrobial Resistance

India is one of the largest consumers and producers of antibiotics and a hot spot for the emergence and proliferation of antimicrobial resistance genes (ARGs). Indian hospital wastewater (HWW) accumulates ARGs from source hospitals and often merges with urban wastewater, with the potential for environmental and human contamination. Despite its putative clinical importance, there is a lack of high-resolution resistome profiling of Indian hospital wastewater, with most studies either relying on conventional PCR-biased techniques or being limited to one city. In this study, we comprehensively analyzed antibiotic resistomes of wastewater from six Indian hospitals distributed in rural and urban areas of northern India through shotgun metagenomics. Our study revealed the predominance of ARGs against aminoglycoside, macrolide, carbapenem, trimethoprim, and sulfonamide antibiotics in all the samples through both read-based analysis and assembly-based analysis. We detected the mobile colistin resistance gene mcr-5.1 for the first time in Indian hospital sewage. blaNDM-1 was present in 4 out of 6 samples and was carried by Pseudomonas aeruginosa in HWW-2, Klebsiella pneumoniae in HWW-4 and HWW-6, and Acinetobacter baumanii in HWW-5. Most ARGs were plasmid-mediated and hosted by Proteobacteria. We identified virulence factors and transposable elements flanking the ARGs, highlighting the role of horizontal gene transmission of ARGs. IMPORTANCE There is a paucity of research on detailed antibiotic resistome and microbiome diversity of Indian hospital wastewater. This study reports the predominance of clinically concerning ARGs such as the beta-lactamases blaNDM and blaOXA and the colistin resistance gene mcr and their association with the microbiome in six different Indian hospital wastewaters of both urban and rural origin. The abundance of plasmid-mediated ARGs and virulence factors calls for urgent AMR crisis management. The lack of proper wastewater management strategies meeting international standards and open drainage systems further complicates the problem of containing the ARGs at these hospitals. This metagenomic study presents the current AMR profile propagating in hospital settings in India and can be used as a reference for future surveillance and risk management of ARGs in Indian hospitals.

Outbreak of colistin resistant, carbapenemase (bla NDM, bla OXA-232) producing Klebsiella pneumoniae causing blood stream infection among neonates at a tertiary care hospital in India

Infections caused by multi-drug resistant Klebsiella pneumoniae are a leading cause of mortality and morbidity among hospitalized patients. In neonatal intensive care units (NICU), blood stream infections by K. pneumoniae are one of the most common nosocomial infections leading to poor clinical outcomes and prolonged hospital stays. Here, we describe an outbreak of multi-drug resistant K. pneumoniae among neonates admitted at the NICU of a large tertiary care hospital in India. The outbreak involved 5 out of 7 neonates admitted in the NICU. The antibiotic sensitivity profiles revealed that all K. pneumoniae isolates were multi-drug resistant including carbapenems and colistin. The isolates belonged to three different sequence types namely, ST-11, ST-16 and ST-101. The isolates harboured carbapenemase genes, mainly bla NDM-1, bla NDM-5 and bla OXA-232 besides extended-spectrum β-lactamases however the colistin resistance gene mcr-1, mcr-2 and mcr-3 could not be detected. Extensive environmental screening of the ward and healthcare personnel led to the isolation of K. pneumoniae ST101 from filtered incubator water, harboring bla NDM-5, bla OXA-232 and ESBL genes (bla CTX-M) but was negative for the mcr genes. Strict infection control measures were applied and the outbreak was contained. This study emphasizes that early detection of such high-risk clones of multi-drug resistant isolates, surveillance and proper infection control practices are crucial to prevent outbreaks and further spread into the community.

Bloodstream infections in neonates with central venous catheters in three tertiary neonatal intensive care units in Pune, India

BACKGROUND

Neonates admitted to the neonatal intensive care unit (NICU) are at risk for healthcare-associated infections, including central line-associated bloodstream infections. We aimed to characterize the epidemiology of bloodstream infections among neonates with central venous catheters admitted to three Indian NICUs.

METHODS

We conducted a prospective cohort study in three tertiary NICUs, from May 1, 2017 until July 31, 2019. All neonates admitted to the NICU were enrolled and followed until discharge, transfer, or death. Cases were defined as positive blood cultures in neonates with a central venous catheter in place for greater than 2 days or within 2 days of catheter removal.

RESULTS

During the study period, 140 bloodstream infections were identified in 131 neonates with a central venous catheter. The bloodstream infection rate was 11.9 per 1000 central line-days. Gram-negative organisms predominated, with 38.6% of cases caused by Klebsiella spp. and 14.9% by Acinetobacter spp. Antimicrobial resistance was prevalent among Gram-negative isolates, with 86.9% resistant to third- or fourth-generation cephalosporins, 63.1% to aminoglycosides, 61.9% to fluoroquinolones, and 42.0% to carbapenems. Mortality and length of stay were greater in neonates with bloodstream infection than in neonates without bloodstream infection (unadjusted analysis, p < 0.001).

CONCLUSIONS

We report a high bloodstream infection rate among neonates with central venous catheters admitted to three tertiary care NICUs in India. Action to improve infection prevention and control practices in the NICU is needed to reduce the morbidity and mortality associated with BSI in this high-risk population.

Tracking the Outbreak of Carbapenem-Resistant Klebsiella pneumoniae in an Emergency Intensive Care Unit by Whole Genome Sequencing

Purpose

The spread of carbapenem-resistant Klebsiella pneumoniae (CRKP) has become a great threat to human health, especially in the intensive care unit. The aim of this study was to identify the origin and transmission route of a CRKP outbreak in an emergency intensive care unit (EICU), so as to provide prevention and control strategies for CRKP outbreak.

Methods

Between Mar and Jun 2018, 10 CRKP isolates from 5 patients in the EICU ward of Shanghai Ruijin hospital north were collected. Modified carbapenem inactivation method (mCIM) and whole-genome sequencing (WGS) were performed on all 10 CRKP isolates. By integrating the genomic and epidemiological data of our isolates and 9 CRKP isolates from an outbreak in another hospital, a putative transmission map was constructed.

Results

All 10 outbreak strains were carbapenemase positive in mCIM and belonged to the sequence type 11 (ST11) clone, harbored a set of resistance genes and virulence genes. The phylogenetic tree of CRKP isolates based on two outbreaks revealed that the initial isolate A1 in our EICU ward belonged to one branch of isolates in another hospital, this introductive isolate evolved and caused a subsequent outbreak in our EICU.

Conclusion

Integration of genomic and epidemiological data can yield a clear transmission map of CRKP outbreak. Monitoring the rapid evolution of CRKP at the early stage of outbreak, CRKP monitoring after patients are discharged, active surveillance of newly admitted patients, environmental hygiene and efficient antibiotic treatment may be the key to prevent and control of CRKP outbreak.

Clinical carbapenem-resistant Klebsiella pneumoniae isolates simultaneously harboring blaNDM-1, blaOXA types and qnrS genes from the Kingdom of Bahrain: Resistance profile and genetic environment

The prevalence of Carbapenem-resistant Klebsiella pneumoniae (CRKP) is currently increasing worldwide, prompting WHO to classify it as an urgent public health threat. CRKP is considered a difficult to treat organism owing to limited therapeutic options. In this study, a total of 24 CRKP clinical isolates were randomly collected from Salmaniya Medical Complex, Bahrain. Bacterial identification and antibiotic susceptibility testing were performed, on MALDI-TOF and VITEK-2 compact, respectively. The isolates were screened for carbapenem resistance markers (bla_NDM,bla_OXA-23,bla_OXA-48 and bla_OXA-51) and plasmid-mediated quinolone resistance genes (qnrA, qnrB, and qnrS) by monoplex PCR. On the other hand, only colistin-resistant isolates (n=12) were screened for MCR-1, MCR-2 and MCR-3 genes by monoplex PCR. Moreover, the Genetic environment of bla_NDM, integrons analysis, and molecular characterization of plasmids was also performed. Antibiotic susceptibility revealed that all the isolates (100%) were resistant to ceftolozane/tazobactam, piperacillin/tazobactam, 96% resistant to ceftazidime, trimethoprim/sulfamethoxazole, 92% resistant to meropenem, gentamicin and cefepime, 88% resistant to ciprofloxacin, imipenem, and 37% resistant to amikacin. Ceftazidime/avibactam showed the least resistance (12%). 75% (n=12/16) were resistant to colistin and 44% (n=7/16) showed intermediate susceptibility to tigecycline. The detection of resistant determinants showed that the majority (95.8%) of CRKP harbored bla_NDM-1, followed by bla_OXA-48 (91.6%) bla_OXA-51 (45.8%), and bla_OXA-23 (41.6%). Sequencing of the bla_NDM amplicons revealed the presence of bla_NDM-1. Alarmingly, 100% of isolates showed the presence of qnrS. These predominant genes were distributed in various combinations wherein the majority were bla_NDM-1 + bla_OXA-51+ qnrS + bla_OXA-48 (n =10, 41.7%), bla_NDM-1 + bla_OXA-23+ qnrS + bla_OXA-48 (n=8, 33.3%), among others. In conclusion, the resistance rate to most antibiotics is very high in our region, including colistin and tigecycline, and the genetic environment of CRKP is complex with the carriage of multiple resistance markers. Resistance to ceftazidime/avibactam is uncommon and hence can be used as a valuable option for empirical therapy. Molecular data on resistance markers and the genetic environment of CRKP is lacking from this geographical region; this would be the first report addressing the subject matter. Surveillance and strict infection control strategies should be reinforced in clinical settings to curb the emergence and spread of such isolates.