In vitro selection of Neisseria gonorrhoeae unveils novel mutations associated with extended-spectrum cephalosporin resistance.

The emergence of Neisseria gonorrhoeae strains resistant to extended-spectrum cephalosporins (ESCs) is a worldwide concern because this class of antibiotics represents the last empirical treatment option for gonorrhea. The abusive use of antimicrobials may be an essential factor for the emergence of ESC resistance in N. gonorrhoeae. Cephalosporin resistance mechanisms have not been fully clarified. In this study, we mapped mutations in the genome of N. gonorrhoeae isolates after resistance induction with cefixime and explored related metabolic pathways. Six clinical isolates with different antimicrobial susceptibility profiles and genotypes and two gonococcal reference strains (WHO F and WHO Y) were induced with increasing concentrations of cefixime. Antimicrobial susceptibility testing was performed against six antimicrobial agents before and after induction. Clinical isolates were whole-genome sequenced before and after induction, whereas reference strains were sequenced after induction only. Cefixime resistance induction was completed after 138 subcultures. Several metabolic pathways were affected by resistance induction. Five isolates showed SNPs in PBP2. The isolates M111 and M128 (ST1407 with mosaic penA-34.001) acquired one and four novel missense mutations in PBP2, respectively. These isolates exhibited the highest minimum inhibitory concentration (MIC) for cefixime among all clinical isolates. Mutations in genes contributing to ESC resistance and in other genes were also observed. Interestingly, M107 and M110 (ST338) showed no mutations in key determinants of ESC resistance despite having a 127-fold increase in the MIC of cefixime. These findings point to the existence of different mechanisms of acquisition of ESC resistance induced by cefixime exposure. Furthermore, the results reinforce the importance of the gonococcal antimicrobial resistance surveillance program in Brazil, given the changes in treatment protocols made in 2017 and the nationwide prevalence of sequence types that can develop resistance to ESC.

Genetic diversity and antimicrobial resistance of invasive, noninvasive and colonizing group B Streptococcus isolates in southern Brazil.

Introduction: Group B Streptococcus (GBS) is a human commensal bacterium that is also associated with infection in pregnant and non-pregnant adults, neonates and elderly people. Gap Statement: The authors hypothesize that knowledge of regional GBS genetic patterns may allow the use of prevention and treatment measures to reduce the burden of streptococcal disease. Aim: The aim was to report the genotypic diversity and antimicrobial sensitivity profiles of invasive, noninvasive urinary and colonizing GBS strains, and evaluate the relationships between these findings. Methodology: The study included consecutive and non-duplicated GBS isolates recovered in southern Brazil from 2015 to 2017. We performed multiple-locus variable-number tandem repeat analysis (MLVA) and PCR analyses to determine capsular serotypes and identify the presence of the resistance genes mefA/E, ermB and ermA/TR, and also antibiotic susceptibility testing. Results: The sample consisted of 348 GBS strains, 42 MLVA types were identified, and 4 of them represented 64 % of isolates. Serotype Ia was the most prevalent (42.2 %) and was found in a higher percentage associated with colonization, followed by serotypes V (24.4 %), II (17.8 %) and III (7.8 %). Serotype V was associated with invasive isolates and serotypes II and III with noninvasive isolates, without significant differences. All isolates were susceptible to penicillin. GBS 2018/ hvgA was observed in 17 isolates, with 11 belonging to serogroup III. The Hunter-Gaston diversity index was calculated as 0.879. The genes mefA/E, erm/B and erm/A/TR were found in 45, 19 and 46 isolates. Conclusion: This report suggests that the circulating GBS belong to a limited number of genetic lineages. The most common genotypes were Ia/MT12 and V/MT18, which are associated with high resistance to macrolides and the presence of the genes mefA/E and ermA/TR. Penicillin remains the antibiotic of choice. Implementation of continuous surveillance of GBS infections will be essential to assess GBS epidemiology and develop accurate GBS prevention, especially strategies associated with vaccination.

Spectinomycin, gentamicin, and routine disc diffusion testing: An alternative for the treatment and monitoring of multidrug-resistant Neisseria gonorrhoeae?

INTRODUCTION: Neisseria gonorrhoeae is a major concern of public health due to its extraordinary capacity to develop and acquire resistance to different antimicrobials used to treat gonorrhoea. Limited treatment options and uncontrolled transmission have raised the need to assess the antimicrobial susceptibility profile of the isolates and to establish affordable alternatives for laboratory diagnosis. OBJECTIVES: This study aimed to (i) determine the susceptibility profile of 336 clinical isolates of N. gonorrhoeae to ceftriaxone, azithromycin, ciprofloxacin, spectinomycin and gentamicin by the gold standard agar dilution method; (ii) assess the agreement among agar dilution and disc diffusion results for ciprofloxacin, azithromycin, ceftriaxone, spectinomycin and gentamicin. RESULTS: All isolates were susceptible to ceftriaxone and spectinomycin. The levels of resistance to azithromycin and ciprofloxacin were 3.9% and 35.1%, respectively. Intermediate susceptibility to gentamicin was observed in 19.4% of isolates. There was 100% agreement between methods for spectinomycin and ceftriaxone, 99.7% for ciprofloxacin, and 85.7% for azithromycin. For gentamicin, there was 86.3% agreement between agar dilution and disc diffusion, resulting in intermediate susceptible by one method and susceptible by the other method, defined as minor errors. The discordance among agar dilution and disc diffusion results is acceptable for ciprofloxacin, ceftriaxone and spectinomycin as per CLSI M23-Ed4. CONCLUSIONS: Spectinomycin and gentamicin can be considered in some cases as options for the treatment of gonorrhoea in Brazil. Disc diffusion can be an alternative method in routine testing with comparable accuracy to agar dilution.

Genomic characterization of variants on mycolic acid metabolism genes in Mycobacterium tuberculosis isolates from Santa Catarina, Southern Brazil.

Mycobacterium tuberculosis has a complex cell wall containing mycolic acids (MA), which play an important role in pathogenesis, virulence, and survival by protecting the cell against harsh environments. Studies have shown that genes encoding enzymes involved in MA synthesis are essential to mycobacterial functionality. Here, we used whole-genome sequencing to evaluate mutations in genes related to MA metabolism in M. tuberculosis isolates from pulmonary tuberculosis patients of the Florianópolis Metropolitan Area, Santa Catarina, Brazil, and assessed associations with clinical, epidemiological, and genotypic data. The mutations Rv3057c Asp112Ala (104/151), Rv3720 His70Arg (104/151), and Rv3802c Val50Phe (105/151) were identified in about 69% of the isolates and were related to the LAM lineage. SIT 216/LAM5 (13.2%, 20/151) had the highest frequency and presented the mutations accD2 Lys23Glu, kasA Gly269Ser, mmaA4 Asn165Ser, otsB1 Asp617Asn, Rv3057c Asp112Ala, Rv3720 His70Arg, Rv3802c Val50Phe, and tgs4 Ala216Glu. All SIT 73/T isolates (6.6%, 10/151) showed a characteristic and exclusive gene mutation pattern: amiD Rv3376 3790075G > A, fbpA-aftB 4266941G > A, echA11 Asn220fs, and otsB2 Ser110Arg. SITs 20/LAM1, 64/LAM6, 50/H3, 137/X2, and 119/X1 were also related to specific mutations. SITs from the LAM lineage differed in mutation profile from those of the T, Haarlem, and X lineages. Isolates from patients who had treatment failure showed mutations that do not seem to have a pattern related to this outcome. It was possible to identify a broad repertoire of single-nucleotide polymorphisms in genes related to MA metabolism in M. tuberculosis isolates. This study also described, for the first time, the variability between different SITs/sublineages of Lineage 4 circulating in Florianópolis Metropolitan Area.

Healthcare-Associated Infections-Related Bacteriome and Antimicrobial Resistance Profiling: Assessing Contamination Hotspots in a Developing Country Public Hospital.

Hospital-built environment colonization by healthcare-associated infections-related bacteria (HAIrB) and the interaction with their occupants have been studied to support more effective tools for HAI control. To investigate HAIrB dynamics and antimicrobial resistance (AMR) profile we carried out a 6-month surveillance program in a developing country public hospital, targeting patients, hospital environment, and healthcare workers, using culture-dependent and culture-independent 16S rRNA gene sequencing methods. The bacterial abundance in both approaches shows that the HAIrB group has important representativeness, with the taxa Enterobacteriaceae, Pseudomonas, Staphylococcus, E. coli, and A. baumannii widely dispersed and abundant over the time at the five different hospital units included in the survey. We observed a high abundance of HAIrB in the patient rectum, hands, and nasal sites. In the healthcare workers, the HAIrB distribution was similar for the hands, protective clothing, and mobile phones. In the hospital environment, the healthcare workers resting areas, bathrooms, and bed equipment presented a wide distribution of HAIrB and AMR, being classified as contamination hotspots. AMR is highest in patients, followed by the environment and healthcare workers. The most frequently detected beta-lactamases genes were, bla SHV-like, bla OXA- 23 -like, bla OXA- 51 -like, bla KPC-like, bla CTX-M- 1, bla CTX-M- 8, and bla CTX-M- 9 groups. Our results demonstrate that there is a wide spread of antimicrobial resistance due to HAIrB in the hospital environment, circulating among patients and healthcare workers. The contamination hotspots identified proved to be constant over time. In the fight for patient safety, these findings can reorient practices and help to set up new guidelines for HAI control.

Genomic analysis of Neisseria elongata isolate from a patient with infective endocarditis.

Neisseria elongata is part of the commensal microbiota of the oropharynx. Although it is not considered pathogenic to humans, N. elongata has been implicated in several cases of infective endocarditis (IE). Here, we report a case of IE caused by N. elongata subsp. nitroreducens (Nel_M001) and compare its genome with 17 N. elongata genomes available in GenBank. We also evaluated resistance and virulence profiles with Comprehensive Antibiotic Resistance and Virulence Finder databases. The results showed a wide diversity among N. elongata isolates. Based on the pangenome cumulative curve, we demonstrate that N. elongata has an open pangenome. We found several different resistance genes, mainly associated with antibiotic efflux pumps. A wide range of virulence genes was observed, predominantly pilus formation genes. Nel_M001 was the only isolate to present two copies of some pilus genes and not present nspA gene. Together, our results provide insights into how this commensal microorganism can cause IE and may assist further biological investigations on nonpathogenic Neisseria spp. Case reporting and pangenome analyses are critical for enhancing our understanding of IE pathogenesis, as well as for alerting physicians and microbiologists to enable rapid identification and treatment to avoid unfavorable outcomes.

An investigation about chronic prostatitis in ankylosing spondylitis.

BACKGROUND: Chronic prostatitis has been a common disease reported with high frequency in ankylosing spondylitis (AS) even from decades ago. Infectious (Chlamydia trachomatis) or non-infectious (uric acid) prostatitis can hypothetically trigger vertebral inflammation in AS. This study aimed to assess the features of chronic prostatitis in patients with AS compared to healthy controls. METHODS: A cross-sectional study including male patients with AS and healthy controls who agreed to undergo a prostate examination was conducted. Structured clinical interviews, prostate physical examinations, and cytological, biochemical, and microbiological tests on urinary samples collected before and after standardized prostatic massage (pre- and post-massage test) were performed. RESULTS: Ninety participants (45 AS patients, mean age: 52.5 ± 10.0 years, with longstanding disease, 12.4 ± 6.9 years, and 45 controls, mean age: 52.8 ± 12.1 years) were included. National Institutes of Health - Chronic Prostatitis Symptom Index (NIH-CPSI) scores were similar in the AS and control groups (4.0 [1.0-12.0] vs. 5.0 [1.0-8.5], p = 0.994). The frequencies of symptoms of chronic prostatitis (NIH-CPSI Pain Domain ≥4) were also similar in both groups (23.3% vs. 22.7%, p = 0.953). Results of polymerase chain reaction tests for Chlamydia trachomatis were negative in all tested urinary samples, and uric acid concentrations and leukocyte counts were similar in all pre- and post-massage urinary samples. CONCLUSIONS: In this study, chronic prostatitis occurred in male patients with AS, but its frequency and characteristics did not differ from those found in the healthy male population of similar age.

An investigation about chronic prostatitis in ankylosing spondylitis

Abstract Background: Chronic prostatitis has been a common disease reported with high frequency in ankylosing spondylitis (AS) even from decades ago. Infectious (Chlamydia trachomatis) or non-infectious (uric acid) prostatitis can hypothetically trigger vertebral inflammation in AS. This study aimed to assess the features of chronic prostatitis in patients with AS compared to healthy controls. Methods: A cross-sectional study including male patients with AS and healthy controls who agreed to undergo a prostate examination was conducted. Structured clinical interviews, prostate physical examinations, and cytological, biochemical, and microbiological tests on urinary samples collected before and after standardized prostatic massage (pre- and post-massage test) were performed. Results: Ninety participants (45 AS patients, mean age: 52.5 ± 10.0 years, with longstanding disease, 12.4 ± 6.9years, and 45 controls, mean age: 52.8 ± 12.1 years) were included. National Institutes of Health - Chronic Prostatitis Symptom Index (NIH-CPSI) scores were similar in the AS and control groups (4.0 [1.0-12.0] vs. 5.0 [1.0—8.5], p = 0.994). The frequencies of symptoms of chronic prostatitis (NIH-CPSI Pain Domain ≥4) were also similar in both groups (23.3% vs. 22.7%, p = 0.953). Results of polymerase chain reaction tests for Chlamydia trachomatis were negative in all tested urinary samples, and uric acid concentrations and leukocyte counts were similar in all pre- and post-massage urinary samples. Conclusions: In this study, chronic prostatitis occurred in male patients with AS, but its frequency and characteristics did not differ from those found in the healthy male population of similar age.

Author Correction: Genomic epidemiology of Mycobacterium tuberculosis in Santa Catarina, Southern Brazil.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Genomic epidemiology of Mycobacterium tuberculosis in Santa Catarina, Southern Brazil.

Mycobacterium tuberculosis (M.tb), the pathogen responsible for tuberculosis (TB) poses as the major cause of death among infectious diseases. The knowledge about the molecular diversity of M.tb enables the implementation of more effective surveillance and control measures and, nowadays, Whole Genome Sequencing (WGS) holds the potential to produce high-resolution epidemiological data in a high-throughput manner. Florianópolis, the state capital of Santa Catarina (SC) in south Brazil, shows a high TB incidence (46.0/100,000). Here we carried out a WGS-based evaluation of the M.tb strain diversity, drug-resistance and ongoing transmission in the capital metropolitan region. Resistance to isoniazid, rifampicin, streptomycin was identified respectively in 4.0% (n = 6), 2.0% (n = 3) and 1.3% (n = 2) of the 151 studied strains by WGS. Besides, resistance to pyrazinamide and ethambutol was detected in 0.7% (n = 1) and reistance to ethionamide and fluoroquinolone (FQ) in 1.3% (n = 2), while a single (0.7%) multidrug-resistant (MDR) strain was identified. SNP-based typing classified all isolates into M.tb Lineage 4, with high proportion of sublineages LAM (60.3%), T (16.4%) and Haarlem (7.9%). The average core-genome distance between isolates was 420.3 SNPs, with 43.7% of all isolates grouped across 22 genomic clusters thereby showing the presence of important ongoing TB transmission events. Most clusters were geographically distributed across the study setting which highlights the need for an urgent interruption of these large transmission chains. The data conveyed by this study shows the presence of important and uncontrolled TB transmission in the metropolitan area and provides precise data to support TB control measures in this region.

Performance of centralized versus decentralized tuberculosis treatment services in Southern Brazil, 2006-2015.

BACKGROUND: Tuberculosis (TB) control programs face the challenges of decreasing incidence, mortality rates, and drug resistance while increasing treatment adherence. The Brazilian TB control program recommended the decentralization of patient care as a strategy for combating the disease. This study evaluated the performance of this policy in an area with high default rates, comparing epidemiological and operational indicators between two similar municipalities. METHODS: This study analyzed epidemiological and operational indicators on new cases of pulmonary tuberculosis reported in the Brazilian Notifiable Diseases Information System between 2006 and 2015. In addition, to characterize differences between the populations of the two studied municipalities, a prospective cohort study was conducted between 2014 and 2015, in which patients with new cases of culture-confirmed pulmonary tuberculosis were interviewed and monitored until the disease outcome. A descriptive analysis, the chi-square test, and a Poisson regression model were employed to compare TB treatment outcomes and health care indicators between the municipalities. RESULTS: Two thousand three hundred nine cases were evaluated, of which 207 patients were interviewed. Over the 2006-2015 period, TB incidence per 100,000 population in the municipality with decentralized care was significantly higher (39%, 95% CI 27-49%) in comparison to that of the municipality with centralized care. TB treatment default rate (45%, 95% CI 12-90%) was also higher in the municipality with decentralized care. During the two-year follow-up, significant differences were found between patients in centralized care and those in decentralized care regarding treatment success (84.5 vs. 66.1%), treatment default (10.7 vs. 25.8%), illicit drug use (27.7 vs. 45.9%), and homelessness (3.6 vs. 12.9%). The operational indicators revealed that the proportion of control smear tests, medical imaging, and HIV tests were all significantly higher in the centralized care. However, a significantly higher proportion of patients started treatment in the early stages of the disease in the municipality with decentralized care. CONCLUSIONS: These data showed a low success rate in TB treatment in both municipalities. Decentralization of TB care, alone, did not improve the main epidemiological and operational indicators related to disease control when compared to centralized care. Full implementation of strategies already recommended is needed to improve TB treatment success rates.

Molecular epidemiology of Mycobacterium tuberculosis strains from prison populations in Santa Catarina, Southern Brazil.

The Tuberculosis (TB) notification rates are 5 to 81 times higher in prisons worldwide when compared to the general population. The state of Santa Catarina (SC) has few epidemiological data regarding TB in prisons. The aim of this study was to evaluate the molecular epidemiology of circulating strains in prisons of SC. The study comprised 95 clinical samples from six prisons. Among the cases included, all subjects were male, predominantly caucasians, and young adults, with low education level. The positive smear in the TB diagnosis comprised 62.0% of cases. About 50% of subjects had some condition associated with TB. The Spoligotyping results showed that the most frequent lineages were LAM (50.7%), T (22.2%) and S (11.6%). The 12-loci MIRU generated 62 different genotypes. The MSTs showed evolutionary relationships between Mycobacterium tuberculosis spoligotypes from SC and evolutionary relationships between the prison isolates and studied parameters. This first study on TB in prison units of SC highlighted the predominance of SIT216/LAM5, and SIT34/S. Interestingly, his profile was found to be different from that observed in a previous study performed with the state's general population. This data shows the need for continued surveillance of episodes of TB occurring among prison inmates in an emerging country like Brazil.

Antibiotic-Induced Pathobiont Dissemination Accelerates Mortality in Severe Experimental Pancreatitis.

Although antibiotic-induced dysbiosis has been demonstrated to exacerbate intestinal inflammation, it has been suggested that antibiotic prophylaxis may be beneficial in certain clinical conditions such as acute pancreatitis (AP). However, whether broad-spectrum antibiotics, such as meropenem, influence the dissemination of multidrug-resistant (MDR) bacteria during severe AP has not been addressed. In the currently study, a mouse model of obstructive severe AP was employed to investigate the effects of pretreatment with meropenem on bacteria spreading and disease outcome. As expected, animals subjected to biliopancreatic duct obstruction developed severe AP. Surprisingly, pretreatment with meropenem accelerated the mortality of AP mice (survival median of 2 days) when compared to saline-pretreated AP mice (survival median of 7 days). Early mortality was associated with the translocation of MDR strains, mainly Enterococcus gallinarum into the blood stream. Induction of AP in mice with guts that were enriched with E. gallinarum recapitulated the increased mortality rate observed in the meropenem-pretreated AP mice. Furthermore, naïve mice challenged with a mouse or a clinical strain of E. gallinarum succumbed to infection through a mechanism involving toll-like receptor-2. These results confirm that broad-spectrum antibiotics may lead to indirect detrimental effects during inflammatory disease and reveal an intestinal pathobiont that is associated with the meropenem pretreatment during obstructive AP in mice.

Molecular characterization and resistance profile of Salmonella Enteritidis PT4 and PT9 strains isolated in Brazil.

A total of 41 Salmonella Enteritidis strains, including phago-types (PTs) PT4 and PT9, were characterized by antimicrobial resistance profiles and PFGE. Of these strains, 34 were isolated from patients and foods, and 7 were of poultry origin. All strains were susceptible to ampicillin, chloramphenicol, cefotaxime, ciprofloxacin and trimethoprim/sulfamethoxazole, and 41.5 % (n = 17) were resistant to nalidixic acid. PFGE analysis using XbaI and SpeI restriction enzymes resulted in X1S1 as the prevalent pattern, which was present in 48.8 % (n = 20) of epidemic strains and in one strain isolated from discarded hatching eggs. Distinct patterns were found for the other strains isolated from poultry (X3S1, X8S8, X11S12, X11S13, X16S1 and X13S15). The S. Enteritidis PT9 strains associated with outbreaks of salmonellosis were highly similar (≥0.90), suggesting clonality. The PFGE genotypes were related to the PTs, and it was possible to differentiate strains isolated from patients with salmonellosis from other strains of non-epidemic origin. The PFGE results suggested that the S. Enteritidis strains of poultry origin were a possible source of human salmonellosis during the study period.

Phenotypic and genotypic characterization of group B streptococcal isolates in southern Brazil.

One-hundred sixty-eight group B streptococcal (GBS) isolates from a Brazilian hospital were phenotypically and genotypically characterized. Isolates were recovered from human sources from April 2006 to May 2008 and classified as either invasive, noninvasive, or colonizing isolates. Classical methods for serotyping and antibiotic resistance profiling were employed. Clonal groups were also defined by pulsed-field gel electrophoresis (PFGE). Results showed that susceptibility to beta-lactam antimicrobials was predominant among the isolates. Only 4.7% were resistant to erythromycin and clindamycin. The erm(B) gene was widely detected in our GBS isolates, according to our phenotypic results (constitutive macrolide-lincosamide-streptogramin B [cMLSB] resistance phenotype), and the erm(A) gene was also detected in some isolates. MLSB resistance was restricted to strains isolated from patients with noninvasive infections and carriers. Serotype Ia was predominant (38.1%), serotype IV isolates were found at a high frequency (13.1%), and few isolates of serotype III were identified (3%). Pulsed-field gel electrophoresis results revealed a variety of types, reflecting the substantial genetic diversity among GBS strains, although a great number of isolates could be clustered into two major groups with a high degree of genetic relatedness. Three main PFGE clonal groups were found, and isolates sharing the same PFGE type were grouped into different serotypes. Furthermore, in a few cases, isolates from the same patients and possessing the same PFGE type were of different serotypes. These findings could be related to the occurrence of capsular switching by horizontal transfer of capsular genes.

Carbapenem-resistant Pseudomonas aeruginosa: clonal spread in southern Brazil and in the state of Goiás

This study evaluated the clonal spread of carbapenem-resistant P. aeruginosa producing SPM-1 type metallo-β-lactamase (MBL), at the university hospital of Florianópolis, Santa Catarina, Brazil, compared to an epidemic clone previously reported, as well as strains collected in other three Brazilian states. Among the isolates, 17 (62 percent) were clonal and highly related to strains from other regions of Brazil. Six clonal strains harbored the blaSPM-1 gene. The finding of a unique SPM-1 producer clone suggests that its dissemination has contributed to the high resistance to carbapenems in Brazilian hospitals.

Intrahospital spread of carbapenem-resistant Pseudomonas aeruginosa in a University Hospital in Florianópolis, Santa Catarina, Brazil.

INTRODUCTION: Carbapenem-resistant Pseudomonas aeruginosa (CRPA) has been isolated with increasing frequency in Brazilian hospitals. Since June 2003, its detection in a teaching hospital in the city of Florianópolis, Brazil, has increased. This study aimed to investigate the minimal inhibitory concentration (MIC), presence of Metallo-beta-lactamase (MbetaL) and a possible clonal relationship among the isolates. METHODS: The study included 29 CRPA and seven isolates with reduced susceptibility. The MIC was determined by agar-dilution. Detection of MbetaL was performed by Double Disk Sinergism (DDS) and Combined Disk (CD). The MbetaL gene was verified by PCR and nucleotide sequence analysis. Epidemiological typing was performed by pulsed-field gel electrophoresis. RESULTS: Among the 29 carbapenem-resistant isolates, polymyxin B presented 100% susceptibility and piperacillin/tazobactam 96.7%. Seventeen (62%) strains were verified as clonal (A clone) and among these, six isolates indicated phenotypically positive tests for MbetaL and harbored the blaSPM-1 gene. The first CRPA isolates were unrelated to clone A, harbored blaIMP-16 and were phenotypically positive only by CD. CONCLUSIONS: The spread of a high-level of resistance clone suggests cross transmission as an important dissemination mechanism and has contributed to the increased rate of resistance to carbapenems. This study emphasizes the need for continuous surveillance and improved strategies.