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Sarunyou Chusri, Division of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand, Tel +66 8 973 40446, Email sarunyouchusri@hotmail.comPurpose: The spread of New Delhi metallo-β-lactamase (NDM) encoded by the blaNDM gene has been a global health crisis for many years. Most of blaNDM-harboring bacteria commonly carry various antimicrobial resistance (AMR) genes on their chromosomes or plasmids, leading to limited treatment options. Thus, we aimed to evaluate the synergistic effects of fosfomycin in combination with other antimicrobial agents against blaNDM-harboring carbapenem-resistant Escherichia coli (CREC) and to characterize the whole-genome and plasmid sequences of these pathogens.Methods: Thirty-eight CREC isolates were collected from patients in the Medicine Ward, Songklanagarind Hospital, Thailand. The activity of fosfomycin in combination with other antimicrobial agents against CREC isolates harboring blaNDM on the plasmid was evaluated using the checkerboard method. In this method, the serial dilutions of two antibiotics were mixed with the cultured CREC, the mixtures were incubated, and FICI was calculated to interpret the synergistic activity of the combination. The whole-genome and particular plasmids of these pathogens were sequenced using next-generation sequencing. Sequence analysis, especially on antimicrobial resistance (AMR) genes, mobile-genetic elements (MGEs), and virulence genes was performed using many bioinformatics tools.Results: Of the E. coli 38 isolates, only 3 isolates contained the blaNDM-1 gene, which is located on the IncN2 plasmid. The combinations of fosfomycin with aminoglycosides, colistin, tigecycline, sitafloxacin, and ciprofloxacin were synergies against blaNDM-1-harboring CREC isolates. Genomic analysis revealed that these isolates harbored many β-lactam resistance genes and other AMR genes that may confer resistance to aminoglycoside, fluoroquinolone, rifampicin, trimethoprim, sulfonamide, tetracycline, and macrolide. Also, various MGEs, especially the blaNDM-1-bearing IncN2 plasmid, were present in these isolates.Conclusion: Our study demonstrated some synergistic effects of antimicrobial combination against CREC isolates harboring blaNDM-1 on the IncN2 plasmid. Also, our data on the whole-genome and plasmid sequences might be beneficial in the control of the spread of blaNDM-1-harboring CREC isolates. The linkages between blaNDM-1-carrying plasmid, patient information, and time of collection will be elucidated to track the horizontal gene transfer in the future.

Purpose: The spread of New Delhi metallo-[beta]-lactamase (NDM) encoded by the [bla.sub.NDM] gene has been a global health crisis for many years. Most of [bla.sub.NDM]-harboring bacteria commonly carry various antimicrobial resistance (AMR) genes on their chromosomes or plasmids, leading to limited treatment options. Thus, we aimed to evaluate the synergistic effects of fosfomycin in combination with other antimicrobial agents against [bla.sub.NDM]-harboring carbapenem-resistant Escherichia coli (CREC) and to characterize the wholegenome and plasmid sequences of these pathogens. Methods: Thirty-eight CREC isolates were collected from patients in the Medicine Ward, Songklanagarind Hospital, Thailand. The activity of fosfomycin in combination with other antimicrobial agents against CREC isolates harboring [bla.sub.NDM] on the plasmid was evaluated using the checkerboard method. In this method, the serial dilutions of two antibiotics were mixed with the cultured CREC, the mixtures were incubated, and FICI was calculated to interpret the synergistic activity of the combination. The whole-genome and particular plasmids of these pathogens were sequenced using next-generation sequencing. Sequence analysis, especially on antimicrobial resistance (AMR) genes, mobile-genetic elements (MGEs), and virulence genes was performed using many bioinformatics tools. Results: Of the E. coli 38 isolates, only 3 isolates contained the [bla.sub.NDM-1] gene, which is located on the IncN2 plasmid. The combinations of fosfomycin with aminoglycosides, colistin, tigecycline, sitafloxacin, and ciprofloxacin were synergies against [bla.sub.NDM-1]-harboring CREC isolates. Genomic analysis revealed that these isolates harbored many [beta] -lactam resistance genes and other AMR genes that may confer resistance to aminoglycoside, fluoroquinolone, rifampicin, trimethoprim, sulfonamide, tetracycline, and macrolide. Also, various MGEs, especially the [bla.sub.NDM-1]-bearing IncN2 plasmid, were present in these isolates. Conclusion: Our study demonstrated some synergistic effects of antimicrobial combination against CREC isolates harboring [bla.sub.NDM-1] on the IncN2 plasmid. Also, our data on the whole-genome and plasmid sequences might be beneficial in the control of the spread of [bla.sub.NDM-1]-harboring CREC isolates. The linkages between [bla.sub.NDM-1]-carrying plasmid, patient information, and time of collection will be elucidated to track the horizontal gene transfer in the future. Keywords: antimicrobial resistance gene, checkerboard method, next-generation sequencing, bioinformatics tool, mobile genetic element

The spread of New Delhi metallo-β-lactamase (NDM) encoded by the gene has been a global health crisis for many years. Most of -harboring bacteria commonly carry various antimicrobial resistance (AMR) genes on their chromosomes or plasmids, leading to limited treatment options. Thus, we aimed to evaluate the synergistic effects of fosfomycin in combination with other antimicrobial agents against -harboring carbapenem-resistant (CREC) and to characterize the whole-genome and plasmid sequences of these pathogens. Thirty-eight CREC isolates were collected from patients in the Medicine Ward, Songklanagarind Hospital, Thailand. The activity of fosfomycin in combination with other antimicrobial agents against CREC isolates harboring on the plasmid was evaluated using the checkerboard method. In this method, the serial dilutions of two antibiotics were mixed with the cultured CREC, the mixtures were incubated, and FICI was calculated to interpret the synergistic activity of the combination. The whole-genome and particular plasmids of these pathogens were sequenced using next-generation sequencing. Sequence analysis, especially on antimicrobial resistance (AMR) genes, mobile-genetic elements (MGEs), and virulence genes was performed using many bioinformatics tools. Of the 38 isolates, only 3 isolates contained the gene, which is located on the IncN2 plasmid. The combinations of fosfomycin with aminoglycosides, colistin, tigecycline, sitafloxacin, and ciprofloxacin were synergies against -harboring CREC isolates. Genomic analysis revealed that these isolates harbored many β-lactam resistance genes and other AMR genes that may confer resistance to aminoglycoside, fluoroquinolone, rifampicin, trimethoprim, sulfonamide, tetracycline, and macrolide. Also, various MGEs, especially the -bearing IncN2 plasmid, were present in these isolates. Our study demonstrated some synergistic effects of antimicrobial combination against CREC isolates harboring on the IncN2 plasmid. Also, our data on the whole-genome and plasmid sequences might be beneficial in the control of the spread of -harboring CREC isolates. The linkages between -carrying plasmid, patient information, and time of collection will be elucidated to track the horizontal gene transfer in the future.