Search Results (290)

The increasing prevalence of infections caused by multidrug-resistant (MDR) Gram-negative bacteria represents a major global public health challenge. Among hospital-acquired infections (HAIs), ventilator-associated pneumonia (VAP) caused by non-fermenting Gram-negative pathogens, particularly the Acinetobacter baumannii-calcoaceticus complex, it is associated with limited therapeutic options and high mortality. Sulbactam–durlobactam is a novel combination consisting of sulbactam, a β-lactamase inhibitor with intrinsic activity against Acinetobacter spp., and durlobactam, a diazabicyclooctane β-lactamase inhibitor targeting Ambler class A, C, and D enzymes. This review summarizes current evidence on the pharmacological properties, clinical efficacy, and resistance mechanisms associated with this combination. Clinical trials have demonstrated that sulbactam–durlobactam is non-inferior to colistin in the treatment of infections caused by carbapenem-resistant A. baumannii, with a significantly lower risk of nephrotoxicity. The combination is generally well tolerated and represents a promising therapeutic option for difficult-to-treat infections. However, emerging resistance mechanisms, including PBP3 mutations, metallo-β-lactamase production, and efflux pump overexpression, may limit its long-term effectiveness. Further research is required to better understand resistance development and optimize clinical use. Full article

Background: Antimicrobial resistance (AMR) among ESKAPE pathogens—Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.—represents a major global health threat and accounts for a substantial proportion of healthcare-associated infections. Their genomic plasticity and adaptive regulatory responses facilitate the rapid emergence and dissemination of resistance and virulence determinants. Artificial intelligence (AI) has emerged as a powerful approach for analyzing large-scale biological datasets and identifying molecular signatures associated with antimicrobial resistance and pathogenicity. Objectives: This review examines AI-driven frameworks for predictive target discovery in ESKAPE pathogens, focusing on approaches that leverage genomic and transcriptomic data and extend toward the integration of additional omics layers within network-based and systems-level modeling frameworks. We discuss how AI methods are evolving beyond phenotypic prediction toward more biologically interpretable inference for prioritizing resistance mechanisms, virulence determinants, and candidate antimicrobial targets. Conclusions and Future Directions: Current AI applications exploit genomic, transcriptomic, and network-level data to prioritize resistance and virulence determinants and to support antimicrobial discovery, including small molecules and antimicrobial peptides. However, integrative multi-layer modeling and comprehensive experimental validation remain limited. Future advances will depend on improved integration of complementary biological data, enhanced model interpretability, and robust translational validation frameworks to enable clinically actionable AI-guided novel pathogen-targeted next-generation diagnostics, therapeutic and stewardship strategies against ESKAPE pathogens. Full article

Pneumonia remains a leading cause of morbidity and mortality worldwide, with bacterial pathogens contributing significantly to its burden. While Pseudomonas aeruginosa and Acinetobacter baumannii complex are well-recognized non-fermenting Gram-negative bacteria (NFGNB) causing severe pneumonia, particularly in healthcare settings, an expanding array of other, rarer NFGNB species is increasingly implicated. These species include, but are not limited to, Achromobacter spp., Ochrobactrum spp., Burkholderia spp., Aeromonas spp., Roseomonas spp., Elizabethkingia spp., Chryseobacterium spp. Alcaligenes spp., Ralstonia spp., Cupriavidus spp., Sphingomonas spp., Rhizobium spp., Empedobacter spp., and Brevundimonas spp. In this article we aim to provide a focused review of the contemporary epidemiology and specific risk factors for pneumonia caused by this diverse group of rare NFGNB, explicitly excluding P. aeruginosa, Stenotrophomonas maltophilia, and A. baumannii. We seek to delineate the emerging patterns of pneumonia associated with Achromobacter spp., Burkholderia spp., Aeromonas spp., Roseomonas spp., Elizabethkingia spp., Pandoraea spp., Sphingomonas spp., and K. gyiorum. Moreover, we discuss antimicrobial treatment strategies for pneumonia caused by rarer NFGNB including Ochrobactrum spp., Chryseobacterium spp., Alcaligenes spp., Ralstonia spp., Cupriavidus spp., Rhizobium spp., Empedobacter spp., and Brevundimonas spp. A deeper understanding of these specific epidemiological trends and risk factors is important for guiding precise diagnostic approaches, informing antimicrobial stewardship programs, and developing targeted infection prevention and control strategies with the aim of mitigating the impact of these challenging pathogens in the clinical setting. Full article

Mango (Mangifera indica L.), a major tropical fruit crop, suffers severe anthracnose damage caused by Colletotrichum spp., and traditional chemical control has environmental and food safety risks, with plant-microbe interaction-based biological control as a sustainable alternative. However, the regulatory role of phyllosphere microbiota in the tripartite interactions among mango, beneficial microbes and Colletotrichum remains unclear. This study explored phyllosphere microbiota’s function in mango resistance to Colletotrichum and clarified the biocontrol mechanism of key beneficial isolates. We found Colletotrichum infection significantly reshaped mango leaf endophytic and epiphytic microbial communities, enriching Burkholderia, Acinetobacter, Bacillus and other dominant genera. We isolated a B. subtilis strain L-1 from the epiphytic microbiota that was 18-fold enriched in Colletotrichum-infected mango leaves. This strain exhibited potent antagonistic activity against Colletotrichum siamense with a relative inhibition rate of 82.10%, and delivered 79.77% biocontrol efficacy on mango leaves via two synergistic pathways: inhibiting pathogen spore germination and penetration by producing antimicrobial secreted metabolites and volatile organic compounds, and enhancing host disease resistance. Our findings advance the understanding of plant-phyllosphere microbiota-pathogen tripartite interactions and provide elite microbial resources for sustainable anthracnose management. Full article

In recent decades, antibiotic-resistant bacteria have become an increasingly urgent public health concern. The uncontrolled use of antibiotics, along with inadequate implementation of prevention and control measures, is the primary factor contributing to this issue. The hospital environment is a major source of multidrug-resistant bacteria, and in recent years, there has been growing concern about hospital wastewater, which acts as a significant reservoir for these bacteria and their resistance genes. This situation leads to the spread of multidrug-resistant bacteria in the environment. One particular concern is Acinetobacter, especially Acinetobacter baumannii, which has emerged as a pathogenic threat in healthcare-associated infections. This bacterium is found in high densities in hospital wastewater. Most strains of A. baumannii express resistance not only to carbapenems but also to several other classes of antibiotics, including tetracyclines, fluoroquinolones, and aminoglycosides. These strains must be combated through effective measures. Bacteriophages represent a potential mitigation strategy for antibiotic-resistant Acinetobacter spp. originating from hospital wastewater. This review summarizes studies from online databases regarding the identification and characterization of Acinetobacter strains in hospital wastewater worldwide, and presents progress in isolating and characterizing bacteriophages against A. baumannii found in hospital wastewater. Full article

Several species of the genus Acinetobacter are nosocomial pathogens with a well-documented ability to acquire resistance to multiple antibiotics. Although Acinetobacter is one of the most abundant genera in meat processing environments, data on this genus outside of clinical environments remains limited. The objective of this study was to ascertain the prevalence, diversity and antimicrobial resistance profile of Acinetobacter spp. in 200 samples collected from food contact surfaces, non-food contact surfaces, carcasses and final meat cuts across five pork, chicken and beef processing facilities, each comprising physically connected slaughterhouses and meat processing plants. Acinetobacter spp. were detected in 80% (95% CI = 71–87%) and 70% (95% CI = 60–79%) of samples from slaughterhouses and processing plants, respectively. The facilities harboured a wide diversity of Acinetobacter species, with 27 different species identified. Acinetobacter baumannii was the species most frequently detected. Whole-genome sequencing of 18 Acinetobacter spp. isolates revealed the presence of ARGs conferring resistance to beta-lactams, tetracyclines and aminoglycosides, and disclosed phylogenetic relationships with isolates from fresh meat. Phenotypic resistance to beta-lactams, fluoroquinolones, aminoglycosides, folate pathway inhibitors and/or tetracyclines was observed in 77.8% of the sequenced isolates, with 44.4% classified as multidrug-resistant. These findings identify meat processing environments as an important reservoir of Acinetobacter spp. and highlight the need for further investigation to prevent the dissemination of antimicrobial-resistant strains. Full article

Background and Objectives: ESKAPE pathogens—Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.—are major contributors to antimicrobial resistance and are associated with considerable morbidity and mortality. Their involvement in community-acquired necrotizing fasciitis (CA-NF) remains insufficiently characterized. This study aimed to determine whether ESKAPE pathogens are implicated in cases of CA-NF and to describe their prevalence, antimicrobial resistance profiles, and associated clinical outcomes. Materials and Methods: We conducted a retrospective single-center study of NF cases treated in the Plastic Surgery Department of the Emergency Hospital Bucharest (2012–2022). Sixty-five patients met clinical and surgical diagnostic criteria; cases without microbiological data were excluded. Of these, 21 patients had ESKAPE pathogens isolated within 60 min of admission and formed the study cohort. Demographic, clinical, laboratory, microbiological, susceptibility, treatment, and outcome data were analyzed descriptively, with a focus on associated mortality with exploratory comparisons to ESKAPE-negative cases. Results: ESKAPE pathogens were identified in 31.8% (21/65) of patients. S. aureus was most common (61.9%); 14.3% were MRSA (Methicillin resistant Staphylococcus aureus) and 47.6% MSSA (Methicillin sensitive Staphylococcus aureus). Overall, 52% of ESKAPE isolates were multidrug-resistant and 12% were extensively drug-resistant. These resistance patterns have implications for empiric therapy in community-acquired NF. Conclusions: ESKAPE pathogens accounted for a substantial proportion of CA-NF and frequently displayed multidrug resistance. These findings highlight the importance of considering ESKAPE pathogens in empiric management strategies for NF, particularly within regional clinical practice. Full article

Background: To evaluate the potential of cefiderocol as a topical ophthalmic antibiotic by determining the susceptibility of keratitis isolates from an extensive panel of Gram-negative bacterial species to this siderophore-cephalosporin class antibiotic. Methods: Minimum Inhibitory Concentrations (MICs) of cefiderocol were determined by the broth dilution method using iron-depleted, cation-adjusted Mueller–Hinton broth. The following Gram-negative bacteria were included: Acinetobacter baumannii (n = 13), Achromobacter xylosoxidans (n = 14), Escherichia coli (n = 15), Klebsiella aerogenes (n = 14), Klebsiella pneumoniae (n = 13), Klebsiella oxytoca (n = 14), Moraxella spp. (n = 15), Proteus mirabilis (n = 13), Pseudomonas aeruginosa (n = 17), Serratia marcescens (n = 14) and Stenotrophomonas maltophilia (n = 12). MIC₉₀ values were calculated for each of the species. Results: MIC₉₀ values (µg/mL): A. baumannii (0.5), A. xylosoxidans (0.25), E. coli (0.5), K. aerogenes (1.0), K. oxytoca (0.5), K. pneumoniae (0.5), Moraxella spp. (0.5), P. mirabilis (0.25), P. aeruginosa (0.5), S. marcescens (0.5), and S. maltophilia (0.25). In total, 100% of the isolates were determined to be susceptible to cefiderocol in vitro except for A. xylosoxidans and Moraxella spp., for which there are no established breakpoints for cefiderocol. Conclusions: Cefiderocol demonstrated in vitro activity against the tested panel of Gram-negative keratitis isolates. The results of this study suggest cefiderocol may be useful for the treatment of keratitis caused by numerous Gram-negative pathogens. Further development of cefiderocol for the topical treatment of Gram-negative keratitis is indicated. Full article

Background: Hospital wastewater (HWW) is a critical reservoir for carbapenem-resistant Gram-negative bacteria. Methods: Between November 2024 and August 2025, sixty 24 h composite wastewater samples were collected from five tertiary hospitals. Of the 244 carbapenem-resistant isolates recovered, 34 bla_NDM-1-positive Acinetobacter isolates were subjected to phenotypic, genotypic, and plasmid analyses. Results: Eleven species were identified among the 34 carbapenem-resistant Acinetobacter isolates, predominantly non-baumannii Acinetobacter (NBA). All isolates were carbapenem-resistant (34/34, 100%) with high-level MICs (meropenem MIC_50/90, 32/64 mg/L; imipenem MIC_50/90, >128/>128 mg/L); 21% (7/34) of isolates were resistant to colistin, and resistance to ceftazidime, cefepime, and trimethoprim-sulfamethoxazole was 100%, 94%, and 76%, respectively. Core-genome SNP analysis revealed highly similar isolates across hospitals within the same season (1-2 SNPs) or within the same hospital across seasons (19 SNPs). Genomic analysis showed that bla_NDM-1 was present in all isolates (34/34, 100%), with plasmid carriage in 85.3% (29/34); bla_OXA-58 co-occurred in 62.1% (18/29), mainly on Rep_3 plasmids (19/29), especially R3-T28 (15/29) that frequently carried bla_OXA-58 (10/15). Two unclassified plasmids co-harboring bla_NDM-1 and bla_OXA-23 were detected in Acinetobacter tandoii isolates. The bla_NDM-1 gene was embedded in a conserved Tn125-like structures with variable flanks. Conclusions: Overall, carbapenem-resistant Acinetobacter from hospital wastewater frequently carried Rep_3 plasmid-borne bla_NDM-1, especially R3-T28 and often co-occurring with bla_OXA-58, within a conserved Tn125-like core structures. These findings highlight HWW as a potential hotspot for dissemination of carbapenem resistance and support routine genomic surveillance under a One Health framework. Full article

Background/Objectives: Carbapenem-resistant Acinetobacter spp. represent an emerging concern in human medicine; however, their epidemiology and genetic backgrounds in companion animals in Japan remain unclear. This study aimed to determine the prevalence of carbapenem resistance among Acinetobacter spp. isolated from diseased dogs and cats and elucidate the underlying genetic mechanisms. Methods: In this surveillance study conducted as part of the Japanese Veterinary Antimicrobial Resistance Monitoring (JVARM) program, 139 isolates were collected from diseased companion animals across Japan (84 from dogs and 55 from cats) during 2020, 2021 and 2023. Antimicrobial susceptibility testing was performed for seven antimicrobials and carbapenem-resistant isolates (meropenem MIC ≥ 8 μg/mL) underwent whole-genome sequencing to identify resistance genes, genomic contexts, and associated mobile genetic elements. Results: Resistance rates to all tested antimicrobials were below 20%. Meropenem resistance was detected in three isolates: one from a dog and two from cats. These resistant strains were identified as A. radioresistens, A. proteolyticus, and A. johnsonii, all harboring carbapenemase genes. The A. radioresistens isolate carried chromosomal bla_OXA-23, the A. proteolyticus isolate carried bla_OXA-58, and the A. johnsonii isolate possessed a plasmid containing bla_NDM-1 and bla_OXA-58. This represents the first report of bla_NDM-1-harboring Acinetobacter isolate from companion animals in Japan. Conclusions: Carbapenem-resistant Acinetobacter spp. remain rare in companion animals in Japan; however, insertion sequence mobility may promote resistance gene dissemination. As carbapenems are not approved for veterinary use in Japan, strict antimicrobial stewardship and appropriate hygiene management are essential. Full article

Background/Objectives: In the broad and current context of antimicrobial resistance, antibiotic management and therapeutic surveillance are essential in hospitals. The present study (five-year retrospective, 2020–2024) aimed to analyze antibiotic consumption in relation to pathogens identified in a multidisciplinary hospital. Results: In terms of antibiotic consumption (overall 2020–2024), although initially Watch antibiotics were predominantly used, a decrease was observed in favor of Access class antibiotics (sharply increase from 2022 to 2023 and maximum in 2024). For Reserve antibiotics, only slight annual fluctuations were observed, but there was an important reduction in colistin consumption. The most used were cephalosporins (cefazolin, cefuroxime and ceftriaxone), carbapenems (meropenem and ertapenem), vancomycin and linezolid. Regarding pathogens, the most notable were: Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, Enterococcus spp., Pseudomonas aeruginosa. Among the ESKAPE bacteria, Acinetobacter baumannii was the least frequent in our samples. ESKAPE bacteria predominantly colonized specimens from the respiratory tract, digestive tract, skin and soft tissue. Resistant strains were observed, mainly Methicillin-resistant Staphylococcus aureus (MRSA) and Extended-Spectrum Beta-Lactamase (ESBL) Klebsiella spp., but no alarming increases in number were recorded in the analyzed period. Methods: The analysis was carried out using tools recommended by the World Health Organisation (Access Watch Reserve antibiotics classification (AWaRe); Bacterial Priority Pathogen List (BBPL); Defined Daily Dose (DDD)), Average Annual Percent Change (AAPC) calculation and ESKAPE classification (bacteria group: Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter spp.). Conclusions: Relatively stable trends in bacterial isolates and resistant strains over five years (2020–2024) are consistent with effective antimicrobial stewardship practices. Full article

Objectives: To evaluate the capability of the BD Phoenix NMIC-461 panel in the detection and classification of carbapenemase production and antimicrobial susceptibility testing of 10 antimicrobial agents among Enterobacterales, Pseudomonas aeruginosa, and Acinetobacter spp. Methods: A total of 714 non-repetitive clinical isolates from three tertiary hospitals in China were enrolled. Carbapenemase production was confirmed by the modified carbapenem inactivation method (mCIM), while carbapenemase typing was validated by polymerase chain reaction (PCR) and Sanger sequencing. Antimicrobial susceptibility testing (AST) for ten antimicrobial agents was performed using broth microdilution (BMD) as the reference method. Results: The sensitivity and specificity of carbapenemase detection were 98.8% (95% CI, 96.6–99.6) and 92.4% (95% CI, 89.5–94.6) separately compared to sequencing. Classification accuracy was compromised by carbapenemase-positive unclassified strains, particularly reducing sensitivity for Enterobacterales. Excluding unclassified strains, the sensitivity and specificity were: for class A, 100% (95% CI, 94.0–100) and 97.3% (95% CI, 95.6–98.4); for class B, 97.1% (95% CI, 89.7–99.2) and 97.6% (95% CI, 96.0–98.6); and for class D, 94.0% (95% CI, 87.9–97.3) and 99.1% (95% CI, 97.8–99.7). The panel was subject to limitations for carbapenemase detection when applied to Pseudomonas aeruginosa. The NMIC-461 panel demonstrated excellent performance for ten BMD-evaluated agents across four bacterial categories, with essential agreement (EA) exceeding 95% and category agreement (CA) exceeding 90% except for Levofloxacin, and major error (ME) and very major error (VME) rates below 3% and 1.5%, respectively. Conclusions: The BD Phoenix NMIC-461 panel provides reliable AST results for commonly encountered Gram-negative bacterial isolates. Regarding carbapenemase detection, the panel demonstrates high sensitivity but only moderate specificity in classifying carbapenemase-producing organisms (CPO), with a relatively high proportion of positive unclassified isolates among Enterobacterales and low specificity for P. aeruginosa. Overall, the implementation of NMIC-461 testing holds promise for significantly reducing turnaround time in both carbapenemase detection and classification. Full article

Background: Acinetobacter spp., particularly A. baumannii, is a major intensive care unit (ICU) pathogen frequently associated with carbapenem non-susceptibility and delayed initiation of receipt of therapy. Methods: We conducted a single-center retrospective ICU cohort study in Romania (January 2019–December 2024) of adults with clinical cultures positive for Acinetobacter spp. (first isolate per patient). Susceptibility was interpreted per EUCAST. We assessed species distribution, carbapenem non-susceptibility, receipt of at least one in vitro active empiric agent, time to active therapy (TTAT, from index culture collection), early inflammatory biomarkers [neutrophile-to-lymphocyte ratio (NLR) and C-reactive protein (CRP)], and 30-day mortality. Predictors of mortality were evaluated using multivariable logistic regression and receiver operating characteristic (ROC) analysis. Results: A total of 234 episodes were included; A. baumannii accounted for 87.6% (205/234). Carbapenem non-susceptibility among Acinetobacter spp. isolates was 89.3% (209/234). Empiric antibiotics were initiated within 24 h in 95.7% of patients (224/234), yet only 49.6% (116/234) received at least one empiric agent later confirmed to be active. TTAT was 6 days (IQR 4–7), and active therapy within 72 h occurred in 8.5% (20/234). Thirty-day mortality was 73.1% (171/234) and did not differ between carbapenem non-susceptible (EUCAST I + R) and carbapenem-susceptible (EUCAST S) A. baumannii episodes (73.2% vs. 72.0%, p = 1.00). In multivariable analysis, age was independently associated with mortality (OR 1.36 per 10-year increase, 95% CI 1.04–1.90), with acceptable model discrimination (area under the curve = 0.74). Early NLR and CRP did not differ between carbapenem non-susceptible and carbapenem-susceptible A. baumannii episodes. Conclusions: In this ICU cohort, A. baumannii was the predominant species, and carbapenem non-susceptibility was highly prevalent. Despite early empiric therapy, receipt of at least one in vitro active agent was often delayed, and early inflammatory biomarkers had limited discriminatory value. These findings support locally tailored empiric strategies informed by local epidemiology and reinforce the need for improved diagnostics and stewardship interventions in high-burden ICU settings. Full article

Background. The aim of this study is to analyze changing trends in isolated organisms and antibiotic resistance of bacterial keratitis (BK) over 26 years. Methods. A retrospective medical record review included 542 strains isolated from 462 BK patients between 1998 and 2023. We analyzed routinely generated in vitro antibiotic susceptibility testing results recorded in the laboratory information system and did not perform additional susceptibility testing for research purposes. The entire period was divided into two (first half: 1998–2010, 297 isolates from 255 patients; second half: 2011–2023, 245 isolates from 207 patients) and compared. Results. During the entire period, Staphylococcus spp. (32.3%) and Pseudomonas spp. (18.1%) were common isolates, and a significant increase in Acinetobacter spp. (1.3% vs. 10.6%, p < 0.001) was observed. Among Gram-positive bacteria, methicillin resistance rates remained stable between the two periods (52.6% vs. 46.7%, p = 0.525), and an increase in vancomycin-resistant Enterococci (VRE, 0% vs. 26.1%, p = 0.074) was found. Among Gram-negative bacteria (GNB), ciprofloxacin (7.5% vs. 14.4%, p = 0.108) and imipenem (2.9% vs. 6.5%, p = 0.255) resistance increased slightly, resistance to ceftazidime (8.3% vs. 8.8%, p > 0.999) was maintained, and resistance to aminoglycosides (17.8% vs. 7.2%, p = 0.010) decreased. Conclusions. Our study suggests that conventional topical fortified antibiotic eye drops (tobramycin, ceftazidime) can still be considered as an empirical treatment option for BK. However, our findings revealed a long-term trend of increasing Acinetobacter spp. and VRE, as well as a slight trend of increasing resistance to ciprofloxacin and imipenem in GNB, which may present future challenges in BK treatment. Full article

Antimicrobial resistance (AMR) in hospital wastewater is a recognized public health concern, yet the dynamics of its emergence remain poorly understood. This study aimed to characterize the quantitative and qualitative changes in the microbial community of a newly built internal medicine intensive care hospital wing following the start of patient treatment. Wastewater samples were collected regularly from eight relevant sites, including seven patient-associated locations within the intensive care ward and the central sanitary sewer where all effluent converged. Culture-based analyses targeted the “ESCAPE-SO” bacterial and fungal groups (“Enterococci”, “Staphylococci”, “Candida”, “Acinetobacter”, “Pseudomonas”, “Enterobacteriaceae”, “Stenotrophomonas”, “Others”). Comparisons were made between a 12-month pre-operation period (only flushing every 72 h to prevent contamination of the drinking water system) and the first 12 months of patient treatment. The results showed a significant increase in mean bacterial concentrations from 53 [0–349] CFU/mL before patient treatment to 8423 [3054–79,490] CFU/mL during patient treatment (p = 0.0224) with a particular focus on Pseudomonas spp. as the dominant genus. Resistance against all four main antibiotic classes of the WHO AWaRe essential “watch” list (carbapenems, third-generation cephalosporins, broad-spectrum penicillin and ciprofloxacin) emerged within the first twelve months and depended on the amount of prescribed antibiotics and the number of patients treated. These findings indicate that hospital activity drives rapid development of antimicrobial resistance in wastewater microbial communities, highlighting the critical role of clinical antibiotic use in shaping environmental resistomes. This study provides quantitative evidence that resistance can emerge within months of hospital operation, emphasizing the need for early monitoring and targeted interventions to mitigate the spread of AMR from hospital effluents into broader environmental systems. Full article