Abstract
BACKGROUND: Carbapenem-resistant Enterobacterales (CRE) pose a significant public health threat, particularly in low- and middle-income countries like Bangladesh, where efforts to contain antimicrobial resistance remain inadequate. CRE infections are major contributors to healthcare-associated infections (HAI) and are associated with high mortality, limited treatment options, and increased healthcare costs. This study evaluates the prevalence, resistance patterns, and temporal trends of CRE in Bangladesh using data from standard public and private microbiology laboratories. METHODS: We conducted a retrospective, cross-sectional analysis of antimicrobial susceptibility testing (AST) data from 2017 to 2020. Data were initially collected from 34 microbiology laboratories across Bangladesh, with 26 ultimately meeting quality criteria for inclusion. CRE was defined based on Clinical & Laboratory Standards Institute (CLSI) guidelines. Data were standardized using WHONET and analyzed using STATA 17. A total of 123,933 Enterobacterales isolates with defined CRE status were included in the final analysis after excluding isolates lacking complete carbapenem susceptibility data. RESULTS: Of the 123,933 Enterobacterales isolates analyzed, 12.3% (n = 15,252) were identified as CRE. Males (16.5%; 8,274/50,142) were more frequently affected than females (9.5%; 6,978/73,791), with the highest prevalence among patients aged < 1 year (18.1%; 528/2,912) and ≥ 60 years (14.4%; 5,442/37,856). The annual prevalence of CRE remained stable over the study period: 12.3% (2,713/21,982) in 2017, 12.4% (4,709/37,896) in 2018, 12.3% (5,540/44,898) in 2019, and 12.0% (2,290/19,157) in 2020 (p = 0.427). CRE was most frequently detected in tracheal aspirates (57.7%; 1,481/2,567) and wound swabs (20.9%; 3,950/18,878) compared to urine (7.4%; 5,468/73,939). Indoor samples showed a significantly higher prevalence (18.4%; 6,402/34,727) compared to outdoor samples (8.8%; 6,876/78,005), suggesting a high burden likely associated with healthcare settings. Klebsiella spp. (24.9%; 7,995/32,067) had a higher proportion of CRE than Escherichia coli (7.9%; 5,846/74,060). Among CRE isolates, resistance to individual carbapenems was high: imipenem (75.3%–91.1%) and meropenem (93.9%–100.0%). Resistance was near-universal for third and fourth-generation cephalosporins, including cefotaxime (92.1%–99.3%) and ceftazidime (87.1%–97.6%), as well as the monobactam aztreonam (75.2%–97.5%). Resistance to aminoglycosides remained comparatively lower but still substantial, with amikacin and gentamicin resistance ranging from 61.5% to 86.4% and 68.1%–86.8%, respectively. CONCLUSIONS: CRE prevalence in Bangladesh remains high, with extensive resistance to carbapenems and β-lactams. However, the comparatively lower resistance to aminoglycosides suggests a narrow but valuable therapeutic window. Strengthened infection prevention, antimicrobial stewardship, and surveillance are urgently needed to contain further spread. CLINICAL TRIAL NUMBER: Not applicable.