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We analyzed 1227\n                    <jats:italic>tmexCD\u2010toprJ<\/jats:italic>\n                    \u2010positive genomes from 42 countries and 16 genera, including 1189 public genomes and 38 newly sequenced clinical isolates. The increase was most pronounced in China, where\n                    <jats:italic>tmexCD\u2010toprJ<\/jats:italic>\n                    prevalence rose from 0.282% before 2011 to 1.504% after 2020, and approximately half of post\u20102015 Chinese isolates were classified as dual\u2010positive, co\u2010harboring\n                    <jats:italic>bla<\/jats:italic>\n                    <jats:sub>NDM<\/jats:sub>\n                    ,\n                    <jats:italic>bla<\/jats:italic>\n                    <jats:sub>KPC<\/jats:sub>\n                    , or\n                    <jats:italic>mcr<\/jats:italic>\n                    .\n                    <jats:italic>tmexCD\u2010toprJ<\/jats:italic>\n                    was mainly plasmid borne and distributed across diverse\n                    <jats:italic>Klebsiella<\/jats:italic>\n                    and\n                    <jats:italic>Pseudomonas<\/jats:italic>\n                    lineages and plasmid backbones. Dual\u2010positive plasmids showed distinct contexts: acquisition of\n                    <jats:italic>tmexCD\u2010toprJ<\/jats:italic>\n                    by pre\u2010existing\n                    <jats:italic>bla<\/jats:italic>\n                    <jats:sub>KPC<\/jats:sub>\n                    \u2010 or\n                    <jats:italic>mcr<\/jats:italic>\n                    \u2010positive IncF backbones, and remodeling of multiple resistance regions in\n                    <jats:italic>tmexCD\u2010toprJ<\/jats:italic>\n                    \u2010\n                    <jats:italic>bla<\/jats:italic>\n                    <jats:sub>NDM<\/jats:sub>\n                    IncU\/IncHI1B plasmids. Ecological distributions also differed;\n                    <jats:italic>bla<\/jats:italic>\n                    <jats:sub>NDM<\/jats:sub>\n                    combinations spanned human, animal, and environmental sources, whereas\n                    <jats:italic>bla<\/jats:italic>\n                    <jats:sub>KPC<\/jats:sub>\n                    and\n                    <jats:italic>mcr<\/jats:italic>\n                    combinations were mainly human and animal associated, respectively. Clinical isolates experiment confirmed resistance to the corresponding antibiotic classes, stable maintenance of dual\u2010positive plasmids, and transferability of a subset of plasmids. Under antibiotic pressure, the\n                    <jats:italic>tmexCD\u2010toprJ<\/jats:italic>\n                    region was mobilized across plasmids into a\n                    <jats:italic>bla<\/jats:italic>\n                    <jats:sub>KPC<\/jats:sub>\n                    plasmid. These findings reveal multiple evolutionary routes driving convergence of last\u2010line resistance determinants and highlight the need for integrated genomic and phenotypic surveillance.\n                  <\/jats:p>","DOI":"10.1002\/advs.77169","type":"journal-article","created":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T09:39:12Z","timestamp":1787218752000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Convergence of Plasmid\u2010Mediated\n                    <i>tmexCD\u2010toprJ<\/i>\n                    With Critical Resistance Genes Fuels Spread of Multidrug Resistant Bacteria"],"prefix":"10.1002","author":[{"given":"Kaiwen","family":"Song","sequence":"first","affiliation":[{"name":"Department of Clinical Laboratory Peking University People's Hospital; Beijing Key Laboratory of Innovative &amp; Transformable Warning and Intervention Technologies for Drug\u2010Resistant Pathogens  Beijing China"},{"name":"Institute of Medical Technology Peking University Health Science Center  Beijing China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Meng","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Clinical Laboratory Peking University People's Hospital; 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