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However, two-copy KPC variant-mediated resistance to CZA has rarely been reported to date. Here, we aimed to clarify the evolutionary trajectory of CZA resistance driven by mutations in double-copy\n              <jats:italic>bla<\/jats:italic>\n              <jats:sub>KPC-2<\/jats:sub>\n              to\n              <jats:italic>bla<\/jats:italic>\n              <jats:sub>KPC-189<\/jats:sub>\n              carried by the tandem core structure (IS\n              <jats:italic>Kpn6-bla<\/jats:italic>\n              <jats:sub>KPC<\/jats:sub>\n              -IS\n              <jats:italic>Kpn27-tnpR<\/jats:italic>\n              -IS\n              <jats:italic>26<\/jats:italic>\n              ) during treatment of ST11 carbapenem-resistant\n              <jats:italic>K. pneumoniae<\/jats:italic>\n              (CRKP). The CZA-resistant KP strain carried double-copy\n              <jats:italic>bla<\/jats:italic>\n              <jats:sub>KPC-189<\/jats:sub>\n              , a variant with alanine\u2013threonine and aspartate\u2013tyrosine substitutions at Ambler amino acid positions 172 (A172T) and 179 (D179Y) of\n              <jats:italic>bla<\/jats:italic>\n              <jats:sub>KPC-2<\/jats:sub>\n              . Clone experiments confirmed that, compared with that of the wild-type\n              <jats:italic>bla<\/jats:italic>\n              <jats:sub>KPC-2<\/jats:sub>\n              clone strain, the minimum inhibitory concentration of CZA increased 16-fold in the\n              <jats:italic>bla<\/jats:italic>\n              <jats:sub>KPC-189<\/jats:sub>\n              -mutant strain. Furthermore, protein structure analysis revealed the A172T and D179Y mutations of\n              <jats:italic>bla<\/jats:italic>\n              <jats:sub>KPC-189<\/jats:sub>\n              can have a direct effect on the binding affinity of CAZ and AVI for KPC. Sequence comparison revealed that\n              <jats:italic>bla<\/jats:italic>\n              <jats:sub>KPC-189<\/jats:sub>\n              was mutated in a double-copy format upon CZA exposure, which was carried by the IS\n              <jats:italic>26<\/jats:italic>\n              -mediated tandem core structure IS\n              <jats:italic>Kpn27-bla<\/jats:italic>\n              <jats:sub>KPC<\/jats:sub>\n              -IS\n              <jats:italic>Kpn6<\/jats:italic>\n              . This tandem core structure apparently evolves\n              <jats:italic>in vivo<\/jats:italic>\n              during infection, although not by self-transferring, and multiple IS\n              <jats:italic>Kpn27-bla<\/jats:italic>\n              <jats:sub>KPC<\/jats:sub>\n              -IS\n              <jats:italic>Kpn6<\/jats:italic>\n              copy numbers could mediate transferable CZA resistance upon mobilization. In addition, compared with the wild-type\n              <jats:italic>bla<\/jats:italic>\n              <jats:sub>KPC-2<\/jats:sub>\n              gene, the\n              <jats:italic>bla<\/jats:italic>\n              <jats:sub>KPC-189<\/jats:sub>\n              gene had no fitness cost. In summary, our study highlighted the emergence of CZA-resistant\n              <jats:italic>bla<\/jats:italic>\n              <jats:sub>KPC-189<\/jats:sub>\n              variants in the ST11 clone and the presence of a double-copy\n              <jats:italic>bla<\/jats:italic>\n              <jats:sub>KPC-189<\/jats:sub>\n              in the IncFII-type plasmid, which is carried by a tandem core structure (IS\n              <jats:italic>26-<\/jats:italic>\n              IS\n              <jats:italic>Kpn6-bla<\/jats:italic>\n              <jats:sub>KPC-189<\/jats:sub>\n              -IS\n              <jats:italic>Kpn27-tnpR<\/jats:italic>\n              -IS\n              <jats:italic>26<\/jats:italic>\n              ).\n            <\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>IMPORTANCE<\/jats:title>\n            <jats:p>\n              To date, ceftazidime\u2013avibactam (CZA) resistance caused by double-copy\n              <jats:italic>Klebsiella pneumoniae<\/jats:italic>\n              carbapenemase (KPC) variants has not been elucidated. The multicopy forms of carbapenem resistance genes carried by the same plasmid are relatively rare in most carbapenem-resistant\n              <jats:italic>Enterobacteriaceae<\/jats:italic>\n              . In this study, we elucidate the evolutionary trajectory of CZA resistance in ST11 carbapenem-resistant\n              <jats:italic>K. pneumoniae<\/jats:italic>\n              harboring a double-copy blaKPC and provide new insights into the mechanisms of acquired resistance to CZA.\n            <\/jats:p>\n          <\/jats:sec>","DOI":"10.1128\/msystems.00722-24","type":"journal-article","created":{"date-parts":[[2024,9,17]],"date-time":"2024-09-17T17:00:36Z","timestamp":1726592436000},"update-policy":"https:\/\/doi.org\/10.1128\/asmj-crossmark-policy-page","source":"Crossref","is-referenced-by-count":22,"title":["Evolution of ceftazidime\u2013avibactam resistance driven by mutations in double-copy\n            <i>bla<\/i>\n            <sub>KPC-2<\/sub>\n            to\n            <i>bla<\/i>\n            <sub>KPC-189<\/sub>\n            during treatment of ST11 carbapenem-resistant\n            <i>Klebsiella pneumoniae<\/i>"],"prefix":"10.1128","volume":"9","author":[{"given":"Xiaofan","family":"Zhang","sequence":"first","affiliation":[{"name":"Centre of Laboratory Medicine, Zhejiang Provincial People\u2019s Hospital, People\u2019s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China"},{"name":"Department of Clinical Laboratory, Feicheng Hospital of Traditional Chinese Medicine, Feicheng, Shandong, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yinrong","family":"Xie","sequence":"additional","affiliation":[{"name":"Department of Clinical Laboratory, Xiamen Hospital of Traditional Chinese Medicine, Xiamen, Fujian, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ying","family":"Zhang","sequence":"additional","affiliation":[{"name":"Centre of Laboratory Medicine, Zhejiang Provincial People\u2019s Hospital, People\u2019s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2067-1787","authenticated-orcid":true,"given":"Tailong","family":"Lei","sequence":"additional","affiliation":[{"name":"Department of Infectious Diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Longjie","family":"Zhou","sequence":"additional","affiliation":[{"name":"Centre of Laboratory Medicine, Zhejiang Provincial People\u2019s Hospital, People\u2019s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jiayao","family":"Yao","sequence":"additional","affiliation":[{"name":"Centre of Laboratory Medicine, Zhejiang Provincial People\u2019s Hospital, People\u2019s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, 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