{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T02:29:49Z","timestamp":1789093789735,"version":"build-2803163510"},"reference-count":40,"publisher":"American Society for Microbiology","issue":"4","license":[{"start":{"date-parts":[[2026,4,7]],"date-time":"2026-04-07T00:00:00Z","timestamp":1775520000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,4,7]],"date-time":"2026-04-07T00:00:00Z","timestamp":1775520000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.asm.org\/non-commercial-tdm-license"}],"content-domain":{"domain":["journals.asm.org"],"crossmark-restriction":true},"short-container-title":["Microbiol Spectr"],"published-print":{"date-parts":[[2026,4,7]]},"abstract":"ABSTRACT<\/jats:title>\n \n \n \n Ceftazidime-avibactam (CZA) is considered one of the most effective antimicrobial agents for treating infections caused by\n Klebsiella pneumoniae<\/jats:italic>\n carbapenemase-producing\n Klebsiella pneumoniae<\/jats:italic>\n . However, rising CZA resistance poses a critical clinical challenge, primarily driven by\n bla<\/jats:italic>\n KPC<\/jats:sub>\n mutations. From a single CZA-treated patient, we isolated two CZA-susceptible and three CZA-resistant\n K. pneumoniae<\/jats:italic>\n strains. Whole-genome sequencing of CZA-resistant strains CYH4028 and CYH1535 revealed two key resistance pathways: (i) acquisition of a conjugative IncN plasmid harboring\n bla<\/jats:italic>\n NDM-1<\/jats:sub>\n and (ii) mutation of the\n bla<\/jats:italic>\n KPC-2<\/jats:sub>\n gene to\n bla<\/jats:italic>\n KPC-33<\/jats:sub>\n with an \u03a9-loop D179Y substitution. The\n bla<\/jats:italic>\n NDM-1<\/jats:sub>\n gene resided within a truncated Tn\n 125<\/jats:italic>\n transposon that formed part of an IS\n 26<\/jats:italic>\n -associated translocatable unit in the self-transferable IncN plasmid pCYH4028_NDM. Phylogenetic analysis of 257 IncN plasmids revealed the highest plasmid prevalence in China (34.6%), with\n K. pneumoniae<\/jats:italic>\n as the predominant host (41.6%) and\n bla<\/jats:italic>\n KPC<\/jats:sub>\n as the most frequent carbapenemase gene (36.2%). Conjugation assays further confirmed self-transferability of pCYH4028_NDM. The\n bla<\/jats:italic>\n KPC-33<\/jats:sub>\n gene was located within an IS\n 26<\/jats:italic>\n -truncated Tn\n 6296<\/jats:italic>\n transposon on the hybrid plasmid pCYH1535_Vir_KPC, which formed via IS\n 5075<\/jats:italic>\n -mediated homologous recombination and XerD-driven site-specific recombination. Notably, acquisition of CZA resistance incurred varying\n in vitro<\/jats:italic>\n fitness costs, whereas the\n bla<\/jats:italic>\n KPC-33<\/jats:sub>\n -harboring strain exhibited greater competitive advantage than the\n bla<\/jats:italic>\n NDM-1<\/jats:sub>\n -harboring strain. All strains exhibited attenuated virulence (reduced mucoviscosity and biofilm production) due to IS\n Kpn26<\/jats:italic>\n disruption of\n rmpA<\/jats:italic>\n , a mucoid phenotype regulator. These findings elucidate within-host adaptive evolution in ST11-KL64 hypervirulent carbapenem-resistant\n K. pneumoniae<\/jats:italic>\n and highlight the necessity for continuous genomic surveillance during therapy.\n <\/jats:p>\n <\/jats:sec>\n \n IMPORTANCE<\/jats:title>\n \n The alarming rise of ceftazidime-avibactam (CZA) resistance, primarily through\n bla<\/jats:italic>\n \n KPC<\/jats:sub>\n <\/jats:sc>\n mutations, constitutes a critical threat to global health. Here, we reported the within-host evolution of CZA resistance, driven by IncN plasmid-encoded\n bla<\/jats:italic>\n NDM-1<\/jats:sub>\n and\n bla<\/jats:italic>\n KPC<\/jats:sub>\n mutations, in a high-risk ST11-KL64 hypervirulent carbapenem-resistant\n Klebsiella pneumoniae<\/jats:italic>\n lineage during patient therapy. Our study demonstrates the emergence of simultaneous, independent evolutionary pathways under CZA pressure. Crucially, an IncN\n bla<\/jats:italic>\n NDM-1<\/jats:sub>\n plasmid acted as a helper plasmid, facilitating co-transfer of\n bla<\/jats:italic>\n NDM-1<\/jats:sub>\n with\n bla<\/jats:italic>\n KPC-2<\/jats:sub>\n and virulence genes. These direct insights highlight the urgent need for enhanced genomic surveillance against this evolving threat.\n <\/jats:p>\n <\/jats:sec>","DOI":"10.1128\/spectrum.02367-25","type":"journal-article","created":{"date-parts":[[2026,2,19]],"date-time":"2026-02-19T14:00:07Z","timestamp":1771509607000},"update-policy":"https:\/\/doi.org\/10.1128\/asmj-crossmark-policy-page","source":"Crossref","is-referenced-by-count":2,"title":["Within-host evolution drives the emergence of ceftazidime-avibactam resistance mediated by IncN plasmid-encoded\n bla<\/i>\n NDM-1<\/sub>\n and\n bla<\/i>\n KPC-33<\/sub>\n in ST11-KL64 hypervirulent\n Klebsiella pneumoniae<\/i>"],"prefix":"10.1128","volume":"14","author":[{"given":"Peiwen","family":"Xia","sequence":"first","affiliation":[{"id":[{"id":"https:\/\/ror.org\/033vnzz93","id-type":"ROR","asserted-by":"publisher"}],"name":"Department of Laboratory Medicine, The First Affiliated Hospital of Chongqing Medical University","place":["Chongqing, 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