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Antimicrobial susceptibility testing was performed using disc diffusion and VITEK2 compact system. Isolates were classified as multidrug-resistant\n                      <jats:italic>P. aeruginosa<\/jats:italic>\n                      (MDR-PA), extensively drug-resistant\n                      <jats:italic>P. aeruginosa<\/jats:italic>\n                      (XDR-PA), and DTR-PA. Conventional PCR was used to detect carbapenemase genes (\n                      <jats:italic>bla<\/jats:italic>\n                      <jats:sub>NDM<\/jats:sub>\n                      ,\n                      <jats:italic>bla<\/jats:italic>\n                      <jats:sub>VIM<\/jats:sub>\n                      ,\n                      <jats:italic>bla<\/jats:italic>\n                      <jats:sub>IMP<\/jats:sub>\n                      ,\n                      <jats:italic>bla<\/jats:italic>\n                      <jats:sub>KPC<\/jats:sub>\n                      , and\n                      <jats:italic>bla<\/jats:italic>\n                      <jats:sub>OXA-48<\/jats:sub>\n                      ). Quantitative real-time PCR (qRT-PCR) identified the over expression of efflux pump genes (\n                      <jats:italic>mexB<\/jats:italic>\n                      ,\n                      <jats:italic>mexY<\/jats:italic>\n                      ) and the down regulation of outer membrane porin (\n                      <jats:italic>oprD<\/jats:italic>\n                      ) gene.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Fifty-two (52) CRPA isolates were categorized according to resistance phenotype into three main groups where 46% were identified as DTR-PA, 38% as XDR-PA, 8% as MDR-PA and 8% remained uncategorized. In DTR-PA, carbapenemase genes were detected in 92% of isolates with\n                      <jats:italic>bla<\/jats:italic>\n                      <jats:sub>\n                        <jats:italic>NDM<\/jats:italic>\n                      <\/jats:sub>\n                      being the most prevalent (75%), followed by\n                      <jats:italic>bla<\/jats:italic>\n                      <jats:sub>VIM<\/jats:sub>\n                      (54%) and\n                      <jats:italic>bla<\/jats:italic>\n                      <jats:sub>OXA-48<\/jats:sub>\n                      (38%). Co-existence of multiple carbapenemase genes was common. Efflux pump mechanism was the most common mechanism of resistance as overexpression of\n                      <jats:italic>MexB<\/jats:italic>\n                      and\n                      <jats:italic>MexY<\/jats:italic>\n                      was observed in 98% and 71% of isolates, respectively, whereas downregulation of\n                      <jats:italic>oprD<\/jats:italic>\n                      was detected in 92%. The DTR-PA phenotype demonstrated the least sensitive profiles and most of the isolates (92%) were positive to all the studied resistant mechanisms (carbapenemase production, overexpression of efflux pump, and porin loss) with a statistically significant association (\n                      <jats:italic>P<\/jats:italic>\n                      \u2009=\u20090.001).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>\n                      Difficult to treat\n                      <jats:italic>Pseudomonas aeruginosa<\/jats:italic>\n                      is highly prevalent among CRPA isolates in our setting and is caused by multiple resistance mechanisms, particularly\n                      <jats:italic>bla<\/jats:italic>\n                      <jats:sub>NDM<\/jats:sub>\n                      carriage, efflux pump overexpression, and\n                      <jats:italic>oprD<\/jats:italic>\n                      downregulation. These findings underscore the urgent need for enhanced molecular surveillance and antimicrobial stewardship to limit further dissemination of highly resistant\n                      <jats:italic>Pseudomonas aeruginosa<\/jats:italic>\n                      (\n                      <jats:italic>P. aeruginosa)<\/jats:italic>\n                      iaolates. Future studies utilizing the DTR-PA definition are needed, as this category highlights the most resistant CRPA isolates with maximum resistance profiles that most likely to pose clinical challenges.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12866-026-05550-2","type":"journal-article","created":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T01:44:21Z","timestamp":1788486261000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Detection of carbapenem resistance mechanisms in difficult-to-treat Pseudomonas aeruginosa clinical isolates from a tertiary care hospital in Egypt"],"prefix":"10.1186","volume":"26","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4880-2240","authenticated-orcid":false,"given":"Dalia","family":"Salem","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manar","family":"Zaiton","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ahmed","family":"El-Shenawy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Heba","family":"Dahroug","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samah","family":"El-Dein","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Doaa","family":"Gamal","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Azza Ali","family":"Althoqapy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amr AW.","family":"Mohamed","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohamed A.","family":"Shemis","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manal","family":"Diab","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Soheir S.","family":"Maklad","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,9,4]]},"reference":[{"key":"5550_CR1","doi-asserted-by":"publisher","unstructured":"Riccobene T, Ye G, Lock J, Yu KC, Ai C, Gregory S, Gupta V. 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