Gonzales-Rodriguez, A.; Gonzales-Escalante, E.; Champi, R.; Alvarado, L.; Gomez-de-la-Torre, J. C.; Sandoval, R.; Perez, G.; Matta, J.; Morales, L.; Sierra, E.; Canseco, J.; Escobar, A.

Carbapenemase-producing Enterobacterales represent a growing global threat due to their extensive antimicrobial resistance and rapid dissemination. This study characterized the phenotypic and genomic features of Escherichia coli and Klebsiella pneumoniae isolates collected between 2020 and 2022 from four healthcare institutions in Lima, Peru. A total of 320 non-redundant isolates (61 E. coli and 259 K. pneumoniae) were analyzed through antimicrobial susceptibility testing, polymerase chain reaction, and whole-genome sequencing. The most frequent carbapenemase gene was blaNDM (69%), followed by blaKPC (16.9%) and blaOXA-48-like (4.6%). Eleven K. pneumoniae isolates co-produced NDM and KPC, and one E. coli isolate co-harbored NDM and OXA-48-like. All isolates were multidrug resistant, and 5% were pandrug resistant. Novel {beta}-lactam/{beta}-lactamase inhibitor combinations such as aztreonam/avibactam and cefiderocol showed complete activity against all classes of carbapenemases. Genomic analysis revealed predominant E. coli sequence types ST167 and ST410 and K. pneumoniae lineages ST147, ST15, ST45, and ST273. The blaNDM-5 allele was detected for the first time in Peru, mostly in E. coli ST167, carried on multireplicon IncF-type plasmids. In K. pneumoniae, ST147 was identified as a dominant clone associated with blaNDM-1, indicating sustained local dissemination of high-risk clonal groups. The coexistence of multiple carbapenemases and plasmid backbones highlights the ongoing evolution of resistance mechanisms. These findings provide actionable evidence to guide treatment strategies in settings with high prevalence of metallo-{beta}-lactamases and underscores the need for continuous genomic surveillance and antimicrobial stewardship to mitigate their clinical and epidemiological impact.