Beyond patient contact: combined short- and long read sequencing reveals continuous occurrence of genomically related carbapenemase-producing Enterobacterales and plasmid mobility in a hospital, Germany, 2018 to 2021

BACKGROUNDCarbapenemase-producing Enterobacterales (CPE) frequently cause nosocomial outbreaks. To investigate these, tracing focused on patients with related CPE strains and spatiotemporal contact (e.g. contact with each other in a room or on a ward during overlapping periods) has limitations. Moreover, as widely available molecular typing methods cannot detect plasmid-related transmissions, carbapenemase gene transfer across enteric bacteria through plasmids in hospitals remains poorly understood.AIMBecause whole-genome sequencing (WGS), particularly long-read sequencing, can offer insights into bacterial relationships both at core-genome and plasmid levels, we tested its utility, using VIM-CPE as example, to investigate plasmid and CPE spread in a hospital beyond outbreaks.METHODSWe included inpatient episodes from 2018 to 2021 involving <i>bla</i> _VIM-bearing CPE isolates. Short- and long-read WGS data were combined with patient movement information to identify genomically related hospital-acquired VIM-CPE and putative transmission routes.RESULTSAmong 43 included inpatient episodes, 27 isolates were hospital-acquired, with 23 genomically related based on core-genome or plasmid analyses. For 14 of these 23 isolates, patient movement data supported suspected transmission events. Plasmid and core-genome level analyses revealed that most transmission events did not temporally concur, occurring over up to 33 months. Thus, conventional infection tracing methods focusing on concurrent spatiotemporal contact missed a substantial proportion of transmission events.CONCLUSIONWith our findings, we advocate for broader epidemiological investigations of temporal connections if genomic data suggest relatedness. We emphasise considering plasmid transfer alongside analyses of core-genome relatedness of bacteria beyond patient contact events to study CPE and resistance spread, and guide infection control strategies.