**4.4 Emergence of** *E. coli* **resistance in Asia**

*E. coli* is the most common bacterial pathogen associated with UTIs and IAIs, leading to bacteremia in severe cases, Infections caused by AMRs *E. coli* are becoming a serious threat over the last few years [100]. Strain ST-131 is reported worldwide and its infections rate is soaring. In addition, ST-131 strains have been associated with the increased rate of AMRs with *CTX-M* type ESBLs variant [101]. In Asian countries, *CTX-M* and ST-131producing *E. coli* have evolved as a foremost cause of hospital and community-acquired infections [102]. According to an earlier surveillance study, the occurrence of ESBL producing *E. coli* in Asian countries ranged from 2.3% to 40% [103]. *CTX-M* ESBLs are considered the most dominant phenotype. *CTX-M* producing *E. coli* pose a serious threat for densely populated cities and regions [41, 42]. Additionally *KPC* and *NDM* beta-lactamase-producing *E. coli* have been found to be on the rise in certain parts of Asian countries [104]. In some of the most Asian countries particularly [China, Malaysia, Macau, and Thailand], the prevalence rate in newborn sepsis due to AMR *E. coli* was found about 26.1% [105].

## *4.4.1 China*

China was the 2nd largest consumer of antibiotics in 2010 around the world. According to the available data, the prescription of antibiotics for outpatient and inpatient was 52.9% and 77.5% respectively and only 39.4% and 24.6% were considered appropriate respectively. Among BRICS countries only in China usage of antibiotics has been escalated [57%] as compared to other nations [106]. According to European Antibiotic Resistance Monitoring Network (EARS-Net), in *E. coli* resistance to third-generation cephalosporins has surged from 1.7% to 8% in the period between 2002 and 2009 [107]. Similarly in other findings were conducted on bloodstreams infections where *E. coli* is the most common bacteria. Moreover, *CTX-M-14* was reported as the most persistent ESBL while ST-131 was the most prevalent sequence type [108]. China has the world's fast proliferation of antibiotics resistance, the ratio of *E. coli* resistant to 3rd generation cephalosporins was reported 54.2% in China in 2017 which was higher than Europe (54.2%) [109, 110] According to one study, antimicrobial resistance is potentially responsible for 214,000 of 690,000 annual

neonatal deaths (31%) caused by sepsis. Carbapenems are β-lactam antibiotics that are used to cure severe infections caused by MDRs bacteria particularly *E. coli* [111].
