*4.4.4 Pakistan*

Pakistan is the 6th largest most populous country in the world. Resistance has increased in *E. coli* around the world and sensitivity patterns significantly vary across geographic settings and within the populations [120]. Early in 2000, *CTX-M* producing *E. coli* has been found the most widespread uropathogenic in Pakistan [121]. ESBL and Amp C were observed in 35 and 64% of the *E. coli* isolates [122]. Furthermore, pandemic *CTX-M* producing *E. coli* ST-131 were also reported. *NDM*-producing *E. coli* was predominantly found in hospitalized patients with resistance to ceftriaxone. From 2013 to 2017, a comprehensive report was released on the susceptibility pattern of *E. coli* isolates in hospitalized and non-hospitalized patients. Where *E. coli* isolates of hospitalized patients were more resistant to all antibiotics [123]. The variation in the ratio of resistance between hospitalized and non-hospitalized patients forces us for prior antibiotic susceptibility screening [124]. In Enterobacteriaceae *E. coli* has a high resistance to β-lactam antibiotic*s* of having ESBL phenotype [125]*.* ESBL positive cases have been reported in different parts of the country [126].
