Pakistan-US Science and Technology Cooperation Program  Phase 6 (2015 Deadline) Multidrug-Resistant Pathogen Surveillance in Pakistani and U.S. Hospitals US partner: Gautam Dantas, Washington University Pak partner: Saadia Andleeb, National University of Science and Technology, Islamabad Progress Reports 2016: We successfully completed an initial 3-month sampling period of Intensive Care Unit (ICU) surfaces in Pakistan Hospitals and first 6-month sampling period for the US Hospital. Many species of bacteria that are commonly associated with hospital acquired infections have been isolated from surface samples in these rooms. Additionally, we have obtained fecal specimens from patients in the corresponding Pakistan and US ICUs. From fecal specimens from intensive care unit patients, multi-drug resistant bacterial pathogens were recovered. In total we have more than 700 bacterial isolates from ICU surfaces and more than 150 bacterial isolates from fecal specimens for additional characterization, including antimicrobial susceptibility testing and genomic analysis. 2017: During this reporting period, we successfully finished the 6 month and 1 year sample collection of bacteria that exist on hospital surfaces in the United States and Pakistan. We have made significant progress on performing whole genome sequencing on a representative set of surface bacteria from both locations. Additionally, we have finished the culturing of bacteria from stool samples obtained from individuals at either site during the yearlong study. We have successfully developed computational pipelines to survey the diversity of bacteria recovered from either location and their resistance genes. These programs are amendable to scaling up for the entire cohort once all whole genome sequencing is accomplished. We have adopted protocols from scientific literature to understand the mechanism by which these bacterial specimens may exist on hospital surfaces. 2018: In our ongoing collaboration between the Dantas, Burnham, and Andleeb labs, we are investigating the prevalence, transmission dynamics, and genomics of clinically relevant multidrug resistant bacterial organisms in Pakistan and in the United States. In the first phase of this project we have examined bacterial burdens on hospital intensive care unit surfaces in Pakistan and in the US. Through this research, we found high bacterial burdens on the Pakistani hospital surfaces with clinically relevant pathogens, including major agents of hospital acquired infections. These bacteria were found to carry many resistance genes of clinical importance and to have high phenotypic resistant to commonly used antimicrobials. In addition to these common hospital pathogens, we found many rare and some unknown bacterial species on the surfaces. Our in-depth analysis of resistance genes found that horizontal transfer of resistance genes is likely between bacterial species that we collected. The next phases of our project will focus on bacteria collected from water systems in Pakistan and the United States and from ICU patient stools in Pakistan and the United States. These two projects will continue to elucidate transmission dynamics and resistance gene prevalence in clinically relevant multidrug resistant organisms.