Carbapenem-Resistant Klebsiella pneumoniae in Romania and South-Eastern Europe: A Multilingual Narrative Review of Pandemic-Era Trajectories, 2020-2025.
11 affiliations
- 1Department of Infectious Diseases and Epidemiology, Faculty of Medicine, Ovidius University of Constanta, 1 University Alley, 900470 Constanta, Romania.
- 2Clinical Infectious Diseases Hospital, Ferdinand Blvd. No. 100, 900709 Constanța, Romania.
- 3Doctoral School, Faculty of Medicine, Ovidius University of Constanta, 1 University Alley, 900470 Constanta, Romania.
- 4County Clinical Emergency Hospital "St. Apostle Andrew", Tomis Blvd. No. 145, 900591 Constanța, Romania.
- 5Department of Public Health and Management, Faculty of Medicine, Ovidius University of Constanta, 1 University Alley, 900470 Constanta, Romania.
- 6Service of Infectious Diseases, University Hospital Center "Mother Teresa", 1007 Tirane, Albania.
- 7Department of Epidemiology I, University of Medicine and Pharmacy "Carol Davila", Bd. Eroii Sanitari 8, Sector 5, 050474 Bucharest, Romania.
- 8National Institute of Infectious Diseases "Prof. Dr. Matei Balș", 1 Dr. Calistrat Grozovici Street, District 2, 021105 Bucharest, Romania.
- 9Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila", Bd. Eroii Sanitari 8, Sector 5, 050474 Bucharest, Romania.
- 10"Prof. Dr. Agrippa Ionescu" Emergency Clinical Hospital, 077015 Bucharest, Romania.
- 11Academy of Romanian Scientists, 3 Ilfov Street, 050044 Bucharest, Romania.
Abstract
Carbapenem-resistant Klebsiella pneumoniae (CRKP) is the pathogen driving the deterioration of the European antimicrobial resistance landscape, and the burden falls disproportionately on Romania and South-Eastern Europe. The objective of this review was to synthesise evidence published between 2020 and 2025 on the epidemiology, molecular characteristics, clinical impact, and pandemic-era trajectory of CRKP healthcare-associated infections across South-Eastern Europe, including Romania. This retrospective, qualitative narrative review combined the international literature with a deliberately multilingual search of national-language sources in Romanian, Bulgarian, Greek, Croatian, Slovenian, and Serbian, including congress abstract books, doctoral theses, national reference-laboratory reports, and agency surveillance series that are absent from PubMed. Three findings emerge. First, the region is not epidemiologically uniform: estimated incidence of carbapenem-resistant K. pneumoniae bloodstream infection in 2024 ranged from 0.62 per 100,000 population in Slovenia to 20.31 in Romania, against a European Union/European Economic Area (EU/EEA) figure of 3.46, and the steepest relative rise between 2019 and 2024 was recorded in Bulgaria (+374.1%). Second, a distinctive molecular signature has consolidated in the northern half of the region: co-production of a metallo-β-lactamase with an OXA-48-like enzyme (OXA-48, a class D, oxacillinase-type carbapenemase), reported in 44.4-61.2% of characterised Romanian isolates across independent centres, which removes ceftazidime-avibactam from the therapeutic repertoire and leaves aztreonam-avibactam and cefiderocol as the principal remaining options. Third, the pandemic did not produce a single regional signal but a consistent sequence-a transient interruption of upward trends during 2020, a marked acceleration from 2021, and persistence of the elevated level after 2022-with national-language surveillance from Croatia and Slovenia showing that the direction of the apparent pandemic effect depends on whether incidence or resistance proportion is measured. The national-language literature adds granularity unavailable in English, but the evidence base remains structurally uneven: Albania, Kosovo, and North Macedonia contribute almost no primary data, and no country in the region has published a CRKP-attributable mortality estimate for the review period. CRKP in Romania and South-Eastern Europe now maps onto three molecular zones-OXA-48 predominance in the Western Balkans and Croatia, a KPC-to-metallo-β-lactamase transition in Greece, and metallo-β-lactamase plus OXA-48-like co-production in Romania and increasingly Bulgaria-that require different empirical therapy; the COVID-19 pandemic did not create this burden but accelerated and entrenched it, and closing the region's mortality-data and Western Balkan surveillance gaps should be a priority for future research.
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BibTeX
@article{cernat2026carbapenemresistant,
title = {{Carbapenem-Resistant Klebsiella pneumoniae in Romania and South-Eastern Europe: A Multilingual Narrative Review of Pandemic-Era Trajectories, 2020-2025.}},
author = {Roxana-Carmen Cernat and Oana-Elena Ioniţă and Maria-Elena Vodarici and Nicola-Maria Militaru and Rareș-Alexandru Constantin and Nela-Daniela Efrim and Elena Mocanu and Edmond Puca and Daniela Piţigoi and Valeriu Gheorghiţă and Irina-Magdalena Dumitru},
journal = {Pathogens (Basel, Switzerland)},
year = {2026},
month = sep,
doi = {10.3390/pathogens15101004},
url = {https://europepmc.org/article/MED/42931156},
note = {CC BY},
}
RIS
TY - JOUR
TI - Carbapenem-Resistant Klebsiella pneumoniae in Romania and South-Eastern Europe: A Multilingual Narrative Review of Pandemic-Era Trajectories, 2020-2025.
AU - Roxana-Carmen Cernat
AU - Oana-Elena Ioniţă
AU - Maria-Elena Vodarici
AU - Nicola-Maria Militaru
AU - Rareș-Alexandru Constantin
AU - Nela-Daniela Efrim
AU - Elena Mocanu
AU - Edmond Puca
AU - Daniela Piţigoi
AU - Valeriu Gheorghiţă
AU - Irina-Magdalena Dumitru
PY - 2026
DA - 2026/09/22
JO - Pathogens (Basel, Switzerland)
DO - 10.3390/pathogens15101004
UR - https://europepmc.org/article/MED/42931156
AB - Carbapenem-resistant Klebsiella pneumoniae (CRKP) is the pathogen driving the deterioration of the European antimicrobial resistance landscape, and the burden falls disproportionately on Romania and South-Eastern Europe. The objective of this review was to synthesise evidence published between 2020 and 2025 on the epidemiology, molecular characteristics, clinical impact, and pandemic-era trajectory of CRKP healthcare-associated infections across South-Eastern Europe, including Romania. This retrospective, qualitative narrative review combined the international literature with a deliberately multilingual search of national-language sources in Romanian, Bulgarian, Greek, Croatian, Slovenian, and Serbian, including congress abstract books, doctoral theses, national reference-laboratory reports, and agency surveillance series that are absent from PubMed. Three findings emerge. First, the region is not epidemiologically uniform: estimated incidence of carbapenem-resistant K. pneumoniae bloodstream infection in 2024 ranged from 0.62 per 100,000 population in Slovenia to 20.31 in Romania, against a European Union/European Economic Area (EU/EEA) figure of 3.46, and the steepest relative rise between 2019 and 2024 was recorded in Bulgaria (+374.1%). Second, a distinctive molecular signature has consolidated in the northern half of the region: co-production of a metallo-β-lactamase with an OXA-48-like enzyme (OXA-48, a class D, oxacillinase-type carbapenemase), reported in 44.4-61.2% of characterised Romanian isolates across independent centres, which removes ceftazidime-avibactam from the therapeutic repertoire and leaves aztreonam-avibactam and cefiderocol as the principal remaining options. Third, the pandemic did not produce a single regional signal but a consistent sequence-a transient interruption of upward trends during 2020, a marked acceleration from 2021, and persistence of the elevated level after 2022-with national-language surveillance from Croatia and Slovenia showing that the direction of the apparent pandemic effect depends on whether incidence or resistance proportion is measured. The national-language literature adds granularity unavailable in English, but the evidence base remains structurally uneven: Albania, Kosovo, and North Macedonia contribute almost no primary data, and no country in the region has published a CRKP-attributable mortality estimate for the review period. CRKP in Romania and South-Eastern Europe now maps onto three molecular zones-OXA-48 predominance in the Western Balkans and Croatia, a KPC-to-metallo-β-lactamase transition in Greece, and metallo-β-lactamase plus OXA-48-like co-production in Romania and increasingly Bulgaria-that require different empirical therapy; the COVID-19 pandemic did not create this burden but accelerated and entrenched it, and closing the region's mortality-data and Western Balkan surveillance gaps should be a priority for future research.
SN - 2076-0817
ER -