Plasmid conjugation drives within–patient plasmid diversity

Plasmids are well-known vehicles of antimicrobial resistance (AMR) gene dissemination. Through conjugation, plasmid-encoded AMR genes are spread among neighbouring bacteria, irrespective of their strain or even their species. This process is very concerning from a public health perspective, as plasmid-borne AMR gene outbreaks are often not con-fined to single species or strains and are therefore more difficult to fully uncover. At the moment, the impact of plasmid conjugation on within–patient plasmid diversity is not well understood. In this work, we will tackle the role of conjugation on within–patient plasmid diversity using a dataset of carbapenemase-producing Enterobacterales. The dataset of 256 sequences originates from bacterial isolates cultured from 115 English patients over 30 months. Each patient has more than one sequence, with at least one sequence carrying an OXA-48 gene, a well-known plasmid-borne carbapenemase-encoding gene. If more than one sequence carries the OXA-48 gene, they are carried in different bacterial hosts. Using a hybrid de novo–on-reference assembly pipeline, we were able to reconstruct the full OXA-48 plasmid from short read sequencing data for 232 of the 256 sequences. Of the 115 patients, 83 (72%) patients had an identical OXA-48 plasmid in two or more sequences. Only two patients carried very different (>200 SNPs) alleles of the OXA-48 plasmid, probably from separate acquisitions. Our study shows that when more than one bacterial host carrying an OXA-48 plasmid is found in a patient, it is most likely that the same plasmid has been shared via conjugation. The event of separate acquisition of different plasmids in different bacterial hosts is highly unlikely in our dataset.