The rise of WHO-priority pathogens in central line associated bloodstream infection: Challenging the AWaRe paradigm...

Central line-associated bloodstream infections (CLABSIs) pose a serious threat to critically ill patients, particularly in low- and middle-income countries facing rising antimicrobial resistance (AMR). Integrating WHO's Priority Pathogen Lists (PPL) and AWaRe antibiotic classification into CLABSI surveillance provides a clinically meaningful framework to guide antimicrobial stewardship and infection control. We conducted an observational study in ICUs from 2021 to 2024. Patients with central lines in situ for ≥ 2 calendar days were evaluated using CDC-NHSN definitions. Isolates underwent antimicrobial susceptibility testing (CLSI M100). Pathogens were classified using WHO PPL 2024 and analysed as per AWaRe categories. Clinical outcomes were correlated with pathogen class and resistance profile. Among 5,398 ICU patients, 102 developed laboratory-confirmed CLABSIs. Of these, 76.5% were caused by WHO-priority pathogens-63 bacterial and 15 fungal. Carbapenem-resistant Klebsiella pneumoniae and Acinetobacter baumannii predominated, especially in trauma ICUs (88.6%, p = 0.0493). Over 95% of bacterial isolates were resistant to all Access and Watch antibiotics, necessitating the use of Reserve agents like colistin. Among fungal isolates, Candida auris emerged as the most resistant species, while C. tropicalis retained full susceptibility. Mortality was 100% in patients infected with high-priority bacterial pathogens and 85.7% with high-priority fungal pathogens. This study is the first to map CLABSIs against the WHO PPL and AWaRe frameworks, highlighting a convergence of high-risk infections, therapeutic exhaustion, and poor outcomes. The findings underscore the urgent need for targeted stewardship, enhanced surveillance, and policy-level AMR interventions in critical care settings.