The Globally increased emergence of antimicrobial resistance (AMR) is notified by world health organization (WHO) as one of leading health threats for 21st century challenges. [1] It was disseminated in the report that by the year 2050, mortality rate might exceed to 10 million annually. Besides that, the situation will become worsened, in case of persistent deficiency of new anti-microbials. This necessitates an eye opening and vigilant approach to formulate a National followed by Global action plan to combat the scenario.  [2] This highlights the aspect, to have strict implementation of rapid, cost effective and highly accurate diagnostic modalities along with formulation of empirical therapy and escalation protocols for managing new cases or multidrug resistant (MDR) and extensively drug resistant (XDR) cases. [3]

Identification and formulation of microbiology lab diagnostic protocols especially in low middle income countries, will be a big step to improve patient’s survival. Thus, ultimately contributing to reduce financial burden by redcuing hospital stay for the patient and National level AMR crisis. [3]

The Enterobacteriaceae family members are the commensals of human gut microbiome and plays a fundamental role for sepsis in intensive care settings (ICU). They are playing a role of an ecosystem even for the antibiotic-resistant bacteria. [4]

Carbapenem-resistant Enterobacteriales (CRE) and colistin resistant bacteria harbors the AMR genes i.e NDM, IMP, OXA-48, VIM, KPC and mcr 1-8. Their mode of action involves production of ß- lactamase, formulation of low affinity targets for penicillin-binding protein (PBPs), abridged permeability in the outer membrane, and efflux pump malfunctioning. In such scenario last hope of colistin is now even getting diminished as the emergence of chromosomes and plasmid mediated mcr - genes are presenting as resistance pattern. [5]

In view of existing scenario of AMR, and availability of many microbiological diagnostic options, selection of cost effective, rapid and higly sensitive one is the need of an hour. Starting from time consuming but gold standard culture and sensitivity uptil molecular detection, all are having the pluses and minuses. 

In the epoch of AMR, a new diagnostic modality i.e multiplex or array-based PCR via filmarray is a new hope. A published report for the year 2021, by Food and Drug Administration (FDA), United State (US) had approved the usage of multiplex PCR via BioFire FilmArray. Starting from an hour’ time uptil proceedings of positive blood cultures for blood culture identification (BCID) panel contributes to rapid and accurate AMR gene detection along with microbial genetics. Thus, decreasing a turnaround time, became a significant contributor for reducing patient’s morbidity and mortality rates. [6]

It is an excellent contributor for the simultaneous detection of more than 26 bacterial targets, [7] yeast targets and 10 antimicrobial resistance (AMR) genes. But on same time exceeding a cost of 40,000/- Pakistani rupees, is making it very difficult for comfortable inclusion in diagnostic Stewardship. Thus, for low middle income countries, again a trouble shoot scenario has emerged because of high cost per test and non-affordability of poor patients along with Government support. This imposes to identify the equating highly sensitive test to get desired diagnostic results. 

Ranking superior to traditional gold standard cultures, but definitely lesser than biofire filmarray, availability of inhouse developed real time PCR can became a ray of hope for low middle income countries. This is a highly sensitive and specific assay, which can provide approximately same good molecular level diagnosis. Comparatively to biofire filmarray appx one hr turnaround time to uptil positive blood culture evaluation, real time PCR requires 3 hrs appx time uptil evaluation of same positive blood cultures. 7 This is further strengthened by a published study for year 2025, which concluded that a multiplex quantitative RT-PCR assays is a rapid highly sensitive and specific test for simultaneous detection of six bacterial pathogens of low respiratory tract infections (LRTIs) along with AMR genes. [8]

Besides this reduced per sample cost of approximate 3000 per test from more than 40,000 rupees per test via biofire, will be added cost effective measure in such countries to combat financial burden imposed by AMR. In addition to this, for original research purpose using the positive AMR genes and bacterial genetics identified by biofire filmarray, inhouse real time PCR can be developed for AMR and bacterial genes in low middle income countries. 

Despite a thorough search by using different search engines, the literature review was found deficient both at National and International levels. The readiness of good microbiological laboratory services is limited in our country. Even the available laboratories are not well equipped, along with lack of technical expertise. Moreover, the time-consuming cultures proceedings adds up to the misery of patients especially in currently increased scenario of AMR. Therefore, availability of good quality, accurate, rapid and cost effective microbiological diagnostic options are the dire need of time to combat AMR. In light of this scenario, inhouse real time PCR for AMR and bacterial genes can be a ray of hope to atleast fight high financial burden and high morbidity and mortality rates by increased AMR, MDR and XDR cases. 

The above all mentioned aspects is becoming a basis to urge from the National and international level funding organizations to provide funds for such type of researches to low middle income countries. Thus, their national level diagnostic Stewardships can be established to combat worsened AMR scenarios in their extremely limited resources.