Stepwise evolution and convergent recombination underlie the global dissemination of carbapenemase-producing Escherichia coli.

Lineages of CP-Ec have started to disseminate globally. However, their selection is a multistep process involving mutations, recombination, acquisition of antibiotic resistance genes, and selection by β-lactams from diverse families. This process did not yet occur in the high-risk lineage ST131.