-->PONE-D-25-16842-->-->Microbiological Profile and Antimicrobial Resistance Patterns of Blood Culture Isolates at Amhara Public Health institute: Four-year Retrospective Study-->-->PLOS ONE

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Aug 18 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:-->

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Mengistu Hailemariam Zenebe, PhD

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf.

2. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

Before we proceed with your manuscript, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible.

Please update your Data Availability statement in the submission form accordingly.

3. In the online submission form you indicate that your data is not available for proprietary reasons and have provided a contact point for accessing this data. Please note that your current contact point is a co-author on this manuscript. According to our Data Policy, the contact point must not be an author on the manuscript and must be an institutional contact, ideally not an individual. Please revise your data statement to a non-author institutional point of contact, such as a data access or ethics committee, and send this to us via return email. Please also include contact information for the third party organization, and please include the full citation of where the data can be found.

4. Please amend the manuscript submission data (via Edit Submission) to include author Yosef Gashaw.

5. We notice that your supplementary figures are uploaded with the file type 'Figure'. Please amend the file type to 'Supporting Information'. Please ensure that each Supporting Information file has a legend listed in the manuscript after the references list.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Partly

Reviewer #2: Partly

**********

-->2. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

**********

-->3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: No

Reviewer #2: Yes

**********

-->4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: No

Reviewer #2: No

**********

-->5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: The study is valuable in identifying the common pathogens of bloodstream infection as well as their antimicrobial resistance pattern. However, corrections are highly recommended.

Corrections required:

In general:

1. Scientific names of organisms are not in italics.

2. The “spp.” need not be in italics.

3. Digits after decimal point should be uniform.

In abstract:

1. It is mentioned that “..all aged groups..” were included. However, the main article shows not only aged people, but a wide range of patients were included in the study.

2. Why was Gram staining of blood done? It is redundant to diagnose infection.

3. Only 24 hours of incubation of the specimen is mentioned which is inadequate for blood culture.

In main article:

1. Line 69: Correction of “E.colli” is required.

2. Line 71: It should be BSI, not BIS.

3. Line 129: As per Oxoid website, their product is tryptone soya broth, not tryptic soya broth. Confirmation of the product used is recommended.

4. Line 133: Why was the range of 35 to 37oC kept for incubation? Was there any reason for changing the temperature during actual work? Please specify.

5. Line 139: Only MacConkey is mentioned. Whether agar or broth is missing.

6. Lines 149-151: Identification of Enterococcus is missing.

7. Line 154: Why was normal saline used to incubation instead of broth? Any references for this method of AST?

8. Line 159: Spelling is Mueller-Hinton agar, not Muller-Hinton agar.

9. Line 201: ATCC should not be within brackets.

10. Line 205-208: The sentence is unclear.

11. Lines 310-312: Resistance to number of antibiotics is specified in table as R1, R2, etc. It does not fit the MDR criteria.

Reviewer #2: Dear Editor,

Thank you for your invitation to review the manuscript titled “Microbiological Profile and Antimicrobial Resistance Patterns of Blood Culture Isolates at Amhara Public Health institute: Four-year Retrospective Study.” I have provided my comments for each section of the paper.

• Title: It is better modified as, Bacterial Profile and Antimicrobial Resistance Patterns of Blood Culture Isolates at Amhara Public Health institute: Four-year Retrospective Study. It was more about bacteria. The author/s mentioned at once ‘Candida species. And this cannot qualify the status of ‘microbiological profile’. Even microbiological Profile by itself is too broad.

Abstract

• Line 25: Requires revision. For example, ‘Therefore, this study was to analyze the microbiological profile and antimicrobial resistant patterns among patients……….’ It is better written as, ‘Therefore, this study was intended to assess the bacterial profile and antimicrobial resistant patterns among patients……………..

• In the method part of the abstract, first describe the laboratory techniques than encoding to excel or SPSS. Even when you write the lab technique, it seems as you did prospectively. You have to make it compatible to retrospective study. The study was done in a reference laboratory, but you mentioned as you did preliminary test. Please think over it.

• Line 37: not cases. It is better written as, ‘Of them, 267 (55.5%) isolates were Gram-positive, 209 (43.4%) isolates Gram-negative bacteria, and the remaining 5 (1.1%) were Candida species.’

• Line 39: What does ‘ESKAPE’ represent? It should be written in both the long and abbreviated form as its first appearance in combination.

• Line 43: No italics is needed for ‘Coagulase-negative staphylococci’

• Line 44: You can calculate the overall prevalence of each bacterium, but it is impossible to calculate the overall prevalence. For example, based on CLSI guideline, we cannot test the same antibiotics for all isolates. You have to revise it and all the result parts.

Introduction

• The rationale is not explained well. Why you did this research? What has been done before, what is known before and which you intend to fill? The introduction should be coherent and interlinked.

Materials and methods

• The method part should be written in standard English.

• What were the inclusions and exclusion criteria? Have you collected any of what you got?

• Lines 159&166: not Muller Hinton agar, rather ‘Mueller Hinton agar’

Result

• The result should be revised and written well.

• In ‘the associated factors’ part the reference selection was not logical. For example, why you select, ‘Addis Alem General Hospital’ as a reference?

• Specific comments will be forwarded if the paper turns back to me.

Discussion

• Discussion not merely comparison, but it includes justifications of your results

• Try to decrease numbers in the discussion part.

• Your conclusion and recommendation were too ambitious. It should be specific and based on your results.

• Figures and tables should be prepared to the standard.

• The references were not written properly. All references should be written correctly according to Vancouver style.

• Follow the standard binomial nomenclature, italize journal name and the word ‘et al’

• Follow the guideline for manuscript writing protocol for PLoS One.

**********

-->6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review?  For information about this choice, including consent withdrawal, please see our Privacy Policy.-->

Reviewer #1: No

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: Review file.pdf

-->PONE-D-25-16842R1-->-->Bacterial profile and antimicrobial resistance patterns of blood culture isolates at Amhara Public Health Institute, Bahirdar, Ethiopia: Four-year retrospective study-->-->PLOS ONE

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.-->-->

Please submit your revised manuscript by Nov 20 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:-->

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Mengistu Hailemariam Zenebe, PhD

Academic Editor

PLOS ONE

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

Reviewer #4: (No Response)

**********

-->2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Partly

**********

-->3. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

**********

-->4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

**********

-->5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

**********

-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #2: All the comments were adressed well. The declaration section needs improvement during at/or before proof reading, specially authors contribtion should be similar to the submision systems'.

Reviewer #3: Dear Editor

This manuscript is about " Bacterial profile and antimicrobial resistance patterns of blood culture isolates at

Amhara Public Health Institute, Bahirdar, Ethiopia: Four-year retrospective study". It is a good manuscript but it is not suitable for publishing in PLOS ONE. This study is just a simple report of bacterial blood culture and the frequency of their antibiotic resistant. So, It can not catch the eye of your readers. So , I decided to reject it.

Regards,

Reviewer #4: This is regarding a manuscript titled Bacterial profile and antimicrobial resistance patterns of blood culture isolates at Amhara Public Health Institute, Bahirdar, Ethiopia: Four-year retrospective study

General comment

This manuscript narrates the Bacterial profile and antimicrobial resistance patterns of blood culture isolates. The study design is thorough and contextualizes their findings within the urgent national issue of antibiotic resistance in connection with BSI.

At the same time, the work repeats a familiar approach without advancing new methodologies for the identification of bacteria and drug resistance. Speciation of many bacteria and Candida is not done. Besides, BSI-causing anaerobic bacteria are not included. The English part of the manuscript needs to be revised.

Recommendations

The title should be modified

Bacterial profile and antimicrobial resistance patterns of bloodstream infections at Amhara Public Health Institute, Bahirdar, Ethiopia: Four-year retrospective study

Abstract

1. The abstract should be improved

2. Replace specimen with samples throughout the manuscript

3. Line 34 The way the overall culture positive findings are presented in the results is not logical. It should include both bacteria and Yeast

4. Standard bacteriological techniques were followed during blood collection. What does it mean? Have authors followed standardized manual blood culture methods following WHO recommendations for resource-limited settings?

5. Techniques used for the AMST test have to be mentioned

6. Is this a work intended to show the problems of ESKAPE pathogens in BSI

7. How about Community-onset BSIs

8. What is the criteria for including patients for Nosocomial BSI with ESKAPE pathogens

9. The acronym has now been revised as ESKAPEE. So update the results

10. Why didn’t the authors include the WHO priority pathogens in their study?

11. Results of the overall antibiogram profile have to be included, rather than focusing only on ESKAPE pathogens. Results of drug resistance have to be revised by including the names of antibiotics versus the percentage of resistance

12. Avoid repetitive citation of the abbreviation on lines 24 and 47

13. Use the microbiological rule of abbreviating bacteria. Lines 39 and 40

14. Parentheses have to be standardized. N should be placed inside the bracket

15. If P values are reported, please follow standard conventions for decimal places: for P values less than .001, report "P<.001"; for P values between .001 and .01, report the value to the nearest thousandth; for P values greater than or equal to .01, report the value to the nearest hundredth; and for P values greater than .99, report as "P>.99."

16. In conclusion, the authors mentioned the carbapenem resistance without indicating any findings in the results session

17. What about recommending an antimicrobial stewardship programe?

18. Is there any existing antimicrobial stewardship programe in the study setting?

Introduction

It is too general

Clearly state the problem, causes, and outcomes of BSI

Include details of BSI-associated morbimortality in Ethiopia

What type of Research gap exists in the study area?

Include some lines on how BSI infection is treated/managed in Ethiopia

Methods

Study area: Remove irrelevant information for international readers from lines 102 to 109.

Should include cases and fatality related to BSI in terms of morbimortality has to be introduced in the study setting. Standard treatment guidelines of BSI in Ethiopia

Bloodstream infections should be detected through standardized manual blood culture methods following WHO recommendations for resource-limited settings. There is no reference in this regard. Factors that may influence the recovery of pathogens from the blood include the timing of blood collection, the number of sets collected, and blood volume.

True BSIs should be distinguished from potential contaminants (e.g., Micrococcus spp., Bacillus spp. Other than B. anthracis, or coagulase-negative staphylococci (CoNS) using standardized definitions adapted from the CDC guidelines. However, this is missing in this study.

Why this study excludes Community-onset BSIs ?

How only ESKAPE pathogens associated BSI is highlighted?

What is the overall prevalence of ESKAPE pathogens in the study settings

Is there any data related to the upsurge of ESKAPE pathogens in the hospital?

Is there any local antibiotic policy used in the hospital to manage ESKAPE pathogens?

In the results, authors mentioned Candida. However, methodology for its isolation and identification are missing.

What is the selection criteria for antibiotics?

Accurate identification of bacterial species and susceptibility testing is important, but I am not convinced that they have accurately identified the species level of the isolates in their study.

Staphylococcus (CONS), Proteus and Klebsiella are heterogeneous group of pathogenic organisms. It is not acceptable to lump them together, considering the objectives of the study.

The authors are advised to classify the tested isolates to MDR , XDR, and PDR as described by Magiorakos et al.

Why authors didn’t inspected MRSA, since these are the WHO prioritized drug resistant bacteria, since the prevalence of these bacteria are frequently appearing in the papers from Ethiopia.

Why authors didn’t checked the presence of extensive drug resistance (XDR) and pan-drug resistance (PDR), even though the MDR is 68%.

Details of the vital signs of patients have to be included?

Predetermined sample size calculation is missing

Precisely include the eligibility criteria

The details statistical analysis done are vague. Include all variables regardless of their p-value in the univariate analysis to avoid missing important confounders.

Strengthen the discussion. Deepen the critical analysis by comparing findings with other recent plant-based antimicrobial studies (especially >2020).

Discuss limitations more transparently

**********

-->7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review?  For information about this choice, including consent withdrawal, please see our Privacy Policy.-->

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes: ASEER MANILAL

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

-->PONE-D-25-16842R2-->-->Bacterial profile and antimicrobial resistance patterns of bloodstream infections at Amhara Public Health Institute, Bahirdar, Ethiopia-->-->PLOS One

Dear Author,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 11 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:-->

• A letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

-->

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only  the individual author can complete the verification step; PLOS staff cannot  verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Mengistu Hailemariam Zenebe, PhD

Academic Editor

PLOS One

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #2: (No Response)

Reviewer #5: (No Response)

**********

-->2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #2: Partly

Reviewer #5: Yes

**********

-->3. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #2: No

Reviewer #5: Yes

**********

-->4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #2: Yes

Reviewer #5: Yes

**********

-->5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #2: No

Reviewer #5: No

**********

-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #2: • Bahir Dar, not Bahirdar

1. The disk diffusion method (Kirby–Bauer) is useful for routine AST, but it has limitations when classifying advanced resistance categories like XDR and PDR:

• XDR and PDR definitions require testing against all or nearly all relevant antimicrobial categories.

• Disk diffusion panels often exclude critical last-resort drugs such as: colistin, tigecycline and new β-lactam/β-lactamase inhibitor combinations

• Disk diffusion is not reliable for some antibiotics (e.g., colistin), where broth microdilution is the gold standard.

• XDR/PDR classification often benefits from minimum inhibitory concentration (MIC) values to accurately determine resistance levels.

• According to international standards (e.g., ECDC), classification of XDR, and PDR requires: Testing across multiple antimicrobial classes and using validated methods for each drug class

2. To confidently classify isolates as XDR or PDR:

• Combine disk diffusion with: Broth microdilution, automated systems (e.g., VITEK, Phoenix) or gradient diffusion (E-test) for MIC determination

• Ensure the antibiotic panel covers all major antimicrobial categories relevant to the organism.

• The classification of XDR and PDR was based primarily on disk diffusion results, which may not fully capture resistance to all relevant antimicrobial categories, particularly for agents requiring MIC-based methods such as colistin. Therefore, the reported proportions of XDR and PDR should be interpreted with caution and requires revision.

• Lines 131 and 132: Remove ‘Blood culture samples collection, inoculation, identification and antimicrobial susceptibility testing

• Definitions (MDR, XDR and PDR) better be presented using bullet for easy of understanding than a paragraph

• How can you analyze the AST for MDR, XDR and PDR? Which tool used in this case?

• Avoid: This is table 2/3 legend.

• It is possible to assess the MDR, XDR or PDR for a single species, but it is totally wrong to determine/calculate the overall MDR/XDR/PDR for Gram-negatives or Gram-positives because we cannot use the same antimicrobials for all isolates. Therefore, this part should be reconsidered.

• Think of: ‘the Amhara National Regional State’ throughout the manuscript including table/figure titles.

• Why you consider the Addisalem General Hospital (AGH) as a reference variable the associated variables?

• If you mentioned some name of hospitals, why you left others? Were these the only hospitals that referred samples to APHI?

• The ‘discussion’ was too bulky (8 pages). It should be based on the study objective/s. It requires revision and to be targeted.

• Excessive numbers in the discussion part should be minimized

• Too many references for such a single objective and requires revision.

• Lines 19, 25 & 47: Reference, not Organization, W.H. Better say WHO.

• The titles of figures should be avoided from figures if they already placed in the main body of the manuscript. Titles should not be embedded in figures.

• Line 697: Reference (28); There was no article name, author, etc.

Reviewer #5: The revision includes meaningful improvements, particularly regarding contamination definitions and laboratory procedures. However, substantial methodological and analytical clarifications are still required.

Major Concerns

1. Extremely high blood culture positivity rate (~58%)

The reported culture positivity (58.3–58.5%) remains unusually high for routine retrospective laboratory data, even in referral laboratories.

Although the authors now describe contamination criteria (CDC/NHSN), important issues remain:

• Coagulase-negative staphylococci (CoNS) still represent a large proportion of isolates.

• The manuscript does not report:

o number of culture sets per patient actually analyzed

o proportion of isolates meeting “two consecutive cultures” requirement

o contamination rate

o proportion excluded as contaminants

Could the authors report the contamination rate according to their stated criteria?

Could the authors specify how many CoNS isolates were excluded vs retained as true pathogens?

I suggest that the authors provide a flow diagram showing:

• total cultures

• positive cultures

• contaminants excluded

• final pathogen count

Without this, the reported positivity rate remains difficult to interpret.

2. Identification methods remain limited

Bacterial identification relies entirely on conventional biochemical testing.

No confirmatory methods are reported (e.g., automated systems or advanced identification platforms).

While resource constraints are acknowledged, this limitation must be addressed analytically.

I suggest that the authors discuss the potential for species misidentification and its impact on resistance estimates.

Minor Concerns

Numerous grammatical and typographical errors remain.

Scientific nomenclature inconsistent (e.g., species formatting).

Some abbreviations are introduced without definition.

Tables are difficult to interpret due to inconsistent formatting.

Resistance percentages sometimes do not correspond clearly to denominators.

Background section contains repetitive information.

Several sentences require language editing for clarity.

**********

-->7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review?  For information about this choice, including consent withdrawal, please see our Privacy Policy.-->

Reviewer #2: No

Reviewer #5: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

-->

Bacterial profile and antimicrobial resistance patterns of bloodstream infections at Amhara Public Health Institute, Bahir Dar, Ethiopia

PONE-D-25-16842R3

Dear Dr. Getie,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Mengistu Hailemariam Zenebe, PhD

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments: