Quantitative assessment of human exposure to extended spectrum and AmpC β-lactamases bearing E. coli in lettuce attributable to irrigation water and subsequent horizontal gene transfer

Antibiotic resistance of Escherichia coli isolated from food and clinical environment in China from 2001 to 2020

Antibiotics are widely used in China's aquaculture, agricultural, and clinical settings and can lead to antibiotic resistance in various pathogens. Although the pooled prevalence estimate (PPE) and antibiotic resistance of Escherichia coli (E. coli) in food and clinical settings has been extensively studied, a comprehensive analysis of the published literature is lacking. We conducted a comprehensive search for research indicators for 2001-2020 in eight major Chinese and English literature databases. Antibiotic PPE and resistance trends of 5933 and 29,451 E. coli isolates were screened and analysed in 35 food studies (total 1821) and 62 clinical studies (total 5159). E. coli strains derived from food had the highest antibiotic resistance rate to tetracycline (TET, 71.3 %), followed by trimethoprim-sulfamethoxazole (SXT, 62.5 %) and cefazolin (CFZ, 36.2 %). E. coli strains isolated from clinical environments were highly resistant to piperacillin (PIP, 71.7 %), TET (68.3 %) and CFZ (60.9 %), consistent with foodborne E. coli drug resistance patterns. E. coli strains isolated from food and clinical samples collected in laboratories carry multiple antibiotic resistance genes (ARGs), such as blaTEM, gryA, gryB, sul1, and tetA, making E. coli a reservoir of ARGs. This study highlights the presence of drug-resistant E. coli pathogens and ARGs in food and clinical environments.

Contribution of Food to the Human Health Burden of Antimicrobial Resistance

The impact of foodborne antimicrobial resistance (AMR) on the human health burden of AMR infections is unknown. The aim of this review was to evaluate and summarize the scientific literature investigating all potential sources of human AMR infections related to food. A literature search was conducted in Embase (Ovid) and MEDLINE (Ovid) databases to identify appropriate studies published between 2010 and 2023. The results of the search were reviewed and categorized based on the primary subject matter. Key concepts from each category are described from the perspective of food safety as a public health objective. The search yielded 3457 references, 1921 remained after removal of duplicates, abstracts, editorials, comments, notes, retractions, and errata. No properly designed source attribution studies were identified, but 383 journal articles were considered relevant and were classified into eight subcategories and discussed in the context of four streams of evidence: prevalence data, epidemiological studies, outbreak investigations and human health impact estimates. There was sufficient evidence to conclude that AMR genes, whether present in pathogenic or nonpathogenic bacteria, constitute a foodborne hazard. The level of consumer risk owing to this hazard cannot be accurately estimated based on the data summarized here. Key gaps in the literature are noted.

What Is in the Salad? Escherichia coli and Antibiotic Resistance in Lettuce Irrigated with Various Water Sources in Ghana

INTRODUCTION

Safety of the environment in which vegetables are grown, marketed and consumed is paramount as most are eaten raw. Irrigation sources include open drains and streams, which are often contaminated with human and animal waste due to poor sanitation infrastructure. In irrigated vegetable farms using such sources in Ghana, we assessed Escherichia coli counts, antibiotic resistance patterns and resistant genes on irrigated lettuce.

METHODS

A cross-sectional study was conducted between January-May 2022, involving five major vegetable farms in Ghana.

RESULTS

Escherichia coli was found in all 25 composite lettuce samples analyzed. Counts expressed in CFU/g ranged from 186 to 3000, with the highest counts found in lettuce irrigated from open drains (1670) and tap water using hose pipes (3000). Among all bacterial isolates, resistance ranged between 49% and 70% for the Watch group of antibiotics, 59% for the Reserved group and 82% were multidrug-resistant. Of 125 isolates, 60 (48%) were extended-spectrum beta-lactamase-producing, of which five (8%) had the blaTEM-resistant gene.

CONCLUSIONS

Lettuce was contaminated with Escherichia coli with high levels of antibiotic resistance. We call on the Ghana Ministry of Food and Agriculture, Food and Drugs Authority and other stakeholders to support farmers to implement measures for improving vegetable safety.

Characteristics and Global Occurrence of Human Pathogens Harboring Antimicrobial Resistance in Food Crops: A Scoping Review

Background

The role of the crop environment as a conduit for antimicrobial resistance (AMR) through soil, water, and plants has received less attention than other sectors. Food crops may provide a link between the agro-environmental reservoir of AMR and acquisition by humans, adding to existing food safety hazards associated with microbial contamination of food crops.

Objectives

The objectives of this review were: (1) to use a systematic methodology to characterize AMR in food crop value chains globally, and (2) to identify knowledge gaps in understanding exposure risks to humans.

Methods

Four bibliographic databases were searched using synonyms of AMR in food crop value chains. Following two-stage screening, phenotypic results were extracted and categorized into primary and secondary combinations of acquired resistance in microbes of concern based on established prioritization. Occurrence of these pathogen-AMR phenotype combinations were summarized by sample group, value chain stage, and world region. Sub-analyses on antimicrobial resistance genes (ARG) focused on extended-spectrum beta-lactamase and tetracycline resistance genes.

Results

Screening of 4,455 citations yielded 196 studies originating from 49 countries, predominantly in Asia (89 studies) and Africa (38). Observations of pathogen-phenotype combinations of interest were reported in a subset of 133 studies (68%). Primary combinations, which include resistance to antimicrobials of critical importance to human medicine varied from 3% (carbapenem resistance) to 13% (fluoroquinolones), whereas secondary combinations, which include resistance to antimicrobials also used in agriculture ranged from 14% (aminoglycoside resistance) to 20% (aminopenicillins). Salad crops, vegetables, and culinary herbs were the most sampled crops with almost twice as many studies testing post-harvest samples. Sub-analysis of ARG found similar patterns corresponding to phenotypic results.

Discussion

These results suggest that acquired AMR in opportunistic and obligate human pathogens is disseminated throughout food crop value chains in multiple world regions. However, few longitudinal studies exist and substantial heterogeneity in sampling methods currently limit quantification of exposure risks to consumers. This review highlights the need to include agriculturally-derived AMR in monitoring food safety risks from plant-based foods, and the challenges facing its surveillance.

Towards risk assessment for antibiotic resistant pathogens in recycled water: a systematic review and summary of research needs

Risk assessment is critical for identifying target concentrations of antibiotic resistant pathogens necessary for mitigating potential harmful exposures associated with water reuse. However, there is currently limited available data characterizing the concentrations of antibiotic resistant bacteria (ARB) and antibiotic resistance genes (ARGs) in recycled water to support robust efforts at risk assessment. The objective of this systematic review was to identify and synthesize the existing literature documenting the presence and abundance of ARB and ARGs in recycled water. In addition, this review identifies best practices and explores monitoring targets for studying ARB and ARGs in recycled water to guide future work and identifies key research needs aimed at better supporting quantitative microbial risk assessment focused on recycled water and antibiotic resistance. Future efforts to collect data about ARB and ARG prevalence in recycled water should report concentration data per unit volume. Sample metadata should also be provided, including a description of treatment approach, a description of planned water uses (e.g., potable, irrigation), methods for conveyance to the point of use, and available physicochemical water quality data. Additional research is needed aimed at identifying recommended ARB and ARG monitoring targets and for developing approaches to incorporate metagenomic data into risk assessment.

Quantitative analysis of horizontal gene transfer in complex systems

Horizontal gene transfer (HGT) plays a significant role in rapidly propagating diverse traits throughout bacterial populations, thereby accelerating natural evolution and leading to complex community structures. Critical gene transfer rates underlying these occurrences dictate the efficiency and speed of gene spread; these rates are often highly specific to HGT mechanism and environmental context, and have historically been challenging to reliably quantify. In this review, we examine recent works that leverage rigorous quantitative methods to precisely measure these rates in a variety of settings beginning with in vitro studies and advancing to in situ measurements; we emphasize contexts where quantification across multiple scales of complexity has led to fundamental biological insights. Finally, we highlight the applications of these measurements and suggest potential methodological advances to improve our understanding.

Comparative Analysis of Consumer Exposure to Resistant Bacteria through Chicken Meat Consumption in Germany

Human exposure to bacteria carrying antimicrobial resistance (AMR) genes through the consumption of food of animal origin is a topic which has gained increasing attention in recent years. Bacterial transmission can be enhanced, particularly in situations in which the consumer pays less attention to hygiene practices, and consumer exposure to foodborne resistant bacteria through ready-to-eat foods could be increased. It has been demonstrated that even methicillin-resistant Staphylococcus aureus (MRSA) bacteria, which have low prevalence and concentration in raw chicken meat in Germany, may reach the consumer during barbecue events after failures in hygiene practices. This study aimed to quantify the consumer exposure to extended-spectrum beta-lactamase- (ESBL) or ampicillinase class C (AmpC) beta-lactamase-producing E. coli in Germany through the consumption of chicken meat and bread during household barbecues. The study considered cross-contamination and recontamination processes from raw chicken meat by using a previously-developed probabilistic consumer exposure model. In addition, a comparative analysis of consumer exposure was carried out between ESBL-/AmpC-producing E. coli and MRSA. Our results demonstrated that the probability of ESBL-/AmpC-producing E. coli reaching the consumer was 1.85 × 10^-5 with the number of bacteria in the final serving averaging 332. Given the higher prevalence and concentration of ESBL-/AmpC-producing E. coli in raw chicken meat at retail compared to MRSA, comparative exposure assessment showed that the likelihood and extent of exposure were significantly higher for ESBL-/AmpC-producing E. coli than for MRSA. ESBL-/AmpC-producing E. coli was determined to be 7.6 times likelier (p-value < 0.01) than MRSA to reach the consumer, with five times the concentration of bacteria in the final serving (p-value < 0.01).

Whole Genome Sequencing of Escherichia coli From Store-Bought Produce

The role of agriculture in the transfer of drug resistant pathogens to humans is widely debated and poorly understood. Escherichia coli is a valuable indicator organism for contamination and carriage of antimicrobial resistance (AMR) in foods. Whilst whole genome sequences for E. coli from animals and associated meats are common, sequences from produce are scarce. Produce may acquire drug resistant E. coli from animal manure fertilizers, contaminated irrigation water and wildlife, particularly birds. Whole genome sequencing was used to characterize 120 tetracycline (TET) resistant E. coli from store-bought, ready-to-eat cilantro, arugula and mixed salad from two German cities. E. coli were recovered on the day of purchase and after 7 days of refrigeration. Cilantro was far more frequently contaminated with TET-resistant E. coli providing 102 (85%) sequenced strains. Phylogroup B1 dominated the collection (n = 84, 70%) with multi-locus sequence types B1-ST6186 (n = 37, 31%), C-ST165 (n = 17, 14%), B1-ST58 (n = 14, 12%), B1-ST641 (n = 8, 7%), and C-ST88 (n = 5, 4%) frequently identified. Notably, seven strains of diverse sequence type (ST) carried genetic indicators of ColV virulence plasmid carriage. A number of previously identified and novel integrons associated with insertion elements including IS26 were also identified. Storage may affect the lineages of E. coli isolated, however further studies are needed. Our study indicates produce predominantly carry E. coli with a commensal phylogroup and a variety of AMR and virulence-associated traits. Genomic surveillance of bacteria that contaminate produce should be a matter of public health importance in order to develop a holistic understanding of the environmental dimensions of AMR.

A High Resolution DNA Melting Curve Analysis for the Rapid and Efficient Molecular Diagnostics of Extended Spectrum β-Lactamase Determinants from Foodborne Escherichia coli

The accurate identification of Extended-Spectrum β-Lactamase (ESBL) genes in Gram-negative bacteria is necessary for surveillance and epidemiological studies of transmission through foods. We report a novel rapid, cheap, and accurate closed tube molecular diagnostic tool based on two multiplex HRM protocols for analysis of the predominant ESBL families encountered in foods. The first multiplex PCR assay targeted blaCTX-M including phylogenetic groups 1 (CTX-M-1-15, including CTX-M-1, CTX-M-3 and CTX-M-15), 2 (CTX-M-2), and 9 (CTX-M-9-14, including CTX-M-9 and CTX-M-14). The second assay involved blaTEM /bla CTX-M /blaSHV, including TEM variants (TEM-1 and TEM-2), SHV-1-56 (SHV-1, SHV-2 and SHV-56), and CTX-M-8-41 (CTX-M-8, CTX-M-25, CTX-M-26 and CTX-M-39 to CTX-M-41). The individual melting curves were differentiated by a temperature shift according to the type of ESBL gene. The specificity and sensitivity of the first assay were 100% and 98%, respectively. For the second assay, the specificity and sensitivity were 87% and 89%, respectively. The detection of ESBL variants or mutations in existing genes was also demonstrated by the subtyping of a variant of the CTXM-1-15. The HRM is a potential tool for the rapid detection of present β-lactamase genes and their characterization in a highly sensitive, closed-tube, inexpensive method that is applicable in high throughput studies.

Occurrence, Identification, and Antimicrobial Resistance Profiles of Extended-Spectrum and AmpC β-Lactamase-Producing Enterobacteriaceae from Fresh Vegetables Retailed in Gauteng Province, South Africa

Extended-spectrum β-lactamase (ESBL) and AmpC β-lactamase-producing Enterobacteriaceae are no longer restricted to the health care system, but represent increased risks related to environmental integrity and food safety. Fresh produce has been increasingly reported to constitute a reservoir of multidrug-resistant (MDR) potential human pathogenic Enterobacteriaceae. This study aimed to detect, identify, and characterize the antimicrobial resistance of ESBL/AmpC-producing Enterobacteriaceae isolates from fresh vegetables at point of sale. Vegetable samples (spinach, tomatoes, lettuce, cucumber, and green beans; n = 545) were purchased from retailers in Gauteng, the most densely populated province in South Africa. These included street vendors, trolley vendors, farmers' market stalls, and supermarket chain stores. Selective enrichment, plating onto chromogenic media, and matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) confirmation of isolate identities showed that 17.4% (95/545) vegetable samples analyzed were contaminated with presumptive ESBL/AmpC-producing Enterobacteriaceae. Dominant species identified included Escherichia coli, Enterobacter cloacae, Enterobacter asburiae, and Klebsiella pneumoniae. Phenotypic antibiotic resistance analysis showed that 96.1% of 77 selected isolates were MDR, while resistance to aminoglycoside (94.8%), chloramphenicol (85.7%), and tetracycline (53.2%) antibiotic classes was most prevalent. Positive phenotypic analysis for ESBL production was shown in 61 (79.2%) of the 77 isolates, and AmpC production in 41.6% of the isolates. PCR and sequencing confirmed the presence of β-lactamase genes in 75.3% isolates from all vegetable types analyzed, mainly in E. coli, Enterobacter spp., and Serratia spp. isolates. CTX-M group 9 (32.8%) was the dominant ESBL type, while EBC (24.1%) was the most prevalent plasmidic type AmpC β-lactamase. Our findings document for the first time the presence of MDR ESBL/AmpC-producing Enterobacteriaceae in raw vegetables sold at selected retailers in Gauteng Province, South Africa.

Human exposure to antibiotic resistant-Escherichia coli through irrigated lettuce

Antibiotic resistant bacteria (ARB) have been found on fresh fruit and vegetables globally. These types of ARB infections are spreading rapidly and are a major human health threat. A quantitative human exposure assessment model was created using scenario analysis to investigate the potential human exposure to antibiotic resistant Escherichia coli (AR-E. coli) through the consumption of lettuce irrigated with surface water. Scientific literature and site specific data were collected to model each process from farm to fork to calculate the concentration of AR-E. coli on the lettuce at the point of human consumption. The processes examined were the adhesion, colonisation and viability of bacteria on the lettuce; the effect of different post-harvest cleaning processes; the effect of consuming the lettuce before, on or after the expiry date; and the effect of the consumer washing the lettuce. The results show the mean human exposure levels ranged between 1.00 × 10-2 and 1.35 × 106 colony forming units (CFU) of AR-E. coli per 100 g of surface water irrigated lettuce for the different scenarios investigated. The mean probability of illness from consuming 100 g of lettuce contaminated with potential pathogenic antibiotic-sensitive E. coli was between 1.46 × 10-9 to 1.88 × 10-2. A back calculation revealed that in order for the EC No 1441/2007 regulation to be exceeded (≥1000 CFU/g of E. coli on lettuce at the manufacturing stage), the mean contamination levels required in the irrigation water would need to be 2.7, 3.1 or 4.8 log CFU/ml using the post-harvest treatments of washing with water, rapid cooling with water and washing with a chlorine solution respectively. The information generated from this model could help to set guidelines for producers on maximum permissible AR-E. coli contamination levels in irrigation water and provides recommendations on the best post-harvest treatment to use.

Quantitative Risk Assessment of Hemolytic Uremic Syndrome Associated with Consumption of Bulk Milk Sold Directly from Producer to Consumer in South Africa

This study was conducted to estimate the hemolytic uremic syndrome (HUS) risk associated with consumption of producer-distributor bulk milk (PDBM) contaminated with Shiga toxin-producing Escherichia coli (STEC) in South Africa. Data were obtained from recently completed studies in South Africa taking into account prior collected prevalence data of STEC in raw and pasteurized PDBM and survey information from producer-distributor outlets and households. Inputs for the models were complemented with data from published and unpublished literature. A probabilistic exposure model was developed with Monte Carlo simulation in Excel add-in software using @Risk software. Hazard characterization was based on an exponential dose-response model to calculate the probability of illness from STEC infection in individuals 5 years and younger and individuals older than 5 years. The estimated mean STEC level was 0.12 CFU/mL (95% confidence interval [CI]: 0 to 1.2; σ = 0.34) for raw PDBM and 0.08 CFU/mL (95% CI: 0 to 1; σ = 0.27) for pasteurized PDBM. A higher risk of HUS cases per year was recorded in raw than in pasteurized PDBM and also in individuals younger than 5 years of age. For every 100,000 servings consumed, the expected median numbers of HUS cases per year from raw PDBM were 52 for 5 years and younger and 3.2 for older than 5 years. The median numbers of cases per year for pasteurized PDBM were 47 for 5 years and younger and 2.9 for older than 5 years. Sensitivity analysis revealed that serving volume and time taken to sell PDBM at producer-distributor outlets were the factors with the greatest impact on probability of illness. The models developed in this study are an example of risk assessments for milk produced and marketed from similar scenarios across the globe.

ESBL-producing Escherichia coli and Its Rapid Rise among Healthy People

Since around the 2000s, Escherichia coli (E. coli) resistant to both oxyimino-cephalosporins and fluoroquinolones has remarkably increased worldwide in clinical settings. The kind of E. coli is also identified in patients suffering from community-onset infectious diseases such as urinary tract infections. Moreover, recoveries of multi-drug resistant E. coli from the feces of healthy people have been increasingly documented in recent years, although the actual state remains uncertain. These E. coli isolates usually produce extended-spectrum β-lactamase (ESBL), as well as acquisition of amino acid substitutions in the quinolone-resistance determining regions (QRDRs) of GyrA and/or ParC, together with plasmid-mediated quinolone resistance determinants such as Qnr, AAC(6')-Ib-cr, and QepA. The actual state of ESBL-producing E. coli in hospitalized patients has been carefully investigated in many countries, while that in healthy people still remains uncertain, although high fecal carriage rates of ESBL producers in healthy people have been reported especially in Asian and South American countries. The issues regarding the ESBL producers have become very complicated and chaotic due to rapid increase of both ESBL variants and plasmids mediating ESBL genes, together with the emergence of various "epidemic strains" or "international clones" of E. coli and Klebsiella pneumoniae harboring transferable-plasmids carrying multiple antimicrobial resistance genes. Thus, the current state of ESBL producers outside hospital settings was overviewed together with the relation among those recovered from livestock, foods, pets, environments and wildlife from the viewpoint of molecular epidemiology. This mini review may contribute to better understanding about ESBL producers among people who are not familiar with the antimicrobial resistance (AMR) threatening rising globally.