Insights into the relationship between antimicrobial residues and bacterial populations in a hospital-urban wastewater treatment plant system

Integrative metagenomic dissection of last-resort antibiotic resistance genes and mobile genetic elements in hospital wastewaters

Hospital wastewater is a critical source of antimicrobial resistance (AMR), which facilitates the proliferation and spread of clinically significant antimicrobial resistance genes (ARGs) and pathogenic bacteria. This study utilized metagenomic approaches, including advanced binning techniques, such as MetaBAT2, MaxBin2, and CONCOCT, which offer significant improvements in accuracy and completeness over traditional binning methods. These methods were used to comprehensively assess the dynamics and composition of resistomes and mobilomes in untreated wastewater samples taken from two general hospitals and one cancer hospital. This study revealed a diverse bacterial landscape, largely consisting of Proteobacteria, Firmicutes, Bacteroidetes, and Actinobacteria, with notable variations in microbial composition among hospitals. Analysis of the top 15 genera showed unique microbial pattern distribution in each hospital: Aeromonas was predominant in 1stHWTS (49.39 %), Acidovorax in the CAHWTS at 16.85 %, and Escherichia and Bacteroides in the 2ndHWTS at 11.44 % and 11.33 %, respectively. A total of 114 pathogenic bacteria were identified, with drug-resistant Aeromonas caviae and Escherichia coli being the most prevalent. The study identified 34 types and 1660 subtypes of ARGs, including important last-resort antibiotic resistance genes (LARGs), such as blaNDM, mcr, and tet(X). Using metagenomic binning, this study uncovered distinct patterns of host-resistance associations, particularly with Proteobacteria and Firmicutes. Network analysis highlighted the complex interactions among ARGs, mobile genetic elements (MGEs), and bacterial species, all contributing to the dissemination of AMR. These findings emphasize the intricate nature of AMR in hospital wastewater and the influence of hospital-specific factors on microbial resistance patterns. This study provides support for implementing integrated management strategies, including robust surveillance, advanced wastewater treatment, and strict antibiotic stewardship, to control the dissemination of AMR. Understanding the interplay among bacterial communities, ARGs, and MGEs is important for developing effective public health measures against AMR.

The Role of Wastewater Treatment Plants in Dissemination of Antibiotic Resistance: Source, Measurement, Removal and Risk Assessment

Antibiotic Resistance Genes (ARGs) are contaminants of emerging concern with marked potential to impact public and environmental health. This review focusses on factors that influence the presence, abundance, and dissemination of ARGs within Wastewater Treatment Plants (WWTPs) and associated effluents. Antibiotic-Resistant Bacteria (ARB) and ARGs have been detected in the influent and the effluent of WWTPs worldwide. Different levels of wastewater treatment (primary, secondary, and tertiary) show different degrees of removal efficiency of ARGs, with further differences being observed when ARGs are captured as intracellular or extracellular forms. Furthermore, routinely used molecular methodologies such as quantitative polymerase chain reaction or whole genome sequencing may also vary in resistome identification and in quantifying ARG removal efficiencies from WWTP effluents. Additionally, we provide an overview of the One Health risk assessment framework, as well as future strategies on how WWTPs can be assessed for environmental and public health impact.

Selection and horizontal gene transfer underlie microdiversity-level heterogeneity in resistance gene fate during wastewater treatment

Activated sludge is the centerpiece of biological wastewater treatment, as it facilitates removal of sewage-associated pollutants, fecal bacteria, and pathogens from wastewater through semi-controlled microbial ecology. It has been hypothesized that horizontal gene transfer facilitates the spread of antibiotic resistance genes within the wastewater treatment plant, in part because of the presence of residual antibiotics in sewage. However, there has been surprisingly little evidence to suggest that sewage-associated antibiotics select for resistance at wastewater treatment plants via horizontal gene transfer or otherwise. We addressed the role of sewage-associated antibiotics in promoting antibiotic resistance using lab-scale sequencing batch reactors fed field-collected wastewater, metagenomic sequencing, and our recently developed bioinformatic tool Kairos. Here, we found confirmatory evidence that fluctuating levels of antibiotics in sewage are associated with horizontal gene transfer of antibiotic resistance genes, microbial ecology, and microdiversity-level differences in resistance gene fate in activated sludge.

3D printed monoliths: From powder to an efficient catalyst for antibiotic degradation

To improve the effectiveness and durability of wastewater treatment technologies, researchers are showing a growing interest in 3D printing technology. This technology has attracted significant interest owing to its ability to fabricate challenging complex geometries using different material compositions. This manuscript is focused on the development of 3D monoliths from noncommercial filaments, i.e., a powder blend of iron oxide and polylactic acid (PLA) at 15 wt% of the former. Different monolith designs have been prepared to improve the fluid dynamics of the process, so a simple cylinder (15-Fe3O4@PLA) and a cylinder with double the length and an internal mesh (15-Fe3O4@PLA-DM) were used. These monoliths were characterized by Scanning electron microscopy (SEM), Differential scanning calorimetry (DSC) and Mössbauer spectroscopy, then used for water-based ofloxacin degradation in a continuous down-up flow configuration. Additionally, computational fluid dynamics simulations were performed to estimate the degradation rate constants and analyze the distribution of fluid velocity and pollutant concentration along the 15-Fe3O4@PLA-reactor. The oxidant dose was also optimized to develop the highest degradation rate. The degradation of the target pollutant for those monoliths was 55 and 82 % under optimized conditions. In addition, the 15-Fe3O4@PLA-DM monolith was operated for long term experiments, keeping the degradation performance at a good 67 % for up to 120 h. Finally a fixed-bed reactor was mounted with printed pellets of the mixture (15:85), Fe3O4:PLA, after being ground in a range of 125-200 μm. Under this setup configuration, we observed the total degradation of ofloxacin. 3D printing technology is cheap, reproducible and time saving in the development of supported catalysts in comparison with conventional deposition techniques. Moreover, the leaching of active sites on streams was largely diminished. In fact under continuous operation the leached Fe concentration is below 0.1 ppm, corroborating the good adhesion of the catalyst in the PLA support.

Pharmaceutical residues in the ecosystem: Antibiotic resistance, health impacts, and removal techniques

Hospital wastewater has emerged as a major category of environmental pollutants over the past two decades, but its prevalence in freshwater is less well documented than other types of contaminants. Due to compound complexity and improper operations, conventional treatment is unable to remove pharmaceuticals from hospital wastewater. Advanced treatment technologies may eliminate pharmaceuticals, but there are still concerns about cost and energy use. There should be a legal and regulatory framework in place to control the flow of hospital wastewater. Here, we review the latest scientific knowledge regarding effective pharmaceutical cleanup strategies and treatment procedures to achieve that goal. Successful treatment techniques are also highlighted, such as pre-treatment or on-site facilities that control hospital wastewater where it is used in hospitals. Due to the prioritization, the regulatory agencies will be able to assess and monitor the concentration of pharmaceutical residues in groundwater, surface water, and drinking water. Based on the data obtained, the conventional WWTPs remove 10-60% of pharmaceutical residues. However, most PhACs are eliminated during the secondary or advanced therapy stages, and an overall elimination rate higher than 90% can be achieved. This review also highlights and compares the suitability of currently used treatment technologies and identifies the merits and demerits of each technology to upgrade the system to tackle future challenges. For this reason, pharmaceutical compound rankings in regulatory agencies should be the subject of prospective studies.

Antimicrobials and antimicrobial resistance genes in a one-year city metabolism longitudinal study using wastewater-based epidemiology

This longitudinal study tests correlations between antimicrobial agents (AA) and corresponding antimicrobial resistance genes (ARGs) generated by a community of >100 k people inhabiting one city (Bath) over a 13 month randomised monitoring programme of community wastewater. Several AAs experienced seasonal fluctuations, such as the macrolides erythromycin and clarithromycin that were found in higher loads in winter, whilst other AA levels, including sulfamethoxazole and sulfapyridine, stayed consistent over the study period. Interestingly, and as opposed to AAs, ARGs prevalence was found to be less variable, which indicates that fluctuations in AA usage might either not directly affect ARG levels or this process spans beyond the 13-month monitoring period. However, it is important to note that weekly positive correlations between individual associated AAs and ARGs were observed where seasonal variability in AA use was reported: ermB and macrolides CLR-clarithromycin and dmCLR-N-desmethyl clarithromycin, aSPY- N-acetyl sulfapyridine and sul1, and OFX-ofloxacin and qnrS. Furthermore, ARG loads normalised to 16S rRNA (gene load per microorganism) were positively correlated to the ARG loads normalised to the human population (gene load per capita), which indicates that the abundance of microorganisms is proportional to the size of human population and that the community size, and not AA levels, is a major driver of ARG levels in wastewater. Comparison of hospital and community wastewater showed higher number of AAs and their metabolites, their frequency of occurrence and concentrations in hospital wastewater. Examples include: LZD-linezolid (used only in severe bacterial infections) and AMX-amoxicillin (widely used, also in community but with very low wastewater stability) that were found only in hospital wastewater. CIP-ciprofloxacin, SMX-sulfamethoxazole, TMP-trimethoprim, MTZ-metronidazole and macrolides were found at much higher concentrations in hospital wastewater while TET-tetracycline and OTC-oxytetracycline, as well as antiretrovirals, had an opposite trend. In contrast, comparable concentrations of resistant genes were observed in both community and hospital wastewater. This supports the hypothesis that AMR levels are more of an endemic nature, developing over time in individual communities. Both hospital and community wastewater had AAs that exceeded PNEC values (e.g. CLR-clarithromycin, CIP-ciprofloxacin). In general, though, hospital effluents had a greater number of quantifiable AAs exceeding PNECs (e.g. SMX-sulfamethoxazole, ERY-erythromycin, TMP-trimethoprim). Hospitals are therefore an important consideration in AMR surveillance as could be high risk areas for AMR.

Evidence of Bacterial Community Coalescence between Freshwater and Discharged tpm-Harboring Bacterial Taxa from Hospital and Domestic Wastewater Treatment Plants among Epilithic Biofilms

The ability of WWTP outflow bacteria at colonizing rock surfaces and contributing to the formation of river epilithic biofilms was investigated. Bacterial community structures of biofilms (b-) developing on rocks exposed to treated wastewaters (TWW) of a hospital (HTWW) and a domestic (DTWW) clarifier, and to surface waters of the stream located at 10 m, 500 m, and 8 km from the WWTP outlet, were compared. Biofilm bacterial contents were analyzed by cultural approaches and a tpm-based DNA metabarcoding analytical scheme. Co-occurrence distribution pattern analyses between bacterial datasets and eighteen monitored pharmaceuticals were performed. Higher concentrations of iohexol, ranitidine, levofloxacin, and roxithromycin were observed in the b-HTWW while atenolol, diclofenac, propranolol, and trimethoprim were higher in the b-DTWW. MPN growth assays showed recurrent occurrences of Pseudomonas aeruginosa and Aeromonas caviae among these biofilms. An enrichment of multi-resistant P. aeruginosa cells was observed in the hospital sewer line. P. aeruginosa MPN values were negatively correlated to roxithromycin concentrations. The tpm DNA metabarcoding analyses confirmed these trends and allowed an additional tracking of more than 90 species from 24 genera. Among the recorded 3082 tpm ASV (amplicon sequence variants), 41% were allocated to the Pseudomonas. Significant differences through ANOSIM and DESeq2 statistical tests were observed between ASV recovered from b-HTWW, b-DTWW, and epilithic river biofilms. More than 500 ASV were found restricted to a single sewer line such as those allocated to Aeromonas popoffii and Stenotrophomonas humi being strictly found in the b-HTWW file. Several significant correlations between tpm ASV counts per species and pharmaceutical concentrations in biofilms were recorded such as those of Lamprocystis purpurea being positively correlated with trimethoprim concentrations. A tpm source tracking analysis showed the b-DTWW and b-HTWW tpm ASV to have contributed, respectively, at up to 35% and 2.5% of the epilithic river biofilm tpm-taxa recovered downstream from the WWTP outlet. Higher contributions of TWW taxa among epilithic biofilms were recorded closer to the WWTP outlet. These analyses demonstrated a coalescence of WWTP sewer communities with river freshwater taxa among epilithic biofilms developing downstream of a WWTP outlet.

Predicted Environmental Risk Assessment of Antimicrobials with Increased Consumption in Portugal during the COVID-19 Pandemic; The Groundwork for the Forthcoming Water Quality Survey

The environmental release of antimicrobial pharmaceuticals is an imminent threat due to ecological impacts and microbial resistance phenomena. The recent COVID-19 outbreak will likely lead to greater loads of antimicrobials in the environment. Thus, identifying the most used antimicrobials likely to pose environmental risks would be valuable. For that, the ambulatory and hospital consumption patterns of antimicrobials in Portugal during the COVID-19 pandemic (2020–2021) were compared with those of 2019. A predicted risk assessment screening approach based on exposure and hazard in the surface water was conducted, combining consumption, excretion rates, and ecotoxicological/microbiological endpoints in five different regions of Portugal. Among the 22 selected substances, only rifaximin and atovaquone demonstrated predicted potential ecotoxicological risks for aquatic organisms. Flucloxacillin, piperacillin, tazobactam, meropenem, ceftriaxone, fosfomycin, and metronidazole showed the most significant potential for antibiotic resistance in all analysed regions. Regarding the current screening approach and the lack of environmental data, it is advisable to consider rifaximin and atovaquone in subsequent water quality surveys. These results might support the forthcoming monitorisation of surface water quality in a post-pandemic survey.

Antibiotics, antibiotic resistance and associated risk in natural springs from an agroecosystem environment

This study investigates the occurrence, transport, and risks associated to antibiotic residues, antibiotic resistance genes (ARGs) and antibiotic resistant Escherichia coli (AR-E. coli) in eleven natural springs in an agroecosystem environment with intense livestock production, where groundwater nitrate concentration usually sets above 50 mg L^-1. Out of 23 multiple-class antibiotics monitored, tetracycline and sulfonamide residues were the most ubiquitous, and they were detected at concentrations ranging from ng L^-1 to μg L^-1. Five ARGs were monitored, conferring resistance to the antibiotic classes of major use in livestock production. Thus, genes conferring resistance to sulfonamides (sul1 and sul2) and tetracyclines (tetW) as well as a gene proxy for anthropogenic pollution (intI1) were present in most springs. sul1 was the most abundant, with absolute concentrations ranging from 4 × 10² to 5.6 × 10⁶ gene copies L^-1 water. AR-E. coli showing resistance to sulfonamides and tetracyclines was also detected, with a prevalence up to approximately 40 % in some sites but with poor correlations with the concentration of antibiotic residues and ARGs. The occurrence of antibiotics, ARGs and AR-E. coli was characterized by large seasonal variations which were mostly associated to both hydrological factors and reactive transport processes. Finally, a risk assessment approach pointed out towards low risk for both the groundwater environment and human health, when spring water is used for direct human consumption, associated with the occurrence of antibiotics, ARGs and AR-E. coli. However, long-term effects cannot be neglected, and proper actions must be taken to preserve groundwater quality.

Characterization of keystone taxa and microbial metabolic potentials in copper tailing soils

Copper mining has caused serious soil contamination and threaten the balance of underground ecosystem. Effects of metal contamination on the soil microbial community assembly and their multifunctionality are still unclear. In this study, the keystone taxa and microbial metabolic potential of soil microorganisms surrounding a typical copper tailing were investigated. Results showed that pH and metal contents of adjacent soil in copper tailing increased, which largely reduced soil microbial communities' diversity. Metal contaminated soils enriched a group of keystone taxa with metal-tolerance such as Bacteroidota (20-54%) and Firmicutes (24-48%), which were distinct from the uncontaminated background soils that dominated by Proteobacteria (19-24%) and Actinobacteria (13-24%). In the contaminated soils, these keystone taxa were identified as Alistipes, Bacteroides, and Faecalibacterium, suggesting their adaptation to the metal-rich environment. Co-occurrence network analysis showed that the microbial community was loosely connected in the metal contaminated soils with a lower number of nodes and links. Co-occurrence networks further revealed that the dynamics of keystone taxa significantly correlated with copper content. Functional gene analysis of soil microorganisms indicated that metal contamination might inhibit important microbial metabolic potentials, such as secondary metabolites biosynthesis, carbon fixation, and nitrogen fixation. Results also found the flexible adaptation strategies of soil microbial communities to metal-rich environments with metal-resistance or bio-transformation, such as efflux (CusB/CusF/CzsB and pcoB/copB) and oxidation (aoxAB). These findings provide insight into the interaction between keystone taxa and soil environment, which is helpful to reveal the microbial metabolic potential and physiological characteristics in tailing contaminated soils.

Diversity of bacteria carrying antibiotic resistance genes in hospital raw sewage in Southeastern Brazil

In recent decades, antibiotic-resistant bacteria (ARB) emerged and spread among humans and animals worldwide. In this study, we evaluated the presence of ARB and antibiotic resistance genes (ARGs) in the raw sewage of two hospitals in Brazil. Sewage aliquots were inoculated in a selective medium with antibiotics. Bacterial identification was performed by MALDI-TOF and ARGs were assessed by polymerase chain reaction (PCR). A total of 208 strains from both hospitals were isolated (H1 = 117; H2 = 91). A wide variety of Enterobacterales and non-Enterobacterales species were isolated and most of them were Enterobacter spp. (13.0%), Proteus mirabilis (10.1%), and Klebsiella pneumoniae (9.6%). blaTEM and blaKPC were the most frequent β-lactamase-encoding genes and the predominant macrolide resistance genes were mph(A) and mel. Many species had the three tetracycline resistance genes (tetD, tetM, tetA) and strB was the prevalent aminoglycoside resistance gene. Two Staphylococcus haemolyticus strains had the mecA gene. Quinolone, colistin, and vancomycin resistance genes were not found. This study showed that hospital raw sewage is a great ARB and ARG disseminator. Strict monitoring of hospital sewage treatment is needed to avoid the spread of these genes among bacteria in the environment.

Critical review of technologies for the on-site treatment of hospital wastewater: From conventional to combined advanced processes

This review aims to assess different technologies for the on-site treatment of hospital wastewater (HWW) to remove pharmaceutical compounds (PhCs) as sustances of emerging concern at a bench, pilot, and full scales from 2014 to 2020. Moreover, a rough characterisation of hospital effluents is presented. The main detected PhCs are antibiotics and psychiatric drugs, with concentrations up to 1.1 mg/L. On the one hand, regarding the presented technologies, membrane bioreactors (MBRs) are a good alternative for treating HWW with PhCs removal values higher than 80% in removing analgesics, anti-inflammatories, cardiovascular drugs, and some antibiotics. Moreover, this system has been scaled up to the pilot plant scale. However, some target compounds are still present in the treated effluent, such as psychiatric and contrast media drugs and recalcitrant antibiotics (erythromycin and sulfamethoxazole). On the other hand, ozonation effectively removes antibiotics found in the HWW (>93%), and some studies are carried out at the pilot plant scale. Even though, some families, such as the X-ray contrast media, are recalcitrant to ozone. Other advanced oxidation processes (AOPs), such as Fenton-like or UV treatments, seem very effective for removing pharmaceuticals, Antibiotic Resistance Bacteria (ARBs) and Antibiotic Resistance Genes (ARGs). However, they are not implanted at pilot plant or full scale as they usually consider extra reactants such as ozone, iron, or UV-light, making the scale-up of the processes a challenging task to treat high-loading wastewater. Thus, several examples of biological wastewater treatment methods combined with AOPs have been proposed as the better strategy to treat HWW with high removal of PhCs (generally over 98%) and ARGs/ARBs (below the detection limit) and lower spending on reactants. However, it still requires further development and optimisation of the integrated processes.

Impact of Anthropogenic Activities on the Dissemination of ARGs in the Environment-A Review

Over the past few decades, due to the excessive consumption of drugs in human and veterinary medicine, the antimicrobial resistance (AR) of microorganisms has risen considerably across the world, and this trend is predicted to intensify. Many worrying research results indicate the occurrence of pools of AR, both directly related to human activity and environmental factors. The increase of AR in the natural environment is mainly associated with the anthropogenic activity. The dissemination of AR is significantly stimulated by the operation of municipal facilities, such as wastewater treatment plants (WWTPs) or landfills, as well as biogas plants, agriculture and farming practices, including animal production and land application of manure. These activities entail a risk to public health by spreading bacteria resistant to antimicrobial products (ARB) and antibiotic resistance genes (ARGs). Furthermore, subinhibitory concentrations of antimicrobial substances additionally predispose microbial consortia and resistomes to changes in particular environments that are permeated by these micropollutants. The current state of knowledge on the fate of ARGs, their dissemination and the complexity of the AR phenomenon in relation to anthropogenic activity is inadequate. This review summarizes the state-of-the-art knowledge on AR in the environment, in particular focusing on AR spread in an anthropogenically altered environment and related environmental consequences.

Fate characteristics, exposure risk, and control strategy of typical antibiotics in Chinese sewerage system: A review

In China, the sewerage system plays an essential role in antibiotic removal; however, the fate profiles of antibiotics in sewers are not well understood, and risk identification throughout the sewerage system is inadequate. Based on the extensive detection results for typical groups of antibiotics in the discharge sources, influent and effluent from wastewater treatment plants (WWTPs), and excess sludge, a comprehensive evaluation was conducted to reveal the elimination profiles of the antibiotics, identify the fate characteristics in both sewers and WWTPs, assess the exposure risk levels, and propose a control strategy. The total concentration (based on the median concentrations of the target antibiotics) in aqueous waters was estimated to decrease from 7383.4 ng/L at the discharge source to 886.6 ng/L in the WWTP effluent, among which 69.6% was reduced by sewers and 18.4% was reduced by WWTPs. Antibiotic reduction in sewers was a combined effect of dilution, physiochemical reactions, sorption, biodegradation, and retransformation, and the A2O-MBR + ozonation process in the WWTPs exhibited superior performance in diminishing antibiotics. Notably, accumulated antibiotics in the excess sludge posed a high risk to natural environments (with a risk quotient of approximately 13.0), and the potential risk during combined sewer overflows (CSOs) was undetermined. Thus, enhanced sludge treatment techniques, accurate risk prediction, and proper precautions at CSOs are required to mitigate potential risk. A novel scheme involving an accurate estimation of discharge loads, preliminary treatment of highly concentrated discharge sources, and synergic control in sewers was proposed to eliminate antibiotics at the front end of pipes.

Detection, characterization, and antimicrobial susceptibility of Yersinia enterocolitica in different types of wastewater in the Czech Republic

AIMS

The purpose of the study was to evaluate the occurrence of Yersinia enterocolitica in different types of wastewater and to characterize the isolates by biotyping, serotyping, and antimicrobial susceptibility testing. In addition, cultivation protocols were evaluated.

METHODS AND RESULTS

The occurrence of Y. enterocolitica was determined in treated and untreated municipal wastewater, as well as in hospital, slaughterhouse, and cowshed wastewater. Y. enterocolitica was detected in 84.1% of the wastewater samples, while the main sources were untreated municipal and slaughterhouse wastewater. In contrast, the lowest incidence was found in hospital wastewater. An exclusive occurrence of biotype 1A (98.3%) was detected. Pathogenic bio-serotypes 4/O:3 and 3/O:3 were isolated only from slaughterhouse wastewater. The highest resistance rates were observed for ampicillin (92.5%) and amoxicillin-clavulanic acid (36.8%).

CONCLUSIONS

Y. enterocolitica was commonly detected in wastewater, although the prevalence varied depending on the origin of the wastewater. No single cultivation protocol was able to recover Y. enterocolitica isolates from such a complex matrix as wastewater.

SIGNIFICANCE AND IMPACT OF THE STUDY

Our study provided data that can contribute to the evaluation of wastewater as a source of Y. enterocolitica and to understanding the threat of wastewater isolates to human health.

Antimicrobial Resistance and Implications: Impact on Pregnant Women with Urinary Tract Infections

Urinary Tract Infections (UTI) is one of the most common infections, especially among women. Presently accessible antibiotics are a clinician’s first line of defense to treat infections, but antimicrobial resistance menace to reduce their efficacy. The consequences of multi-drug resistance to antibiotics are enhanced morbidity and mortality rates. The yearly death toll is >700,000 population worldwide, rising to ~10 million by 2050. There is a lack of novel antibiotics for UTIs as the return on its investment is poor compared to medicines for lifestyle diseases. The three organisms of utmost worry are methicillin-resistant Staphylococcus aureus (MRSA), Carbapenems and third-generation Cephalosporins resistant Klebsiella pneumoniae, Fluoroquinolones and third-generation Cephalosporins resistant Escherichia coli (E. coli). Among these, Escherichia coli is the foremost cause of community-acquired UTI infections throughout the globe, mainly due to the absence of alertness and inappropriate wastewater treatment. The purpose of this review article is to explore literature on uropathogens, the pattern of their antimicrobial resistance, and the hospital practices concerning the spread, as inadequate studies have been carried out and published on this topic. Hospital personnel are usually familiar with the management of infections, but most do not understand the conditions in their hospital. Implications of hospital practices play a major role in controlling hospital-acquired UTIs and the burden of its antimicrobial resistance. A complete approach involving financial and human resources will improve the infection control practices in hospitals without a doubt. Strict infection control measures in hospitals can help to reduce the number of hospital-acquired infections in pregnant women.

An assessment of hospital wastewater and biomedical waste generation, existing legislations, risk assessment, treatment processes, and scenario during COVID-19

Hospitals release significant quantities of wastewater (HWW) and biomedical waste (BMW), which hosts a wide range of contaminants that can adversely affect the environment if left untreated. The COVID-19 outbreak has further increased hospital waste generation over the past two years. In this context, a thorough literature study was carried out to reveal the negative implications of untreated hospital waste and delineate the proper ways to handle them. Conventional treatment methods can remove only 50%-70% of the emerging contaminants (ECs) present in the HWW. Still, many countries have not implemented suitable treatment methods to treat the HWW in-situ. This review presents an overview of worldwide HWW generation, regulations, and guidelines on HWW management and highlights the various treatment techniques for efficiently removing ECs from HWW. When combined with advanced oxidation processes, biological or physical treatment processes could remove around 90% of ECs. Analgesics were found to be more easily removed than antibiotics, β-blockers, and X-ray contrast media. The different environmental implications of BMW have also been highlighted. Mishandling of BMW can spread infections, deadly diseases, and hazardous waste into the environment. Hence, the different steps associated with collection to final disposal of BMW have been delineated to minimize the associated health risks. The paper circumscribes the multiple aspects of efficient hospital waste management and may be instrumental during the COVID-19 pandemic when the waste generation from all hospitals worldwide has increased significantly.

Antibiotic resistance of Pseudomonas aeruginosa isolated from hospital wastewater in the Czech Republic

Resistant bacteria may leave the hospital environment through wastewater. The opportunistic pathogen Pseudomonas aeruginosa, due to its intrinsic resistance to many antibiotics and its ability to easily acquire antibiotic resistance determinants, poses a significant threat to public health. The aim of this study was to evaluate the antibiotic resistance profiles of cultivated P. aeruginosa in untreated hospital effluents in the Czech Republic. Fifty-nine P. aeruginosa strains isolated from six hospital wastewaters were tested for antimicrobial susceptibility through the disc diffusion method against seven antimicrobial agents. Resistance was found in all antibiotics tested. The highest resistance values were observed for ciprofloxacin (30.5%), gentamicin (28.8%), and meropenem (27.2%). The P. aeruginosa isolates also exhibited resistance to ceftazidime (11.5%), amikacin (11.5%), piperacillin-tazobactam (11.5%), and aztreonam (8.5%). Seventeen strains of P. aeruginosa (28.8%) were classified as multidrug-resistant (MDR). The results of this study revealed that antibiotic-resistant strains are commonly present in hospital wastewater and are resistant to clinically relevant antipseudomonal drugs. In the absence of an appropriate treatment process for hospital wastewater, resistant bacteria are released directly into public sewer networks, where they can serve as potential vectors for the spread of antibiotic resistance.

Prevalence and Diversity of Antibiotic Resistant Escherichia coli From Anthropogenic-Impacted Larut River

Aquatic environments, under frequent anthropogenic pressure, could serve as reservoirs that provide an ideal condition for the acquisition and dissemination of antibiotic resistance genetic determinants. We investigated the prevalence and diversity of antibiotic-resistant Escherichia coli by focusing on their genetic diversity, virulence, and resistance genes in anthropogenic-impacted Larut River. The abundance of E. coli ranged from (estimated count) Est 1 to 4.7 × 105 (colony-forming units per 100 ml) CFU 100 ml−1 to Est 1 to 4.1 × 105 CFU 100 ml−1 with phylogenetic group B1 (46.72%), and A (34.39%) being the most predominant. The prevalence of multiple antibiotic resistance phenotypes of E. coli, with the presence of tet and sul resistance genes, was higher in wastewater effluents than in the river waters. These findings suggested that E. coli could be an important carrier of the resistance genes in freshwater river environments. The phylogenetic composition of E. coli and resistance genes was associated with physicochemical properties and antibiotic residues. These findings indicated that the anthropogenic inputs exerted an effect on the E. coli phylogroup composition, diversification of multiple antibiotic resistance phenotypes, and the distribution of resistance genes in the Larut River.

Landscape of genes in hospital wastewater breaking through the defense line of last-resort antibiotics

Hospital wastewater contains abundant antibiotics, antibiotic resistance genes (ARGs), and pathogens. Last-resort antibiotic resistance genes (LARGs) include the New Delhi metallo-β-lactamase gene blaNDM, mobile colistin resistance gene mcr and tigecycline resistance gene tet(X) which confers resistance to carbapenems, colistin and tigecycline. The presence and significance of LARGs in hospital wastewater treatment systems (HWTS) have not yet been systematically explored. Here, LARG variants were shown to be prevalent both influents and effluents of HWTS. A total of 989 Enterobacteriaceae isolates that confer resistance to last-resort antibiotics were collected from effluents and multiple genetic contexts of LARGs were analyzed. LARGs-carrying plasmids were confirmed to show high multidrug phenotypes and transferability. We also discovered the co-occurrence of plasmids harboring blaNDM-1 and mcr-1 in single Escherichia coli, as well as E. coli HM016 containing two unique mcr-1-carrying plasmids. This result might accelerate co-dissemination of LARGs under environmental selection pressure. Different core genetic arrangements in these strains suggest several evolutionary pathways in HWTS. The resistance functions of LARGs were confirmed in vitro and in vivo by mass spectrometry. This study provides novel insights into the diversity, genetic context and function of critical ARGs in HWTS. The results raise the concern that LARGs may further spread into the environment, thus, more stringent discharge standards and regulations for hospital wastewater are urgently needed.

Distribution of antibiotic resistance genes from human and animal origins to their receiving environments: A regional scale survey of urban settings

Antibiotic resistance is a growing problem for ecosystem health and public healthcare. Hence, the transmission of antibiotic resistance from human and animal origins to natural environments requires careful investigation. In this study, nine antibiotic resistance genes (ARGs), three mobile genetic elements (MGEs), and their relations with antibiotics, heavy metals, and microbiota were investigated in 16 sample sites (Xinxiang, China). Fluoroquinolones (0.13-14.22 μg/L) were most abundant in hospital effluent and oxytetracycline (251.86-5817.47 μg/kg) in animal manure. Animal manure showed the highest levels of zinc (80.79-2597.14 mg/kg) and copper (32.47-85.22 mg/kg), possibly affecting the prevalence of intI1 and aac(6')-Ib genes. Aminoglycoside and sulfonamide resistance genes (aac(6')-Ib, aadA, and sul1) were the main ARGs in this area. In addition, the detected ARGs and MGEs were higher in animal manure than in hospital effluent, except for the sul1 gene. On the other hand, the incomplete removal of antibiotics (29.76-100%), heavy metals (31.25-100%), and ARGs (1-3 orders of magnitude) in MWWTPs resulted in the accumulation of these contaminants in the receiving river. Network analysis suggested that the potential hosts (Jeotgalibaca, Atopostipes, Corynebacterium_1, etc.) of ARGs were more predominant in animal manure rather than hospital effluent, indicating a higher ARG transfer potential in animal manure compared with hospital sources. These results provide useful insights into the different migration and dissemination routes of antibiotics, heavy metals, ARGs, and microbiota from anthropogenic and animal origins to their receiving environments via MWWTP discharge and manure fertilization.

Antimicrobial agents and microbial ecology

Antimicrobials are therapeutic substances used to prevent or treat infections. Disinfectants are antimicrobial agents applied to non-living surfaces. Every year, several thousand tonnes of antimicrobials and their by-products are released into the environment and in particular into the aquatic environment. This type of xenobiotic has ecological consequences in the natural environment but also in technological environments such as wastewater treatment plants and methane fermentation sewage sludge treatment plants. The constant exposure of microbial communities not only to high concentrations but also to sub-inhibitory concentrations of antibiotics is a key element in the development of antibiotic resistance in aquatic environments and in soils. The future of antimicrobials lies in the development of biosourced or bioinspired molecules. The observation and deciphering of interactions between living organisms is the key to this development.

Performance and mechanism in degradation of typical antibiotics and antibiotic resistance genes by magnetic resin-mediated UV-Fenton process

Incomplete removal of antibiotics and antibiotic resistance genes (ARGs) has often been reported in wastewater treatment plants. More efficient treatment processes are needed to reduce their risks to the environment. Herein, we evaluated the degradation of antibiotics and ARGs by using magnetic anion exchange resin (MAER) as UV-Fenton catalyst. Sulfamethoxazole (SMZ), ofloxacin (OFX), and amoxicillin (AMX) were selected as the target compounds. The three antibiotics were almost completely degraded (> 99%) following the MAER UV-Fenton reaction for 30 min. From the degradation mechanism study, it was found that Fe³⁺/Fe²⁺ could be cyclically transferred from the catalyst at permeable interface, and the photo-generated electrons could be effectively separated. The dominant reactive radicals for antibiotics degradation were hydroxide during the MAER UV-Fenton reaction. The degradation pathway for sulfamethoxazole was proposed. In addition, wastewater samples from a wastewater treatment plant were applied to investigate the removal efficiency of antibiotics and their ARGs by the MAER UV-Fenton system. A rapid decrease in antibiotics and ARGs level was observed with this reaction system. The results from this study suggest that the MAER-mediated UV-Fenton reaction could be applied for the effective removal of antibiotics and ARGs in wastewater.

Effective Treatment Strategies for the Removal of Antibiotic-Resistant Bacteria, Antibiotic-Resistance Genes, and Antibiotic Residues in the Effluent From Wastewater Treatment Plants Receiving Municipal, Hospital, and Domestic Wastewater: Protocol for a Systematic Review

Background

The widespread and unrestricted use of antibiotics has led to the emergence and spread of antibiotic-resistant bacteria (ARB), antibiotic-resistance genes (ARGs), and antibiotic residues in the environment. Conventional wastewater treatment plants (WWTPs) are not designed for effective and adequate removal of ARB, ARGs, and antibiotic residues, and therefore, they play an important role in the dissemination of antimicrobial resistance (AMR) in the natural environment.

Objective

We will conduct a systematic review to determine the most effective treatment strategies for the removal of ARB, ARGs, and antibiotic residues from the treated effluent disposed into the environment from WWTPs that receive municipal, hospital, and domestic discharge.

Methods

We will search the MEDLINE, EMBASE, Web of Science, World Health Organization Global Index Medicus, and ProQuest Environmental Science Collection databases for full-text peer-reviewed journal articles published between January 2001 and December 2020. We will select only articles published in the English language. We will include studies that measured (1) the presence, concentration, and removal rate of ARB/ARGs going from WWTP influent to effluent, (2) the presence, concentration, and types of antibiotics in the effluent, and (3) the possible selection of ARB in the effluent after undergoing treatment processes in WWTPs. At least two independent reviewers will extract data and perform risk of bias assessment. An acceptable or narrative synthesis method will be followed to synthesize the data and present descriptive characteristics of the included studies in a tabular form. The study has been approved by the Ethics Review Board at the International Centre for Diarrhoeal Disease Research, Bangladesh (protocol number: PR-20113).

Results

This protocol outlines our proposed methodology for conducting a systematic review. Our results will provide an update to the existing literature by searching additional databases.

Conclusions

Findings from our systematic review will inform the planning of proper treatment methods that can effectively reduce the levels of ARB, ARGs, and residual antibiotics in effluent, thus lowering the risk of the environmental spread of AMR and its further transmission to humans and animals.

International Registered Report Identifier (IRRID)

PRR1-10.2196/33365

Wastewater-Based Surveillance of Antibiotic Resistance Genes Associated with Tuberculosis Treatment Regimen in KwaZulu Natal, South Africa

Essential components of public health include strengthening the surveillance of infectious diseases and developing early detection and prevention policies. This is particularly important for drug-resistant tuberculosis (DR-TB), which can be explored by using wastewater-based surveillance. This study aimed to use molecular techniques to determine the occurrence and concentration of antibiotic-resistance genes (ARGs) associated with tuberculosis (TB) resistance in untreated and treated wastewater. Raw/untreated and treated (post-chlorination) wastewater samples were taken from three wastewater treatment plants (WWTPs) in South Africa. The ARGs were selected to target drugs used for first- and second-line TB treatment. Both conventional polymerase chain reaction (PCR) and the more advanced droplet digital PCR (ddPCR) were evaluated as surveillance strategies to determine the distribution and concentration of the selected ARGs. The most abundant ARG in the untreated wastewater was the rrs gene, associated with resistance to the aminoglycosides, specifically streptomycin, with median concentration ranges of 4.69–5.19 log copies/mL. In contrast, pncA gene, associated with resistance to the TB drug pyrazinamide, was the least detected (1.59 to 2.27 log copies/mL). Resistance genes associated with bedaquiline was detected, which is a significant finding because this is a new drug introduced in South Africa for the treatment of multi-drug resistant TB. This study, therefore, establishes the potential of molecular surveillance of wastewater for monitoring antibiotic resistance to TB treatment in communities.

Metagenomic Analysis of Antibiotic Resistance Genes in Untreated Wastewater From Three Different Hospitals

Controlling antibiotic resistance genes (ARGs) is a worldwide intervention to ensure global health. Hospital wastewater is the main pollution source of antibiotic-resistant bacteria and ARGs in the environment. Expanding our knowledge on the bacterial composition of hospital wastewater could help us to control infections in hospitals and decrease pathogen release into the environment. In this study, a high-throughput sequencing-based metagenomic approach was applied to investigate the community composition of bacteria and ARGs in untreated wastewater from three different types of hospitals [the general hospital, traditional Chinese medicine (TCM) hospital, and stomatology hospital]. In total, 130 phyla and 2,554 genera were identified from the microbiota of the wastewaters, with significantly different bacterial community compositions among the three hospitals. Total ARG analysis using the Antibiotic Resistance Genes Database (ARDB) and Comprehensive Antibiotic Resistance Database (CARD) revealed that the microbiota in the wastewaters from the three hospitals harbored different types and percentage of ARGs, and their composition was specific to the hospital type based on the correlation analysis between species and ARG abundance, some ARGs contributed to different bacterial genera with various relationships in different hospitals. In summary, our findings demonstrated a widespread occurrence of ARGs and ARG-harboring microbiota in untreated wastewaters of different hospitals, suggesting that protection measures should be applied to prevent human infections. Concurrently, hospital wastewater should be treated more specifically for the removal of pathogens before its discharge into the urban sewage system.

Removal of extracellular antibiotic resistance genes using magnetic biochar/quaternary phosphonium salt in aquatic environments: A mechanistic study

The proliferation and spread of antibiotic resistance genes (ARGs) is becoming a worldwide crisis. Extracellular DNA encoding ARGs (eARGs) in aquatic environment plays a critical role in the dispersion of antimicrobial resistance genes. Strategies to control the dissemination of eARGs are urgently required for ecological safety and human health. Towards this goal, magnetic biochar/quaternary phosphonium salt (MBQ), was used to investigate the efficiency and removal mechanism for eARGs. Magnetic biochar modified by quaternary phosphonium salt enhanced the adsorption capacity of extracellular DNA to approximately 9 folds, compared to that of the unmodified. DNA adsorption by MBQ was mainly dominated by chemisorption in heterogeneous systems and was promoted in acidic and low-salt environment. The generation of •OH and MBQ colloid jointly cleaved DNA into fragments, facilitating the adsorption of the phosphate backbone of DNA onto MBQ through electrostatic force as well as the conformational transition of DNA. Furthermore, quantification of extracellular DNA after MBQ was applied in water demonstrated that over 92.7% of resistance genes were removed, indicating a significantly reduced risk of propagation of antimicrobial resistance in aquatic environments. These findings have a practical significance in the application of MBQ in mitigating the spread of ARGs in aquatic environment.

Antibiotic resistance in the environment: a critical insight on its occurrence, fate, and eco-toxicity

The overuse, misuse, and underuse of antibiotics tend to increase the antibiotic burden in the environment resulting into the evolution in microbial community to possess resistance that renders antibiotics ineffective against them. The current review recapitulates the present state of knowledge about the occurrence and fate of antibiotics in various environmental matrices. Also, the prevalence of antibiotic-resistant bacteria/antibiotic-resistant genes (ARB/ARGs) in various biological and non-biological systems, eco-toxicity of antibiotics on non-target organisms, and remediation methods for antibiotics and ARB/ARGs removal were critically reviewed. Furthermore, a comparison of various technologies for their efficiency to eliminate antibiotic residues and ARB/ARGs is made. The study identified gaps in the investigation of toxic effects of low concentration of antibiotics and the mixture of multiple antibiotics on non-target organisms. The study of antibiotics' phytotoxicity and toxicity towards sediment and soil-dwelling organisms are also recognized as a knowledge gap. The review also details policies implemented across the globe to fight against antibiotic resistance, and the scarcity of data on lab to land transferred remediation technology was identified. The present study entails a critical review of literature providing guidelines for the articulation of policies for prudent use of antibiotics, limits on the amount of antibiotics in pharmaceutical formulations, and regular surveillance in the Indian context.

Evidence for selection of multi-resistant E. coli by hospital effluent

There is a risk that residues of antibiotics and other antimicrobials in hospital and municipal wastewaters could select for resistant bacteria. Still, direct experimental evidence for selection is lacking. Here, we investigated if effluent from a large Swedish hospital, as well as influent and effluent from the connected municipal wastewater treatment plant (WWTP) select for antibiotic resistant Escherichia coli in three controlled experimental setups. Exposure of sterile-filtered hospital effluent to a planktonic mix of 149 different E. coli wastewater isolates showed a strong selection of multi-resistant strains. Accordingly, exposure to a complex wastewater community selected for strains resistant to several antibiotic classes. Exposing individual strains with variable resistance patterns revealed a rapid bactericidal effect of hospital effluent on susceptible, but not multi-resistant E. coli. No selection was observed after exposure to WWTP effluent, while exposure to WWTP influent indicated a small selective effect for ceftazidime and cefadroxil resistant strains, and only in the E. coli mix assay. An analysis of commonly used antibiotics and non-antibiotic pharmaceuticals in combination with growth and resistance pattern of individual E. coli isolates suggested a possible contribution of ciprofloxacin and β-lactams to the selection by hospital effluent. However, more research is needed to clarify the contribution from different selective agents. While this study does not indicate selection by the studied WWTP effluent, there is some indications of selective effects by municipal influent on β-lactam-resistant strains. Such effects may be more pronounced in countries with higher antibiotic use than Sweden. Despite the limited antibiotic use in Sweden, the hospital effluent strongly and consistently selected for multi-resistance, indicating widespread risks. Hence, there is an urgent need for further evaluation of risks for resistance selection in hospital sewers, as well as for strategies to remove selective agents and resistant bacteria.

A review on hospital wastewater treatment: A special emphasis on occurrence and removal of pharmaceutically active compounds, resistant microorganisms, and SARS-CoV-2

The hospital wastewater imposes a potent threat to the security of human health concerning its high vulnerability towards the outbreak of several diseases. Furthermore, the outbreak of COVID-19 pandemic demanded a global attention towards monitoring viruses and other infectious pathogens in hospital wastewater and their removal. Apart from that, the presence of various recalcitrant organics, pharmaceutically active compounds (PhACs), etc. imparts a complex pollution load to water resources and ecosystem. In this review, an insight into the occurrence, persistence and removal of drug-resistant microorganisms and infectious viruses as well as other micro-pollutants have been documented. The performance of various pilot/full-scale studies have been evaluated in terms of removal of biochemical oxygen demand (BOD), chemical oxygen demand (COD), total suspended solids (TSS), PhACs, pathogens, etc. It was found that many biological processes, such as membrane bioreactor, activated sludge process, constructed wetlands, etc. provided more than 80% removal of BOD, COD, TSS, etc. However, the removal of several recalcitrant organic pollutants are less responsive to those processes and demands the application of tertiary treatments, such as adsorption, ozone treatment, UV treatment, etc. Antibiotic-resistant microorganisms, viruses were found to be persistent even after the treatment of hospital wastewater, and high dose of chlorination or UV treatment was required to inactivate them. This article circumscribes the various emerging technologies, which have been used to treat PhACs and pathogens. The present review also emphasized the global concern of the presence of SARS-CoV-2 RNA in hospital wastewater and its removal by the existing treatment facilities.

Pitfalls in the Immunochemical Determination of β-Lactam Antibiotics in Water

Contamination of waters with pharmaceuticals is an alarming problem as it may support the evolution of antimicrobial resistance. Therefore, fast and cost-effective analytical methods for potential on-site analysis are desired in order to control the water quality and assure the safety of its use as a source of drinking water. Antibody-based methods, such as the enzyme-linked immunosorbent assay (ELISA), can be helpful in this regard but can also have certain pitfalls in store, depending on the analyte. As shown here for the class of β-lactam antibiotics, hydrolysis of the β-lactam ring is a key factor in the immunochemical analysis as it influences antibody recognition. With the antibody used in this study, the limit of detection (LOD) in the immunoassay could be significantly reduced by hydrolysis for the five tested penicillins, with the lowest LOD for carbenicillin (0.2 nmol/L) and the greatest impact on penicillins G and V (reduction by 85%). In addition to enhanced quantification, our strategy also provides access to information about the degree of hydrolysis in water samples as shown for the most abundant penicillin amoxicillin.

Phycoremediation of X-ray developer solution towards silver removal with concomitant lipid production

The present research is mainly focusing on the characterization of X-ray developer solution and its toxic tolerance studies with Desmodesmus armatus towards the phycoremediation studies for removal of pollutants, silver, and concomitant lipid production. The characterization results suggested the presence of 1.229 ± 0.004 g/l BOD, 27.29 ± 0.230 g/l COD with a silver content of 0.01791 ± 0.000 g/l. The tolerance and toxicity limits of with X-ray developer solution reveals the remarkable growth of microalgae in 3:1.dilution ratio of BBM in the X-ray developer solutions. The phycoremediation with 19 days period shown the noticeable results with a relative BOD (20.86%), COD (13.88%), with 57.10% corresponding total phosphorous removal. The phycoremediation also has proven better relative silver removal potential of 44.06% on the 19th day with concomitant 1.392% lipid production. Overall, the present study shows the potential phycoremediation strategy of hazardous X-ray developer solutions with possible concurrent lipid production through a sustainable approach.

Antimicrobial resistance in Aeromonas species isolated from aquatic environments in Brazil

AIM

The current study was conducted to determine the antimicrobial resistance profile and genetic relatedness of Aeromonas sp. isolated from healthcare and urban effluents, wastewater treatment plant (WWTP) and river water.

METHODS AND RESULTS

We detected the presence of genes conferring resistance to β-lactam, quinolone and aminoglycoside. Multilocus sequence typing was carried out to differentiate the strains, and multilocus phylogenetic analysis was used to identify the species. A total of 28 cefotaxime-resistant Aeromonas sp. strains were identified, harbouring uncommon Guiana-extended-spectrum (GES)-type β-lactamases (GES-1, GES-5, GES-7 and GES-16). Multidrug-resistant Aeromonas sp. were found in hospital wastewater, WWTP and sanitary effluent, and A. caviae was identified as the most prevalent species (85·7%).

CONCLUSION

The release of untreated healthcare effluents, presence of antimicrobials in the environment, in addition to multidrug-resistant Aeromonas sp., are all potential factors for the spread of resistance.

SIGNIFICANCE AND IMPACT OF THE STUDY

We identified a vast repertoire of antimicrobial resistance genes (ARG) in Aeromonas sp. from diverse aquatic ecosystems, including those that encode enzymes degrading broad-spectrum antimicrobials widely used to treat healthcare-associated infections. Hospital and sanitary effluents serve as potential sources of bacteria harbouring ARG and are a threat to public health.

Comparison of antibiotic-resistant bacteria and antibiotic resistance genes abundance in hospital and community wastewater: A systematic review

Antibiotic-resistant bacteria (ARB) and antibiotic-resistance genes (ARGs) are constantly shed into the aquatic environment, with hospital wastewater potentially acting as an important source for resistance spread into the environment. A systematic review was conducted aiming to investigate the role of hospital wastewater on dissemination of antimicrobial resistance in the aquatic environment. Studies included in the review compared the prevalence of ARB and/or ARGs in hospital versus community wastewater. Data were extracted on ARB and/or ARG prevalence. Data on sampling techniques, microbiological methodology and risk of bias of included studies were recorded. Thirty-seven studies were included. Higher frequencies of antibiotic resistance determinants were found in hospital wastewater compared to community sources in 30/37 (81%) of included studies. However, trends for specific multi-drug-resistant bacteria differed. Antibiotic-resistant Gram-negative were more prevalent in hospital compared to community wastewaters, with higher concentrations of extended-spectrum-beta-lactamase-producing pathogens and carbapenemase-producing Enterobacteriaceae in hospital sources in 9/9 studies and 6/7 studies, respectively. Hospitals did not contribute consistently to the abundance of vancomycin-resistant Enterococci (VRE); 5/10 studies found higher abundance of VRE in hospital compared to community wastewaters. Reporting on sampling methods, wastewater treatment processes and statistical analysis were at high risk of bias. Extreme heterogeneity in study methods and outcome reporting precluded meta-analysis. Current evidence concurs that hospital wastewater is an important source for antibiotic resistance in aquatic environments, mainly multidrug-resistant Gram-negative bacteria. Future research is needed to assess the effect of wastewater treatment processes on overall antibiotic resistance in the aquatic environment.

A global multinational survey of cefotaxime-resistant coliforms in urban wastewater treatment plants

The World Health Organization Global Action Plan recommends integrated surveillance programs as crucial strategies for monitoring antibiotic resistance. Although several national surveillance programs are in place for clinical and veterinary settings, no such schemes exist for monitoring antibiotic-resistant bacteria in the environment. In this transnational study, we developed, validated, and tested a low-cost surveillance and easy to implement approach to evaluate antibiotic resistance in wastewater treatment plants (WWTPs) by targeting cefotaxime-resistant (CTX-R) coliforms as indicators. The rationale for this approach was: i) coliform quantification methods are internationally accepted as indicators of fecal contamination in recreational waters and are therefore routinely applied in analytical labs; ii) CTX-R coliforms are clinically relevant, associated with extended-spectrum β-lactamases (ESBLs), and are rare in pristine environments. We analyzed 57 WWTPs in 22 countries across Europe, Asia, Africa, Australia, and North America. CTX-R coliforms were ubiquitous in raw sewage and their relative abundance varied significantly (<0.1% to 38.3%), being positively correlated (p < 0.001) with regional atmospheric temperatures. Although most WWTPs removed large proportions of CTX-R coliforms, loads over 10³ colony-forming units per mL were occasionally observed in final effluents. We demonstrate that CTX-R coliform monitoring is a feasible and affordable approach to assess wastewater antibiotic resistance status.

Hospital Wastewater-Important Source of Multidrug Resistant Coliform Bacteria with ESBL-Production

This work compares the prevalence of antibiotic resistant coliform bacteria in hospital wastewater effluents in Slovak (SR) and Czech Republic (ČR). It also describes selected antibiotic resistant isolates in view of resistance mechanism and virulence factor. The highest number of multidrug resistant bacteria was detected in samples from the hospital in Valašské Meziříčí (ČR). More than half of resistant isolates showed multidrug resistance phenotype as well as strong ability to form biofilm. In 42% of isolates efflux pump overproduction was detected together with tetA and tetE genes. The production of extended-spectrum β-lactamases in coliform isolates was encoded mainly by bla_TEM, bla_CTX-M-2 and bla_CTX-M-8/25 genes. About 62% of resistants contained a combination of two or more extended spectrum beta-lactamases (ESBL) genes. Our results strengthen the fact that hospital effluents are a source of multidrug resistant bacteria which can spread their resistance genes to other bacteria in wastewater treatment plants (WWTPs). Accordingly, hospital wastewater should be better treated before it enters urban sewerage.

Factors associated with elevated levels of antibiotic resistance genes in sewer sediments and wastewater

The sewer environment is a potential hotspot for the proliferation of antibiotic resistance genes (ARGs) and other hazardous microbial agents. Understanding the potential for ARG proliferation and retardation and/or accumulation in sewer sediments is of interest for protecting the health of sewage workers and the broader community in the event of sewer overflows as well as for interpreting sewage epidemiology data. To better understand this understudied environment for antibiotic resistance, a field survey was conducted to identify the factors that may control ARGs in sewer sediments and sewage. qPCR was performed for select ARGs and amplicon sequencing was performed for paired samples from combined and separate sanitary sewer systems. Metagenomic sequencing was performed on combined sewer sediments. The relative abundances of sul1, tet(O), tet(W), ermF, and vanA were higher in wastewater compared to sewer sediments, while NDM-1 was greater in sewer sediment and ermF was similar between the two matrices. NDM-1 was observed in sewer sediment but rarely above detection in wastewater in this study. This may indicate that larger/more frequent wastewater samples are needed for detection and/or that retardation and/or accumulation in sewage sediment may need to be considered when interpreting wastewater-based epidemiology data for ARGs. Random forest analyses indicated that season and conductivity were important variables and to a lesser extent so were pH, TSS, heavy metals, and sewer type for explaining the variance of the ARGs. These variables explained the 19-61% of the variance of sul1, tet(O), tet(G), and tet(W) quantified in wastewater. These variables performed less well for explaining the variance in sewer sediments (0.2-24%). Sewer sediment and wastewater had distinct microbial community structures and biomarkers for each are described. Metagenomics indicated that a high diversity of ARGs, including several of medical importance, were observed in the combined sewer sediment. This work provides insight into the complex sewer microbiome and the potential hazard posed by different sewer matrices.

Performance and bacterial community structure of a novel inverse fluidized bed bioreactor (IFBBR) treating synthetic municipal wastewater

The performance of a lab-scale integrated anoxic and aerobic inverse fluidized bed bioreactors (IFBBR) for biological nutrient removal from synthetic municipal wastewater was studied at chemical oxygen demand (COD) loading rates of 0.34-2.10 kg COD/(m³-d) and nitrogen loading rates of 0.035-0.213 kg N/(m³-d). Total COD removal efficiencies of >84% were achieved, concomitantly with complete nitrification. The overall nitrogen removal efficiencies were >75%. Low biomass yields of 0.030-0.101 g VSS/g COD were achieved. Compared with other FBBR systems, the energy consumption for this IFBBR system was an average 59% less at organic loading rates (OLRs) of 1.02 and 2.10 kg COD/(m³-d). Bacterial community structures of attached and suspended biomass revealed that the dominant phyla were Proteobacteria, Bacteroidetes, and Epsilonbacteraeota, etc. The relative abundance of ammonia-oxidizing bacteria (AOBs) and nitrite-oxidizing bacteria (NOBs) in the aerobic attached biomass were 0.451% and 0.110%, respectively. COD mass balance in the anoxic zone was closed by consideration of sulfate reduction, which was confirmed by the presence of genus Chlorobium (sulfate-reducing bacteria) in the anoxic attached biofilm with a relative abundance of 0.32%.

Hospital discharges in urban sanitation systems: Long-term monitoring of wastewater resistome and microbiota in relationship to their eco-exposome

Wastewaters (WW) are important sources for the dissemination of antimicrobial resistance (AMR) into the environment. Hospital WW (HWW) contain higher loads of micro-pollutants and AMR markers than urban WW (UWW). Little is known about the long-term dynamics of H and U WW and the impact of their joined treatment on the general burden of AMR. Here, we characterized the resistome, microbiota and eco-exposome signature of 126 H and U WW samples treated separately for three years, and then mixed, over one year. Multi-variate analysis and machine learning revealed a robust signature for each WW with no significant variation over time before mixing, and once mixed, both WW closely resembled Urban signatures. We demonstrated a significant impact of pharmaceuticals and surfactants on the resistome and microbiota of H and U WW. Our results present considerable targets for AMR related risk assessment of WW.

Total mercury and methylmercury migration and transformation in an A2/O wastewater treatment plant

Municipal wastewater treatment plants (MWTPs) serve an essential role in reducing mercury (Hg) pollution. However, few studies quantified the transport and transformation of Hg through MWTPs, particularly plants based on the anaerobic-anoxic-aerobic (A²/O) process. Here, we present a mass balance for total mercury (THg) and total methylmercury (TMeHg) at the plant, and investigate the influence of pH, temperature, and dissolved oxygen on the occurrence and fate of methylmercury (MeHg) in the system. The concentrations of the THg and TMeHg in the raw sewage were 40.3 ± 26.6 ng/L (4.3 ± 2.7 g/day) and 1.9 ± 0.6 ng/L (193 ± 58 mg/day), respectively. Their concentrations in the plant's effluent water were 7.4 ± 1.5 ng/L (0.74 ± 0.2 g/day) and 0.04 ± 0.01 ng/L (3.9 ± 1.0 mg/day), corresponding to decreases of ~82% for THg and ~98% for TMeHg. Within the plant, only ~10% of the THg was removed with primary sedimentation, as Hg in the raw sewage was predominately in dissolved form. In contrast, a significant portion of TMeHg (~43%) was associated with incoming particulate matter. Much of the remaining Hg was removed in subsequent A²/O process and secondary clarifiers, with a ~78% of the THg entering the plant transferring to the dewatered sludge (concentration 1.05 ± 0.28 μg/g; 3.2 ± 0.8 g/day). These same steps decreased TMeHg in the water by ~95%, with <10% of that reduction being TMeHg transferred to the sludge (concentration 2.1 ± 1.1 ng/g; 6.2 ± 3.3 mg/day), suggesting >90% TMeHg degradation. In addition, the most important factor that impacted the variation of TMeHg concentrations was pH, then was temperature. Dissolved oxygen showed no relationship with TMeHg and DMeHg. Overall, this study demonstrates that A²/O MWTPs effectively remove MeHg from wastewater, however, sludge remains an important potential source of Hg to the environment.

Physical, chemical, and biological impact (hazard) of hospital wastewater on environment: presence of pharmaceuticals, pathogens, and antibiotic-resistance genes

Hospital wastewater contains various pharmaceuticals and pathogens. Improper management of the wastewater has caused the leakage of these harmful materials to the environment. The presence of pathogens, pharmaceuticals, and their derivatives such as antibiotic resistance genes as the most typical one in the environment leads to physical, chemical, and biological harmful impact. This chapter has reviewed the pharmaceuticals and pathogens in the hospital; discussed the development of antibiotic resistance genes; and revealed the possible impact of these harmful materials in microorganisms, organism, and human being. In addition, the measures that can be taken to prevent the transportation of pharmaceuticals and pathogens into environment have been stated in this chapter.

Microbiology of hospital wastewater

The study of hospital wastewater (HWW) microbiology is important to understand the pollution load, growth of particular pathogenic microbes, shift and drift in microbial community, development and spread of antibiotic resistance in microbes, and subsequent change in treatment efficiencies. This chapter investigates the potential microbes such as bacteria, viruses, fungi, and parasites present in HWW along with the diseases associated and methods of treatment used. Due to the indiscriminate release of antibiotics from hospitals, HWW serves as a hotspot for emergence of antibiotic-resistance genes (ARGs) and antibiotic-resistance bacteria. This chapter discusses the ARGs occurrence in HWW, their prevalence in the environment, the molecular tools used for identification, and different mechanisms of horizontal gene transfer. Thus better understanding of the microbiology of HWW could further help in development of advanced treatment technologies for effective removal of microbes and their bioproducts (toxins and infectious nucleic acid) from HWW and contaminated water.

First nationwide investigation and environmental risk assessment of 72 pharmaceuticals and personal care products from Sri Lankan surface waterways

Pharmaceuticals and personal care products (PPCPs) are known as an emerging class of water contaminants due to their potential adverse effects on aquatic ecosystems. In this study, we conducted the first nationwide survey to understand the distribution and environmental risk of 72 PPCPs in surface waterways of Sri Lanka. Forty-one out of 72 targeted compounds were detected with total concentrations ranging between 5.49 and 993 ng/L in surface waterways in Sri Lanka. The highest level of PPCP contamination was detected in an ornamental fish farm. Sulfamethoxazole was found with the highest concentration (934 ng/L) followed by N,N-diethyl-meta-toluamide (202 ng/L) and clarithromycin (119 ng/L). Diclofenac, mefenamic acid, ibuprofen, trimethoprim, and erythromycin were detected ubiquitously throughout the country. Our data revealed that hospital and domestic wastewater, and aquaculture activities potentially contribute to the presence of PPCPs in Sri Lankan waterways. The calculated risk quotients indicated that several locations face medium to high ecological risk to aquatic organisms from ibuprofen, sulfamethoxazole, diclofenac, mefenamic acid, tramadol, clarithromycin, ciprofloxacin, triclocarban, and triclosan. The aforementioned compounds could affect aquatic organisms from different trophic levels like algae, crustacean and fish, and also influence the emergence of antibiotic resistant bacteria. These findings emphasize that a wide variety of pharmaceuticals have become pervasive environmental contaminants in the country. This data will serve to expand the inventory of global PPCP pollution. Further monitoring of PPCPs is needed in Sri Lanka in order to identify PPCP point sources and to implement strategies for contaminant reduction in wastewater to protect the aquatic ecosystem, wildlife, and human health.

Insights into the Fate and Removal of Antibiotics in Engineered Biological Treatment Systems: A Critical Review

Antibiotics, the most frequently prescribed drugs of modern medicine, are extensively used for both human and veterinary applications. Antibiotics from different wastewater sources (e.g., municipal, hospitals, animal production, and pharmaceutical industries) ultimately are discharged into wastewater treatment plants. Sorption and biodegradation are the two major removal pathways of antibiotics during biological wastewater treatment processes. This review provides the fundamental insights into sorption mechanisms and biodegradation pathways of different classes of antibiotics with diverse physical-chemical attributes. Important factors affecting sorption and biodegradation behavior of antibiotics are also highlighted. Furthermore, this review also sheds light on the critical role of extracellular polymeric substances on antibiotics adsorption and their removal in engineered biological wastewater treatment systems. Despite major advancements, engineered biological wastewater treatment systems are only moderately effective (48-77%) in the removal of antibiotics. In this review, we systematically summarize the behavior and removal of different antibiotics in various biological treatment systems with discussion on their removal efficiency, removal mechanisms, critical bioreactor operating conditions affecting antibiotics removal, and recent innovative advancements. Besides, relevant background information including antibiotics classification, physical-chemical properties, and their occurrence in the environment from different sources is also briefly covered. This review aims to advance our understanding of the fate of various classes of antibiotics in engineered biological wastewater treatment systems and outlines future research directions.

Limited influence of hospital wastewater on the microbiome and resistome of wastewater in a community sewerage system

Effluents from wastewater treatment plants (WWTPs) have been proposed to act as point sources of antibiotic-resistant bacteria (ARB) and antimicrobial resistance genes (ARGs) in the environment. Hospital sewage may contribute to the spread of ARB and ARGs as it contains the feces and urine of hospitalized patients, who are more frequently colonized with multi-drug resistant bacteria than the general population. However, whether hospital sewage noticeably contributes to the quantity and diversity of ARGs in the general sewerage system has not yet been determined.Here, we employed culture-independent techniques, namely 16S rRNA gene sequencing and nanolitre-scale quantitative PCRs, to assess the role of hospital effluent as a point source of ARGs in the sewerage system, through comparing microbiota composition and levels of ARGs in hospital sewage with WWTP influent with and without hospital sewage.Compared to other sites, hospital sewage was richest in human-associated bacteria and contained the highest relative levels of ARGs. Yet, the relative abundance of ARGs was comparable in the influent of WWTPs with and without hospital sewage, suggesting that hospitals do not contribute importantly to the quantity and diversity of ARGs in the investigated sewerage system.

Genetic variation in the conjugative plasmidome of a hospital effluent multidrug resistant Escherichia coli strain

Bacteria harboring conjugative plasmids have the potential for spreading antibiotic resistance through horizontal gene transfer. It is described that the selection and dissemination of antibiotic resistance is enhanced by stressors, like metals or antibiotics, which can occur as environmental contaminants. This study aimed at unveiling the composition of the conjugative plasmidome of a hospital effluent multidrug resistant Escherichia coli strain (H1FC54) under different mating conditions. To meet this objective, plasmid pulsed field gel electrophoresis, optical mapping analyses and DNA sequencing were used in combination with phenotype analysis. Strain H1FC54 was observed to harbor five plasmids, three of which were conjugative and two of these, pH1FC54_330 and pH1FC54_140, contained metal and antibiotic resistance genes. Transconjugants obtained in the absence or presence of tellurite (0.5 μM or 5 μM), arsenite (0.5 μM, 5 μM or 15 μM) or ceftazidime (10 mg/L) and selected in the presence of sodium azide (100 mg/L) and tetracycline (16 mg/L) presented distinct phenotypes, associated with the acquisition of different plasmid combinations, including two co-integrate plasmids, of 310 kbp and 517 kbp. The variable composition of the conjugative plasmidome, the formation of co-integrates during conjugation, as well as the transfer of non-transferable plasmids via co-integration, and the possible association between antibiotic, arsenite and tellurite tolerance was demonstrated. These evidences bring interesting insights into the comprehension of the molecular and physiological mechanisms that underlie antibiotic resistance propagation in the environment.

Performance of secondary wastewater treatment methods for the removal of contaminants of emerging concern implicated in crop uptake and antibiotic resistance spread: A review

Contaminants of emerging concern (CEC) discharged in effluents of wastewater treatment plants (WWTPs), not specifically designed for their removal, pose serious hazards to human health and ecosystems. Their impact is of particular relevance to wastewater disposal and re-use in agricultural settings due to CEC uptake and accumulation in food crops and consequent diffusion into the food-chain. This is the reason why the chemical CEC discussed in this review have been selected considering, besides recalcitrance, frequency of detection and entity of potential hazards, their relevance for crop uptake. Antibiotic-resistant bacteria (ARB) and antibiotic resistance genes (ARGs) have been included as microbial CEC because of the potential of secondary wastewater treatment to offer conditions favourable to the survival and proliferation of ARB, and dissemination of ARGs. Given the adverse effects of chemical and microbial CEC, their removal is being considered as an additional design criterion, which highlights the necessity of upgrading conventional WWTPs with more effective technologies. In this review, the performance of currently applied biological treatment methods for secondary treatment is analysed. To this end, technological solutions including conventional activated sludge (CAS), membrane bioreactors (MBRs), moving bed biofilm reactors (MBBRs), and nature-based solutions such as constructed wetlands (CWs) are compared for the achievable removal efficiencies of the selected CEC and their potential of acting as reservoirs of ARB&ARGs. With the aim of giving a picture of real systems, this review focuses on data from full-scale and pilot-scale plants treating real urban wastewater. To achieve an integrated assessment, technologies are compared considering also other relevant evaluation parameters such as investment and management costs, complexity of layout and management, present scale of application and need of a post-treatment. Comparison results allow the definition of design and operation strategies for the implementation of CEC removal in WWTPs, when agricultural reuse of effluents is planned.

Response of chloramphenicol-reducing biocathode resistome to continuous electrical stimulation

Understanding the fate of overall antibiotic resistance genes (ARGs) during the biological treatment of antibiotic containing wastewater is a central issue for the water ecological safety assessment. Although the microbial electrode-respiration based biotransformation process could significantly detoxify some antibiotic contaminants, e.g. chloramphenicol (CAP), the response of CAP-reducing biocathode microbiome and resistome to continuous electrical stimulation, especially ARGs network interactions, are poorly understood. Here, using highthroughput functional gene array (GeoChip v4.6) and Illumina 16S rRNA gene MiSeq sequencing, the structure, composition, diversity and network interactions of CAP-reducing biocathode microbiome and resistome in response to continuous electrical stimulation were investigated. Our results indicate that the CAP bioelectroreduction process could significantly accelerate the elimination of antibacterial activity of CAP during CAP-containing wastewater treatment compared to the pure bioreduction process. Continuous electrical stimulation could obviously alter both the microbiome and resistome structures and consistently decrease the phylogenetic, functional and overall ARGs diversity and network complexity within the CAP-reducing biofilms. The relative abundances of overall ARGs and specific CAP resistance related major facilitator superfamily (MFS) transporter genes were significantly negatively correlated with the reduction efficiency of CAP to inactive antibacterial product AMCl (partially dechlorinated aromatic amine), which may reduce the ecological risk associated with the evolution of multidrug-resistant bacteria and ARGs during antibiotic-containing wastewater treatment process. This study offers new insights into the response of an antibiotic reducing biocathode resistome to continuous electrical stimulation and provides useful information on the assessment of overall ARGs risk for the bioelectrochemical treatment of antibiotic contaminants.