The effect of hospital effluent on antimicrobial resistant E. coli within a municipal wastewater system

Simultaneous stream assessment of antibiotics, bacteria, antibiotic resistant bacteria, and antibiotic resistance genes in an agricultural region of the United States

Antimicrobial resistance (AMR) is now recognized as a leading global threat to human health. Nevertheless, there currently is a limited understanding of the environment's role in the spread of AMR and antibiotic resistance genes (ARGs). In 2019, the U.S. Geological Survey conducted the first statewide assessment of antibiotic resistant bacteria (ARB) and ARGs in surface water and bed sediment collected from 34 stream locations across Iowa. Environmental samples were analyzed for a suite of 29 antibiotics and plated on selective media for 15 types of bacteria growth; DNA was extracted from culture growth and used in downstream polymerase chain reaction (PCR) assays for the detection of 24 ARGs. ARGs encoding resistance to antibiotics of clinical importance to human health and disease prevention were prioritized as their presence in stream systems has the potential for environmental significance. Total coliforms, Escherichia coli (E. coli), and staphylococci were nearly ubiquitous in both stream water and stream bed sediment samples, with enterococci present in 97 % of water samples, and Salmonella spp. growth present in 94 % and 67 % of water and bed sediment samples. Bacteria enumerations indicate that high bacteria loads are common in Iowa's streams, with 23 (68 %) streams exceeding state guidelines for primary contact for E. coli in recreational waters and 6 (18 %) streams exceeding the secondary contact advisory level. Although antibiotic-resistant E. coli growth was detected from 40 % of water samples, vancomycin-resistant enterococci (VRE) and penicillinase-resistant Staphylococcus aureus (MRSA) colony growth was detected from nearly all water samples. A total of 14 different ARGs were detected from viable bacteria cells from 30 Iowa streams (88 %, n = 34). Study results provide the first baseline understanding of the prevalence of ARB and ARGs throughout Iowa's waterways and health risk potential for humans, wildlife, and livestock using these waterways for drinking, irrigating, or recreating.

Large-scale characterization of hospital wastewater system microbiomes and clinical isolates from infected patients: profiling of multi-drug-resistant microbial species

BACKGROUND

Hospital-acquired infections (HAIs) and infectious agents exhibiting antimicrobial resistance (AMR) are challenges globally. Environmental patient-facing wastewater apparatus including handwashing sinks, showers and toilets are increasingly identified as sources of infectious agents and AMR genes.

AIM

To provide large-scale metagenomics analysis of wastewater systems in a large teaching hospital in the Republic of Ireland experiencing multi-drug-resistant HAI outbreaks.

METHODS

Wastewater pipe sections (N=20) were removed immediately prior to refurbishment of a medical ward where HAIs had been endemic. These comprised toilet U-bends, and sink and shower drains. Following DNA extraction, each pipe section underwent metagenomic analysis.

FINDINGS

Diverse taxonomic and resistome profiles were observed, with members of phyla Proteobacteria and Actinobacteria dominating (38.23 ± 5.68% and 15.78 ± 3.53%, respectively). Genomes of five clinical isolates were analysed. These AMR bacterial isolates were from patients >48 h post-admission to the ward. Genomic analysis determined that the isolates bore a high number of antimicrobial resistance genes (ARGs).

CONCLUSION

Comparison of resistome profiles of isolates and wastewater metagenomes revealed high degrees of similarity, with many identical ARGs shared, suggesting probable acquisition post-admission. The highest numbers of ARGs observed were those encoding resistance to clinically significant and commonly used antibiotic classes. Average nucleotide identity analysis confirmed the presence of highly similar or identical genomes in clinical isolates and wastewater pipes. These unique large-scale analyses reinforce the need for regular cleaning and decontamination of patient-facing hospital wastewater pipes and effective infection control policies to prevent transmission of nosocomial infection and emergence of AMR within potential wastewater reservoirs.

Spatiotemporal dissemination of ESBL-producing Enterobacterales in municipal sewer systems: a prospective, longitudinal study in the city of Basel, Switzerland

Background

The contribution of community and hospital sources to the transmission of extended-spectrum β-lactamase producing Enterobacterales (ESBL-PE) remains elusive.

Aim

To investigate the extent of community dissemination and the contribution of hospitals to the spread of ESBL-PE by exploring their spatiotemporal distribution in municipal wastewater of the central European city of Basel.

Methods

Wastewater samples were collected monthly for two consecutive years throughout Basel, Switzerland, including 21 sites across 10 postcode areas of the city collecting either community wastewater (urban sites, n = 17) or community and hospital wastewater (mixed sites, n = 4). Presumptive ESBL-PE were recovered by selective culture methods. Standard methodologies were applied for species identification, ESBL-confirmation, and quantification.

Results

Ninety-five percent (477/504) of samples were positive for ESBL-PE. Among these isolates, Escherichia coli (85%, 1,140/1,334) and Klebsiella pneumoniae (11%, 153/1,334) were most common. They were recovered throughout the sampling period from all postcodes, with E. coli consistently predominating. The proportion of K. pneumoniae isolates was higher in wastewater samples from mixed sites as compared to samples from urban sites, while the proportion of E. coli was higher in samples from urban sites (p = 0.003). Higher numbers of colony forming units (CFUs) were recovered from mixed as compared to urban sites (median 3.2 × 10² vs. 1.6 × 10² CFU/mL). E. coli-counts showed moderate correlation with population size (rho = 0.44), while this correlation was weak for other ESBL-PE (rho = 0.21).

Conclusion

ESBL-PE are widely spread in municipal wastewater supporting that community sources are important reservoirs entertaining the spread of ESBL-PE. Hospital-influenced abundance of ESBL-PE appears to be species dependent.

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.

Molecular Characterization and Antibiotic Susceptibility Profile of Acinetobacter baumannii Recovered from Hospital Wastewater Effluents

Acinetobacter baumannii (A. baumannii) plays a significant part in nosocomial infections world over and is re-emerging as a formidable pathogen due to the wide range of antibiotic resistance factors it acquires and environmental resilience. The high attendance of patients (outpatients and inpatients) into the health care facilities formed the basis for the selection of the hospitals. Consequently, this study profiled the antibiogram and antibiotic resistance genes of A. baumannii isolated from selected hospital wastewater effluents. A total of twenty-four (24) wastewater samples from three selected hospital drainages were collected and analysed presumptively by culture-dependent methods for A. baumannii. The identity confirmation of A. baumannii was done by the amplification of recA and blaoxa-51 genes. Virulence and antibiotic resistance markers were assessed using polymerase chain reaction. A total of 53 A. baumannii isolates were confirmed and the highest antibiotic resistance profile was 93% (piperacillin). Multiple antibiotic resistance index (MARI) showed a range of 0.23 and 0.46. FimH virulence gene was detected in 29 (55%) of the isolates. Tetracycline and beta-lactam resistance markers were found; 70% and 92% of the isolates possessed tetA and ampC genes. The isolates showed high level of resistance to antibiotics. The multiple antibiotic resistance index (MARI) of ≥ 0.2 indicates that some of the isolates harbour virulence and resistance traits emerging from high-risk source thereby projecting a threat to public health.

EMBRACE-WATERS statement: Recommendations for reporting of studies on antimicrobial resistance in wastewater and related aquatic environments

BACKGROUND

A One Health approach requires integrative research to elucidate antimicrobial resistance (AMR) in the environment and the risks it poses to human health. Research on this topic involves experts from diverse backgrounds and professions. Shortcomings exist in terms of consistent, complete, and transparent reporting in many environmental studies. Standardized reporting will improve the quality of scientific papers, enable meta-analyses and enhance the communication among different experts. In this study, we aimed to generate a consensus of reporting standards for AMR research in wastewater and related aquatic environments.

METHODS

Based on a risk of bias assessment of the literature in a systematic review, we proposed a set of study quality indicators. We then used a multistep modified Delphi consensus to develop the EMBRACE-WATERS statement (rEporting antiMicroBial ResistAnCE in WATERS), a checklist of recommendations for reporting in studies of AMR in wastewater and related aquatic environments.

FINDINGS

Consensus was achieved among a multidisciplinary panel of twenty-one experts in three steps. The developed EMBRACE-WATERS statement incorporates 21 items. Each item contains essential elements of high-quality reporting and is followed by an explanation of their rationale and a reporting-example. The EMBRACE-WATERS statement is primarily intended to be used by investigators to ensure transparent and comprehensive reporting of their studies. It can also guide peer-reviewers and editors in evaluation of manuscripts on AMR in the aquatic environment. This statement is not intended to be used to guide investigators on the methodology of their research.

INTERPRETATION

We are hopeful that this statement will improve the reporting quality of future studies of AMR in wastewater and related aquatic environments. Its uptake would generate a common language to be used among researchers from different disciplines, thus advancing the One Health approach towards understanding AMR spread across aquatic environments. Similar initiatives are needed in other areas of One Health research.

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.

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.

Investigating the potential use of an Antarctic variant of Janthinobacterium lividum for tackling antimicrobial resistance in a One Health approach

The aim of this paper is to describe a new variant of Janthinobacterium lividum - ROICE173, isolated from Antarctic snow, and to investigate the antimicrobial effect of the crude bacterial extract against 200 multi-drug resistant (MDR) bacteria of both clinical and environmental origin, displaying various antibiotic resistance patterns. ROICE173 is extremotolerant, grows at high pH (5.5–9.5), in high salinity (3%) and in the presence of different xenobiotic compounds and various antibiotics. The best violacein yield (4.59 ± 0.78 mg·g⁻¹ wet biomass) was obtained at 22 °C, on R2 broth supplemented with 1% glycerol. When the crude extract was tested for antimicrobial activity, a clear bactericidal effect was observed on 79 strains (40%), a bacteriostatic effect on 25 strains (12%) and no effect in the case of 96 strains (48%). A very good inhibitory effect was noticed against numerous MRSA, MSSA, Enterococci, and Enterobacteriaceae isolates. For several environmental E. coli strains, the bactericidal effect was encountered at a violacein concentration below of what was previously reported. A different effect (bacteriostatic vs. bactericidal) was observed in the case of Enterobacteriaceae isolated from raw vs. treated wastewater, suggesting that the wastewater treatment process may influence the susceptibility of MDR bacteria to violacein containing bacterial extracts.

Human exposure assessment to antibiotic-resistant Escherichia coli through drinking water

Antibiotic-resistant bacteria (ARB) are a potential threat to human health through drinking water with strong evidence of ARB presence in post treated tap water around the world. This study examines potential human exposure to antibiotic-resistant (AR) Escherichia coli (E. coli) through drinking water, the effect of different drinking water treatments on AR E. coli and the concentration of AR E. coli required in the source water for the EU Drinking Water Directive (DWD) (Council Directive 98/83/EC, 0CFU/100ml of E. coli in drinking water) to be exceeded. A number of scenarios were evaluated to examine different water treatment combinations and to reflect site specific conditions at a study site in Europe. A literature search was carried out to collate data on the effect of environmental conditions on AR E. coli, the effect of different water treatments on AR E. coli and typical human consumption levels of tap water. A human exposure assessment model was developed with probability distributions used to characterise uncertainty and variability in the input data. Overall results show the mean adult human exposure to AR E. coli from tap water consumption ranged between 3.44×10^-7 and 2.95×10^-1cfu/day for the scenarios tested and varied depending on the water treatments used. The level of AR E. coli required in the source water pre-treatment to exceed the DWD varied between 1 and 5logcfu/ml, depending on the water treatments used. This can be used to set possible monitoring criteria in pre-treated water for potential ARB exposure in drinking water.

Hospital effluents management: Chemical, physical, microbiological risks and legislation in different countries

Hospital wastewater (HWW) can contain hazardous substances, such as pharmaceutical residues, chemical hazardous substances, pathogens and radioisotopes. Due to these substances, hospital wastewater can represent a chemical, biological and physical risk for public and environmental health. In particular, several studies demonstrate that the main effects of these substances can't be neutralised by wastewater treatment plants (WWTPs). These substances can be found in a wide range of concentrations due to the size of a hospital, the bed density, number of inpatients and outpatients, the number and the type of wards, the number and types of services, the country and the season. Some hazardous substances produced in hospital facilities have a regulatory status and are treated like waste and are disposed of accordingly (i.e., dental amalgam and medications). Legislation is quite homogeneous for these substances in all industrial countries. Problems that have emerged in the last decade concern substances and microorganisms that don't have a regulatory status, such as antibiotic residues, drugs and specific pathogens. At a global level, guidelines exist for treatment methods for these effluents, but legislation in all major industrial countries don't contain limitations on these parameters. Therefore, a monitoring system is necessary for these effluents as well as for substances and pathogens, as these elements can represent a risk to the environment and public health.

Tackling Drug Resistant Infection Outbreaks of Global Pandemic Escherichia coli ST131 Using Evolutionary and Epidemiological Genomics

High-throughput molecular screening is required to investigate the origin and diffusion of antimicrobial resistance in pathogen outbreaks. The most frequent cause of human infection is Escherichia coli, which is dominated by sequence type 131 (ST131)-a set of rapidly radiating pandemic clones. The highly infectious clades of ST131 originated firstly by a mutation enhancing conjugation and adhesion. Secondly, single-nucleotide polymorphisms occurred enabling fluoroquinolone-resistance, which is near-fixed in all ST131. Thirdly, broader resistance through beta-lactamases has been gained and lost frequently, symptomatic of conflicting environmental selective effects. This flexible approach to gene exchange is worrying and supports the proposition that ST131 will develop an even wider range of plasmid and chromosomal elements promoting antimicrobial resistance. To stop ST131, deep genome sequencing is required to understand the origin, evolution and spread of antimicrobial resistance genes. Phylogenetic methods that decipher past events can predict future patterns of virulence and transmission based on genetic signatures of adaptation and gene exchange. Both the effect of partial antimicrobial exposure and cell dormancy caused by variation in gene expression may accelerate the development of resistance. High-throughput sequencing can decode measurable evolution of cell populations within patients associated with systems-wide changes in gene expression during treatments. A multi-faceted approach can enhance assessment of antimicrobial resistance in E. coli ST131 by examining transmission dynamics between hosts to achieve a goal of pre-empting resistance before it emerges by optimising antimicrobial treatment protocols.

Microbiological survey of locally grown lettuce sold at farmers' markets in Vancouver, British Columbia

Increased consumer demand for fresh leafy produce has been paralleled by an increase in outbreaks and illness associated with these foods. Presently, data on the microbiological quality and safety of produce harvested in the Lower Mainland of British Columbia is lacking. Therefore, fresh green, red, and romaine lettuce samples (n = 68) were obtained from five regional farmers' markets in late summer of 2012 and subsequently analyzed to determine total numbers of aerobic bacteria, coliforms, and Escherichia coli. Additionally, enrichment procedures were used to detect low concentrations of E. coli. Obtained E. coli isolates were subjected to multiplex PCRs to determine phylogenetic groupings and the presence of virulence genes (eaeA, hlyA, stx1, and stx2). All E. coli were tested for resistance to 15 antibiotics using a disk diffusion assay. Lettuce samples yielded mean aerobic colony counts of 6.3 log CFU/g. Coliforms were detected in 72% of samples, with a median concentration of 1.9 log CFU/g. Of samples, 13% were found to harbor E. coli, with a median level of 0.7 log CFU/g. Antibiogram typing of all E. coli (n = 33) revealed that 97% possessed resistance to one or more antimicrobials, with resistance to amikacin (58%), trimethoprim (48%), and trimethoprim-sulfamethoxazole (45%) being the most common. Phylogroup typing showed that 79% of these isolates belonged to group B1, with the remaining assigned to groups A (9%) or D (12%); no virulence genes were detected. Considering that phylogroup indicators suggestive of fecal contamination (groups A and D E. coli) were recovered in lettuce samples presented at retail, further work is required to explore at what point along the food chain contamination occurs. Also, this study shows the presence of multidrug-resistant E. coli in fresh vegetables. Summed, these data provide important information on the microbiological quality of leafy vegetables grown in British Columbia through the detection and characterization of frequently used indicator organisms.

Continuous flow photo-Fenton treatment of ciprofloxacin in aqueous solutions using homogeneous and magnetically recoverable catalysts

The degradation of ciprofloxacin was studied in aqueous solutions by using a continuous flow homogeneous photo-Fenton process under simulated solar light. The effect of different operating conditions on the degradation of ciprofloxacin was investigated by changing the hydrogen peroxide (0-2.50 mM) and iron(II) sulphate (0-10 mg Fe L(-1)) concentrations, as well as the pH (2.8-10), irradiance (0-750 W m(-2)) and residence time (0.13-3.4 min) of the process. As expected, the highest catalytic activity in steady state conditions was achieved at acidic pH (2.8), namely 85 % of ciprofloxacin conversion, when maintaining the other variables constant (i.e. 2.0 mg L(-1) of iron(II), 2.50 mM of hydrogen peroxide, 1.8 min of residence time and 500 W m(-2) of irradiance). Additionally, magnetite magnetic nanoparticles (ca. 20 nm of average particle size) were synthesized, characterized and tested as a possible catalyst for this reaction. In this case, the highest catalytic activity was achieved at natural pH, namely a 55 % average conversion of ciprofloxacin in 1.8 min of residence time and under 500 W m(-2). Some of the photocatalytic activity was attributed to Fe(2+) leaching from the magnetic nanoparticles to the solution.

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

The relationship between antimicrobial residues, antibiotic resistance prevalence and bacterial community composition in hospital effluent and in the receiving wastewater treatment plant was studied. Samples from hospital effluent, raw inflow and final effluent of the receiving wastewater treatment plant were characterized for amoxicillin and ciprofloxacin resistance prevalence, content of heavy metals and antimicrobial residues and bacterial community structure, based on 16S rRNA gene PCR-DGGE analysis. The concentration of fluoroquinolones, arsenic and mercury was in general higher in hospital effluent than in raw inflow, while the opposite was observed for tetracyclines, sulfonamides and penicillin G. The prevalence of ciprofloxacin resistance was significantly higher in hospital effluent than in raw inflow. The concentration of antimicrobial residues was observed to be significantly correlated with the prevalence of antibiotic resistant bacteria and with variations in the bacterial community. Hospital effluent was confirmed as a relevant, although not unique, source of antimicrobial residues and antibiotic resistant bacteria to the wastewater treatment plant. Moreover, given the high loads of antibiotic residues and antibiotic resistant bacteria that may occur in hospital effluents, these wastewater habitats may represent useful models to study and predict the impact of antibiotic residues on bacterial communities.