Molecular mechanism of antibiotic resistance induced by mono- and twin-chained quaternary ammonium compounds

Reviewing the complexities of bacterial biocide susceptibility and in vitro biocide adaptation methodologies

Decreased bacterial susceptibility to biocides raises concerns due to their influences on antibiotic resistance. The lack of standardized breakpoints, established methods, and consistent terminology complicates this research. This review summarizes techniques for studying biocide resistance mechanisms, susceptibility testing, and in-vitro adaptation methods, highlighting their benefits and limitations. Here, the challenges in studying biocide susceptibility and the need for standardized approaches in biocide research are emphasized for commonly studied biocide classes.

Synergistic effects of quaternary ammonium compounds and antibiotics on the evolution of antibiotic resistance

The usage of quaternary ammonium compounds (QACs) as disinfectants has surged dramatically during the COVID-19 pandemic and thereafter. QACs can promote antimicrobial resistance, but the combined effects of QACs and antibiotics in driving resistance evolution were yet revealed. This study aimed to evaluate antibiotic resistance of wastewater microorganisms under coexposure to typical antibiotics and the most widely used QAC, dodecyl dimethyl benzyl ammonium chloride (DDBAC). DDBAC exhibited synergistic effects with multiple antibiotics (ampicillin, azithromycin, ciprofloxacin, kanamycin, polymyxin B) in enhancing activated sludge resistance by 1.53-6.67 folds, compared with antibiotics exposure alone. DDBAC-ampicillin coexposure enriched multidrug and aminoglycoside ARGs with relatively high horizontal gene transfer potential. The synergistic mechanism was further explored using sludge-isolated pathogenic E. coli. DDBAC at 1-10 mg/L alone did not induce notable resistance, but synergized with ampicillin on enhancing resistance by 6.56-22.90 folds. Based on mutation analysis and transcriptomics, DDBAC-enhanced resistance evolution was attributable to efflux pump upregulation, target modification, and inhibition of ATP synthesis (a less reported mechanism). Five DDBAC-induced, resistance-conferring mutant genes were highly enriched in globally collected E. coli strains from wastewater outflow (n = 537) than soil/sediments (n = 714, p < 0.05). Considering the strong adsorption and persistence of QACs, their coexistence with antibiotics poses elevated antimicrobial resistance risks, particularly in wastewater treatment systems with long solid retention time and sewage sludge applied farmland.

A survey of 27 quaternary ammonium compounds in surface water, drinking water, stormwater runoff, swimming pool water, and rainwater from New York State, USA

Quaternary ammonium compounds (QACs), including benzylalkyldimethylammonium (BACs), dialkyldimethylammonium (DDACs), and alkyltrimethylammonium compounds (ATMACs), are widely used as disinfectants in industrial and consumer products. Nevertheless, little is known about their occurrence in aquatic environments. We surveyed 7 BACs, 6 DDACs, 6 ATMACs, and 8 hydroxyl‑ and carboxyl- metabolites of BACs (BACm) in various types of water (N = 233) from New York State, USA. The geometric mean (GM) concentration of ∑All (sum concentration of all QACs) varied among different water types in the following decreasing order: stormwater runoff (1140 ng/L) > swimming pool water (109) > river water (49.3) > rainwater (40.5) > lake water (23.7) > tap water (23.3) > bottled water (11.8). DDACs were the major class of QACs in all water types (except for bottled water), accounting for 51-62% of ∑All. Several metabolites of BACs were found in waters for the first time (GM: nondetectable to 82.4 ng/L). Surface water samples collected from the Hudson River and Onondaga Lake contained elevated QAC concentrations. The average annual discharge of QACs through the Hudson River into the Atlantic Ocean was up to 21,000 kg. The risk quotients of QACs in surface water reached up to 5260, highlighting potential ecological risks exerted by these chemicals. This study provides critical information for the risk assessment and management of QACs in the aquatic environment.

Large-scale phenotypic and genomic analysis of Listeria monocytogenes reveals diversity in the sensitivity to quaternary ammonium compounds but not to peracetic acid

Listeria monocytogenes presents a significant concern for the food industry due to its ability to persist in the food processing environment. One of the factors contributing to its persistence is decreased sensitivity to disinfectants. Our objective was to assess the diversity of L. monocytogenes sensitivity to food industry disinfectants by testing the response of 1,671 L. monocytogenes isolates to quaternary ammonium compounds (QACs) and 414 isolates to peracetic acid (PAA) using broth microdilution and growth curve analysis assays, respectively, and to categorize the isolates into sensitive and tolerant. A high phenotype-genotype concordance (95%) regarding tolerance to QACs was obtained by screening the genomes for the presence of QAC tolerance-associated genes bcrABC, emrE, emrC, and qacH. Based on this high concordance, we assessed the QAC genes' dissemination among publicly available L. monocytogenes genomes (n = 39,196). Overall, QAC genes were found in 23% and 28% of the L. monocytogenes collection in this study and in the global data set, respectively. bcrABC and qacH were the most prevalent genes, with bcrABC being the most detected QAC gene in the USA, while qacH dominated in Europe. No significant differences (P > 0.05) in the PAA tolerance were detected among isolates belonging to different lineages, serogroups, clonal complexes, or isolation sources, highlighting limited variation in the L. monocytogenes sensitivity to this disinfectant. The present work represents the largest testing of L. monocytogenes sensitivity to important food industry disinfectants at the phenotypic and genomic level, revealing diversity in the tolerance to QACs while all isolates showed similar sensitivity to PAA.

IMPORTANCE

Contamination of Listeria monocytogenes within food processing environments is of great concern to the food industry due to challenges in eradicating the isolates once they become established and persistent in the environment. Genetic markers associated with increased tolerance to certain disinfectants have been identified, which alongside other biotic and abiotic factors can favor the persistence of L. monocytogenes in the food production environment. By employing a comprehensive large-scale phenotypic testing and genomic analysis, this study significantly enhances the understanding of the L. monocytogenes tolerance to quaternary ammonium compounds (QACs) and the genetic determinants associated with the increased tolerance. We provide a global overview of the QAC genes prevalence among public L. monocytogenes sequences and their distribution among clonal complexes, isolation sources, and geographical locations. Additionally, our comprehensive screening of the peracetic acid (PAA) sensitivity shows that this disinfectant can be used in the food industry as the lack of variation in sensitivity indicates reliable effect and no apparent possibility for the emergence of tolerance.

The Slow Pandemic: Emergence of Antimicrobial Resistance in the Postadvent of SARS-CoV-2 Pandemic

Background: The unprecedented outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has dramatically changed the global approach to public health, emphasizing the importance of measures to control and prevent infections. In response to the COVID-19 crisis, stringent hygiene practices and surface disinfection have become the norm, with an unprecedented surge in the use of disinfectants and antiseptics (DAs). Main Text: While these measures have been crucial in curbing the spread of the virus, an emerging concern has taken center stage: the potential impact of the prolonged and widespread use of antimicrobial compounds in these products on the development of antibiotic resistance. Antimicrobial resistance (AMR) has long been recognized as one of the most pressing global health threats. Quaternary ammonium compounds (QAC) such as benzalkonium chloride, benzethonium chloride, and cetylpyridinium chloride, which are extensively used in DAs formulations, have gained less attention in the context of AMR. Conclusion: A high abundance of QACs was detected in wastewater, and certain bacteria such as Pseudomonas aeruginosa, Acinetobacter baumannii, and Enterococcus species developed resistance to these compounds over time. We analyzed the available evidence from the scientific literature, examining the presence and concentrations of QACs in different water sources, and their resistance mechanisms. This review aimed to shed light on the multifaceted challenges that arise from the dual battle against the COVID-19 pandemic and the ongoing global fight against AMR.

Antihistamine drug loratadine at environmentally relevant concentrations promotes conjugative transfer of antibiotic resistance genes: Coeffect of oxidative stress and ion transport

Due to the widespread use of loratadine (LOR) as an antihistamine, it is widely distributed in the environment as an emerging contaminant. However, its impact on the dissemination of antibiotic resistance genes (ARGs) remains unclear. This study investigated the effect of LOR on the conjugative transfer of ARGs and elucidated the potential mechanisms through transcriptome analysis. The results showed that LOR significantly promoted the frequency of conjugative transfer up to 1.5- to 8.6-fold higher compared with the control group. Exposure to LOR increased reactive oxidative species (ROS) and intracellular Ca2+ concentrations, leading to the upregulation of expression of genes related to transmembrane transport and SOS response. Meanwhile, it stimulated the increase of cell membrane permeability. Moreover, LOR exposure could enhance H+ efflux in donor bacteria, resulting in the decrease of intracellular pH and the elevation of transmembrane potential, which could induce the increase of ion transport, thereby promoting plasmid efflux from the cell membrane. Based on this, we inferred that LOR can induce an increase in ROS level and intracellular Ca2+ concentrations, and promoted the efflux of intracellular H+. This, in turn, triggered the intensification of various ion transport processes on the cell membrane, thereby increasing membrane permeability and accelerating plasmid efflux. Ultimately, the coeffect of oxidative stress response and ion transport promoted conjugative transfer. This study demonstrated that LOR significantly promotes plasmid-mediated conjugative transfer of ARGs, providing novel insights into the mechanisms underlying this process.

Antibiotic resistance evolution driven synergistically by antibiotics and typical organic pollutants in antibiotic production wastewater

A major concern regarding the risk of antibiotic production wastewater (APW) for the transmission of antibiotic resistance (AR) stems from the residual antibiotics. However, APW also contains high concentrations of organic pollutants, many of which have severe biological toxicity and joint toxicity with antibiotics. The contribution of these organic pollutants to the development of AR in the APW treatment system is unknown. In this study, a wild-type Escherichia coli strain was exposed to six typical organic pollutants in APW individually and synergistically with the antibiotic ampicillin (AMP). Independent exposure to organic compounds had negligible effects on the evolution of AR, whereas they synergistically induced AR mutations and increased antibiotic persistence with AMP, especially the raw material d-p-hydroxyphenylglycine (DHPG), at relevant concentrations in APW. Combined exposure to 1-500 mg/L DHPG and 1 mg/L AMP synergistically increased the mutation frequencies against multiple antibiotics by up to 2928.9-fold in a dose-time pattern, and the combination index reached 445.7. Phenotypic and genotypic analyses revealed that the synergism between DHPG and AMP was associated with increased antibacterial activity, enhanced oxidative stress, and stimulation of efflux pump expression. Overall, our results highlight the elevated risk of AR induction caused by antibiotics and organic pollutants in APW.

Challenges of quaternary ammonium antimicrobial agents: Mechanisms, resistance, persistence and impacts on the microecology

Quaternary ammonium compounds (QACs) served as broad spectrum antimicrobial agents are widely applied for surface disinfection, skin and mucous disinfection, and mouthwash. The daily applications of QACs have significantly increased, especially during the COVID-19 pandemic. However, the environmental residues of QACs have demonstrated harmful impacts on the environment, leading to an increase in environmental contamination, resistant microbes and disruption of microecology. The actions of QACs were related to their cationic character, which can impact the negatively charged cell membranes, but the details are still unclear. Moreover, bacteria with lower sensitivity and resistant pathogens have been detected in clinics and environments, while QACs were also reported to induce the formation of bacterial persisters. Even worse, the resistant bacteria even showed co-resistance and cross-resistance with traditional antibiotics, decreasing therapeutic effectiveness, and disrupting the microecology homeostasis. Unfortunately, the resistance and persistence mechanisms of QACs and the effects of QACs on microecology are still not clear, which even neglected during their daily usages. Therefore, we summarized and discussed current understandings on the antimicrobial actions, resistance, persistence and impacts on the microecology to highlight the challenges in the QACs applications and discuss the possible strategies for overcoming their drawbacks.

Lysine and valine weaken antibiotic resistance in Salmonella Typhimurium induced by disinfectant stress

Disinfectants are widely used in food production and environmental sanitation to prevent illness, but bacteria resistance to these disinfectants and co-resistance to antibiotics pose a threat to public health. This study investigated the impact of commonly used disinfectants on the resistance of Salmonella Typhimurium (ST) to disinfectants and antibiotics, and explored the metabolic mechanisms underlying the resistance changes. The results showed that subinhibitory concentrations of disinfectants had a minor impact on the resistance of ST to four disinfectants. However, chlorine-containing disinfectants stress enhanced bacteria resistance to ampicillin, while quaternary ammonium compounds stress increased resistance to tetracycline and gentamicin. Untargeted metabolomics analysis revealed significant changes in glutathione metabolism and lysine and valine degradation pathways after disinfectant exposure. Specifically, ST activated lysine decarboxylation, leading to a significant decrease in lysine levels after benzalkonium chloride exposure, while valine and leucine degradation pathways were activated by sodium hypochlorite stress. The addition of downregulated L-lysine and L-valine increased the sensitivity of ST to antibiotics, providing further evidence for the findings of metabolomics. This study provides guidance for the proper use of disinfectants in food processing and establishes a strategy based on metabolomics to control antibiotic-resistant bacteria.

Role and mechanism of the outer membrane porin LamB in T-2 mycotoxin-mediated extensive drug resistance in Escherichia coli

The influence of mycotoxins in ecological niches shared with antibiotic-resistant bacteria (ARB) remains underexplored. This study examined the impact of T-2 mycotoxin on the evolution of antibiotic resistance in Escherichia coli, highlighting the role of specific porins. Our findings revealed that exposure to 10 ng/mL of T-2 toxin induced multi-drug resistant (MDR) phenotypes in three E. coli. At 10-5 ng/mL, T-2 toxin caused E. coli ATCC 25922 to develop stable resistance to 13 critical antibiotics, with minimum inhibitory concentrations (MICs) increasing 16- to several thousand-fold. This resistance was linked to the downregulation of the mal gene cluster. Notably, T-2 toxin reduced membrane permeability by downregulating lamB, facilitating its own entry and reducing the intracellular accumulation of both the toxin and antibiotics, thereby enhancing resistance development. LamB mediated the XDR phenotypes in E. coli, particularly by blocking last-resort antibiotics such as cephalosporins, carbapenems, tigecycline, and colistin, complicating treatment strategies. LamB demonstrated high binding affinities for T-2 toxin and various antibiotics, with specific binding sites identified for meropenem (Arg134), imipenem (Ser148, Arg170, Lys129), ceftazidime (Phe106, Lys129), and cefepime (Tyr66, Gln267, Lys269), exhibiting binding energies of -2.93, -2.58, -2.53, and -4.3, respectively. These findings suggest that even low levels of T-2 mycotoxin pose a substantial public health risk. They underscore the urgent need to address these contaminants and open new avenues for antibiotic resistance research.

A multi-pronged approach to assessing antimicrobial resistance risks in coastal waters and aquaculture systems

Antimicrobial resistance (AMR) is a global challenge that has impacted aquaculture and surrounding marine environments. In this study, a year-long monitoring program was implemented to evaluate AMR in two different aquaculture settings (i.e., open cage farming, recirculating aquaculture system (RAS)) and surrounding marine environment within a tropical coastal region. The objectives of this study are to (i) investigate the prevalence and co-occurrence of antibiotic-resistant bacteria (ARB), antibiotic resistance genes (ARGs), antibiotics (AB) and various associated chemical compounds at these study sites; (ii) explore the contributing factors to development and propagation of AMR in the coastal environment; and (iii) assess the AMR risks from different perspectives based on the three AMR determinants (i.e., ARB, ARGs and AB). Key findings revealed a distinct pattern of AMR across the different aquaculture settings, notably a higher prevalence of antibiotic-resistant Vibrio at RAS outfalls, suggesting a potential accumulation of microorganisms within the treatment system. Despite the relative uniform distribution of ARGs across marine sites, specific genes such as qepA, blaCTX-M and bacA, were found to be abundant in fish samples, especially from the RAS. Variations in chemical contaminant prevalence across sites highlighted possible anthropogenic impacts. Moreover, environmental and seasonal variations were found to significantly influence the distribution of ARGs and chemical compounds in the coastal waters. Hierarchical cluster analysis that was based on ARGs, chemical compounds and environmental data, categorized the sites into three distinct clusters which reflected strong association with location, seasonality and aquaculture activities. The observed weak correlations between ARGs and chemical compounds imply that low environmental concentrations may be insufficient for resistance selection. A comprehensive risk assessment using methodologies such as the multiple antibiotic resistance (MAR) index, comparative AMR risk index (CAMRI) and Risk quotient (RQ) underscored the complexity of AMR risks. This research significantly contributes to the understanding of AMR dynamics in natural aquatic systems and provides valuable insights for managing and mitigating AMR risks in coastal environments.

Antibiotic intermediates and antibiotics synergistically promote the development of multiple antibiotic resistance in antibiotic production wastewater

Antibiotic resistance (AR) is a major public health concern. Antibiotic intermediates (AIs) used in the production of semisynthetic antibiotics have the same bioactive structure as parent antibiotics and synthetic antibiotic production wastewater usually contains high concentrations of residual AIs; however, the effects of AIs and their interactive effects with antibiotics on the emergence of AR are unknown. In this study, antibiotic-sensitive E. coli K12 was exposed to five types of β-lactam AIs and their parent antibiotic ampicillin to analyze their impact on the evolution of multiple AR. The results indicated that AI 6-APA inhibits bacterial growth and stimulates the production of reactive oxygen species, as well as induces AR and antibiotic persistence like the parent antibiotic AMP. Combined exposure to 6-APA and AMP synergistically stimulated the induction of multiple AR and antibiotic persistence. The resistance mutation frequency increased up to 6.1 × 106-fold under combined exposure and the combination index reached 1326.5, indicating a strong synergy of 6-APA and AMP. Phenotypic and genotypic analyses revealed that these effects were associated with the overproduction of reactive oxygen species, enhanced stress response signatures, and activation of efflux pumps. These findings provide evidence and mechanistic insights into AR induction by AIs in antibiotic production wastewater.

Efficient degradation of benzalkonium chloride (BAC) by zero-valent iron activated persulfate: Kinetics, reaction mechanisms, theoretical calculations and toxicity evolution

The present study systematically investigated the elimination of benzalkonium chloride (BAC) in the zero valent iron activated persulfate (Fe0/PS) system. The influence of operational parameters, including PS concentration, Fe0 dosage and pH, were investigated through a series of kinetic experiments. When the Fe0 dosage was 5.0 mM, the initial ratio of [PS]: [BAC] was 10:1, the degradation efficiency could achieve 91.7% at pH 7.0 within 60 min. Common inorganic anions and humic acid did not significantly affect BAC degradation, implying that Fe0/PS system had a potential application prospect in the actual wastewater remediation. Based on the electron paramagnetic resonance test and quenching experiments, the BAC degradation was found to be contributed by •OH, SO4•- and Fe(IV). A total of 23 intermediates were identified by the liquid chromatography-mass spectrometry, and the degradation pathways were proposed accordingly, including dealkylation and demethylation, hydroxylation, sulfate substitution and benzyl C-N cleavage reactions. Density functional theory based calculations were conducted to realize the rationality of the proposed reaction mechanisms. The toxicity of transformation products was predicted by ECOSAR program. This work demonstrated the possibility of BAC removal in hospital and municipal wastewater by Fe0/PS treatment, and also provides a safe choice for deep treatment of quaternary ammonium salt wastewater.

Occurrence and source identification of the disinfectant didecyldimethylammonium chloride in a Japanese watershed receiving effluent from swine farms

Didecyldimethylammonium chloride (DDAC), a toxic quaternary ammonium compound (QAC) linked to multidrug resistance, is used widely in households and hospitals and on swine farms to prevent disease transmission. However, little is known about its occurrence in watersheds receiving livestock wastewaters or manure. We monitored DDAC and tracers (veterinary and human drugs) once a season over a year at 14 sites in a Japanese watershed where swine outnumbered humans 1.2 to 1 and where both swine and human wastewaters were largely treated on site. DDAC concentrations in sewage-treatment-plant effluent (33-52 ng/L) were close to, whereas those in river waters (3.6-16,672 ng/L) far exceeded, those reported worldwide. DDAC mass flows at the catchment outlet (1692-3816 μg/s) were higher than those of any of the drugs. DDAC concentrations were significantly correlated with total concentrations of veterinary drugs (Spearman's correlation coefficient, 0.95, P < 0.01), indicating that the major pathway of DDAC entry to surface waters was via effluent discharge from swine farms. Comparison of observed and predicted mass flows implied that a substantial percentage of DDAC was washed from the barn floor into swine excrement. To our knowledge, this is the first study to demonstrate QAC hotspots attributable to animal husbandry.

Differential Selection for Survival and for Growth in Adaptive Laboratory Evolution Experiments With Benzalkonium Chloride

Biocides are used to control microorganisms across different applications, but emerging resistance may pose risks for those applications. Resistance to biocides has commonly been studied using adaptive laboratory evolution (ALE) experiments with growth at subinhibitory concentrations linked to serial subculturing. It has been shown recently that Escherichia coli adapts to repeated lethal stress imposed by the biocide benzalkonium chloride (BAC) by increased survival (i.e., tolerance) and not by evolving the ability to grow at increased concentrations (i.e., resistance). Here, we investigate the contributions of evolution for tolerance as opposed to resistance for the outcome of ALE experiments with E. coli exposed to BAC. We find that BAC concentrations close to the half maximal effective concentration (EC50, 4.36 μg mL-1) show initial killing (~40%) before the population resumes growth. This indicates that cells face a two-fold selection pressure: for increased survival and for increased growth. To disentangle the effects of both selection pressures, we conducted two ALE experiments: (i) one with initial killing and continued stress close to the EC50 during growth and (ii) another with initial killing and no stress during growth. Phenotypic characterization of adapted populations showed that growth at higher BAC concentrations was only selected for when BAC was present during growth. Whole genome sequencing revealed distinct differences in mutated genes across treatments. Treatments selecting for survival-only led to mutations in genes for metabolic regulation (cyaA) and cellular structure (flagella fliJ), while treatments selecting for growth and survival led to mutations in genes related to stress response (hslO and tufA). Our results demonstrate that serial subculture ALE experiments with an antimicrobial at subinhibitory concentrations can select for increased growth and survival. This finding has implications for the design of ALE experiments to assess resistance risks of antimicrobials in different scenarios such as disinfection, preservation, and environmental pollution.

Sublethal Sodium Hypochlorite Exposure: Impact on Resistance-Nodulation-Cell Division Efflux Pump Overexpression and Cross-Resistance to Imipenem

Sodium hypochlorite (NaOCl) is widely used in public healthcare facilities; this exposure can result in the development of bacterial tolerance to disinfectants, which has known links to antibiotic cross-resistance. However, the mechanism through which cross-resistance to antibiotics and disinfectants develops remains ambiguous. Therefore, this study aimed to examine the phenotypic and transcriptomic changes caused by disinfectant exposure in Gram-negative bacteria and determine the cause of cross-resistance to antibiotics. The results demonstrated that the misuse of disinfectants plays an important role in the emergence of disinfectant resistance and in the increase in antibiotic resistance. Antibiotic resistance may occur from the exposure of Gram-negative bacteria to subminimal inhibitory concentrations (MICs) of NaOCl. Ten passages of Gram-negative bacteria in increasingly higher subMICs of the NaOCl disinfectant were sufficient to increase the MIC to >2500 µg/mL NaOCl, particularly in K. pneumoniae and P. aeruginosa. To determine the development of cross-resistance to antibiotics due to NaOCl exposure, the MICs for each antibiotic before and after the exposure of each strain to sublethal concentrations of NaOCl were compared. After overnight incubation with a sublethal concentration of NaOCl, a statistically significant increase in MIC was only observed for imipenem (p < 0.01). An investigation of the mechanism of cross-resistance by means of transcriptome analysis revealed that 1250 µg/mL of NaOCl-adapted K. pneumoniae and P. aeruginosa strains increased resistance to imipenem due to the increased expression of resistance-nodulation-cell division (RND) efflux pumps, such as AcrAB-TolC and MexAB/XY-OprM. Therefore, we suggest that exposure to NaOCl can influence the expression of RND efflux pump genes, contributing to imipenem cross-resistance.

Common food preservatives impose distinct selective pressures on Salmonella Typhimurium planktonic and biofilm populations

Food preservatives are crucial in controlling microbial growth in processed foods to maintain food safety. Bacterial biofilms pose a threat in the food chain by facilitating persistence on a range of surfaces and food products. Cells in a biofilm are often highly tolerant of antimicrobials and can evolve in response to antimicrobial exposure. Little is known about the efficacy of preservatives against biofilms and their potential impact on the evolution of antimicrobial resistance. In this study we investigated how Salmonella enterica serovar Typhimurium responded to subinhibitory concentrations of four food preservatives (sodium chloride, potassium chloride, sodium nitrite or sodium lactate) when grown planktonically and in biofilms. We found that each preservative exerted a unique selective pressure on S. Typhimurium populations. There was a trade-off between biofilm formation and growth in the presence of three of the four preservatives, where prolonged preservative exposure resulted in reduced biofilm biomass and matrix production over time. All three preservatives selected for mutations in global stress response regulators rpoS and crp. There was no evidence for any selection of cross-resistance to antibiotics after preservative exposure. In conclusion, we showed that preservatives affect biofilm formation and bacterial growth in a compound specific manner. We showed trade-offs between biofilm formation and preservative tolerance, but no antibiotic cross-tolerance. This indicates that bacterial adaptation to continuous preservative exposure, is unlikely to affect food safety or contribute to antibiotic resistance.

Reassessment of the genetic basis of natural rifampin resistance in the genus Rickettsia

Rickettsia, a genus of obligate intracellular bacteria, includes species that cause significant human diseases. This study challenges previous claims that the Leucine-973 residue in the RNA polymerase beta subunit is the primary determinant of rifampin resistance in Rickettsia. We investigated a previously untested Rickettsia species, R. lusitaniae, from the Transitional group and found it susceptible to rifampin, despite possessing the Leu-973 residue. Interestingly, we observed the conservation of this residue in several rifampin-susceptible species across most Rickettsia phylogenetic groups. Comparative genomics revealed potential alternative resistance mechanisms, including additional amino acid variants that could hinder rifampin binding and genes that could facilitate rifampin detoxification through efflux pumps. Importantly, the evolutionary history of Rickettsia genomes indicates that the emergence of natural rifampin resistance is phylogenetically constrained within the genus, originating from ancient genetic features shared among a unique set of closely related Rickettsia species. Phylogenetic patterns appear to be the most reliable predictors of natural rifampin resistance, which is confined to a distinct monophyletic subclade known as Massiliae. The distinctive features of the RNA polymerase beta subunit in certain untested Rickettsia species suggest that R. raoultii, R. amblyommatis, R. gravesii, and R. kotlanii may also be naturally rifampin-resistant species.

A Label-Free Optical Flow Cytometry Based-Method for Rapid Assay of Disinfectants' Bactericidal Activity

Selecting the appropriate disinfectant to control and prevent healthcare-associated infections (HAIs) is a challenging task for environmental health experts due to the large number of available disinfectant products. This study aimed to develop a label-free flow cytometry (FCM) method for the rapid evaluation of bactericidal activity and to compare its efficacy with that of standard qualitative/quantitative suspension tests. The bactericidal efficiency of eight commercial disinfectants containing quaternary ammonium compounds (QACs) was evaluated against four strains recommended by EN 13727 (Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, Enterococcus hirae) and four multidrug-resistant pathogens. The proposed FCM protocol measures changes in scattered light and counts following disinfectant exposure, neutralization, and culture steps. Unlike other available FCM-based methods, this approach does not rely on autofluorescence measurements, impedance cytometry, or fluorescent dyes. The FCM scattered light signals revealed both decreased count rates and morphological changes after treatment with minimum inhibitory concentrations (MICs) and higher concentrations for all tested bacteria. The results from the FCM measurements showed excellent correlation with those from standard assays, providing a rapid tool for monitoring the susceptibility profile of clinical, multidrug-resistant pathogens to chemical disinfectants, which could support infection prevention and control procedures for healthcare environments. This label-free FCM protocol offers a novel and rapid tool for environmental health experts, aiding in the optimization of disinfectant selection for the prevention and control of HAIs.

The combination of ciprofloxacin and dialkyldimethyl ammonium compound synergistically proliferated intracellular resistance genes in nitrifying system

Antibiotics and quaternary ammonium compounds (QACs) usually co-exist in wastewater treatment plants. Hence, three sequencing batch reactors were established and named as R1, R2 and R3, to investigate the effects of individual and combined exposure of different concentrations of ciprofloxacin (CIP) (0.2, 1.0 and 2.0 mg/L) and dialkyldimethyl ammonium compound (DADMAC) (0.4, 2.0 and 4.0 mg/L) on the performance, microbial community structures and resistance genes (RGs) in nitrifying system during 150 days. Results showed that CIP had a slight effect on ammonia oxidation activity, while 2.0 and 4.0 mg/L DADAMAC could obviously inhibit it, and the combination of CIP and DADMAC had a synergistic inhibitory effect. Besides, both CIP and DADMAC caused partial nitrification, and the order of nitrite accumulation rate was ranked as R3 > R2 > R1. The combination of CIP and DADMAC had an antagonistic effect on the increase of sludge particle size and α-Helix/(β-Sheet + Random coil) was lowest in R3 (0.40). The combination of CIP and DADMAC synergistically stimulated most intracellular RGs in sludge, and the relative abundances of target RGs (e.g., qacEdelta1-01, qacH-01 and qnrS) at the end of operation in R3 were increased by 4.61-18.19 folds compared with those in CK, which were 1.34-5.57 folds higher than the R1 and R2. Moreover, the combination of CIP and DADMAC also promoted the transfer of RGs from sludge to water and enriched more potential hosts of RGs, further promoting the spread of RGs in nitrifying system. Thus, the combined pollution of CIP and DADMAC in wastewaters should attract more attentions.

Synergistic Bactericidal Effects of Quaternary Ammonium Compounds with Essential Oil Constituents

Antimicrobial tolerance is a significant concern in the food industry, as it poses risks to food safety and public health. To overcome this challenge, synergistic combinations of antimicrobials have emerged as a potential solution. In this study, the combinations of two essential oil constituents (EOCs), namely carvacrol (CAR) and eugenol (EUG), with the quaternary ammonium compounds (QACs) benzalkonium chloride (BAC) and didecyldimethylammonium chloride (DDAC) were evaluated for their antimicrobial effects against Escherichia coli and Bacillus cereus, two common foodborne bacteria. The checkerboard assay was employed to determine the fractional inhibitory concentration index (FICI) and the fractional bactericidal concentration index (FBCI), indicating the presence of bactericidal, but not bacteriostatic, synergy in all QAC-EOC combinations. Bactericidal synergism was clearly supported by Bliss independence analysis. The bactericidal activity of the promising synergistic combinations was further validated by time-kill curves, achieving a >4-log10 reduction of initial bacterial load, which is significant compared to typical industry standards. The combinations containing DDAC showed the highest efficiency, resulting in the eradication of bacterial population in less than 2-4 h. These findings emphasize the importance of considering both bacteriostatic and bactericidal effects when evaluating antimicrobial combinations and the potential of EOC-QAC combinations for sanitization and disinfection in the food industry.

Chimeric Amphiphilic Disinfectants: Quaternary Ammonium/Quaternary Phosphonium Hybrid Structures

Cationic biocides play a crucial role in the disinfection of domestic and healthcare surfaces. Due to the rise of bacterial resistance towards common cationic disinfectants like quaternary ammonium compounds (QACs), the development of novel actives is necessary for effective infection prevention and control. Toward this end, a series of 15 chimeric biscationic amphiphilic compounds, bearing both ammonium and phosphonium residues, were prepared to probe the structure and efficacy of mixed cationic ammonium-phosphonium structures. Compounds were obtained in two steps and good yields, with straightforward and chromatography-free purifications. Antibacterial activity evaluation of these compounds against a panel of seven bacterial strains, including two MRSA strains as well as opportunistic pathogen A. baumannii, were encouraging, as low micromolar inhibitory activity was observed for multiple structures. Alkyl chain length on the ammonium group was, as expected, a major determinant of bioactivity. In addition, high therapeutic indexes (up to 125-fold) for triphenyl phosphonium-bearing amphiphiles were observed when comparing antimicrobial activity to mammalian cell lysis activity.

Mutation-driven resistance development in wastewater E. coli upon low-level cephalosporins: Pharmacophore contribution and novel mechanism

Cephalosporins have been widely applied in clinical and veterinary settings and detected at increasing concentrations in water environments. They potentially induce high-level antibiotic resistance at environmental concentrations. This study characterized how typical wastewater bacteria developed heritable antibiotic resistance under exposure to different cephalosporins, including pharmacophore-resistance correlation, resistance mechanism, and occurrence of resistance-relevant mutations in different water environments. Wastewater-isolated E. coli JX1 was exposed to eight cephalosporins individually at 25 µg/L for 60 days. Multidrug resistance developed and diverse mutations arose in selected mutants, where a single mutation in ATP phosphoribosyltransferase encoding gene (hisG) resulted in up to 128-fold increase in resistance to meropenem. Molprint2D pharma RQSAR analysis revealed that hydrogen-bond acceptors and hydrophobic groups in the R1 and R2 substituents of cephalosporins contributed positively to antibiotic resistance. Some of these pharmacophores may persist during bio- or photo-degradation in the environment. hisG mutation confers a novel resistance mechanism by inhibiting fatty acid degradation, and its variants were more abundant in water-related E. coli (especially in the effluent of wastewater treatment plants) compared with those in non-water environments. These results suggest that specific degradation of particular pharmacophores in cephalosporins could be useful for controlling resistance development, and mutations in previously unreported resistance genes (e.g., hisG) can lead to overlooked antibiotic resistance risks in water environments.

Post-Coronavirus Disease 2019 Pandemic Antimicrobial Resistance

BACKGROUND AND AIM

Antimicrobial resistance (AMR) is a chronic issue of our Westernized society, mainly because of the uncontrolled and improper use of antimicrobials. The coronavirus disease 2019 (COVID-19) pandemic has triggered and expanded AMR diffusion all over the world, and its clinical and therapeutic features have changed. Thus, we aimed to review evidence from the literature on the definition and causative agents of AMR in the frame of the COVID-19 post-pandemic era.

METHODS

We conducted a search on PubMed and Medline for original articles, reviews, meta-analyses, and case series using the following keywords, their acronyms, and their associations: antibiotics, antimicrobial resistance, severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), COVID-19 pandemic, personal protective equipment.

RESULTS

AMR had a significant rise in incidence both in in-hospital and outpatient populations (ranging from 5 up to 50%) worldwide, but with a variegated profile according to the germ and microorganism considered. Not only bacteria but also fungi have developed more frequent and diffuse AMR. These findings are explained by the increased use and misuse of antibiotics and preventive measures during the first waves of the SARS-CoV2 pandemic, especially in hospitalized patients. Subsequently, the reduction in and end of the lockdown and the use of personal protective equipment have allowed for the indiscriminate circulation of resistant microorganisms from low-income countries to the rest of the world with the emergence of new multi- and polyresistant organisms. However, there is not a clear association between COVID-19 and AMR changes in the post-pandemic period.

CONCLUSIONS

AMR in some microorganisms has significantly increased and changed its characteristics during and after the end of the pandemic phase of COVID-19. An integrated supranational monitoring approach to this challenge is warranted in the years to come. In detail, a rational, personalized, and regulated use of antibiotics and antimicrobials is needed.

Disinfectants and antiseptics: mechanisms of action and resistance

Chemical biocides are used for the prevention and control of infection in health care, targeted home hygiene or controlling microbial contamination for various industrial processes including but not limited to food, water and petroleum. However, their use has substantially increased since the implementation of programmes to control outbreaks of methicillin-resistant Staphylococcus aureus, Clostridioides difficile and severe acute respiratory syndrome coronavirus 2. Biocides interact with multiple targets on the bacterial cells. The number of targets affected and the severity of damage will result in an irreversible bactericidal effect or a reversible bacteriostatic one. Most biocides primarily target the cytoplasmic membrane and enzymes, although the specific bactericidal mechanisms vary among different biocide chemistries. Inappropriate usage or low concentrations of a biocide may act as a stressor while not killing bacterial pathogens, potentially leading to antimicrobial resistance. Biocides can also promote the transfer of antimicrobial resistance genes. In this Review, we explore our current understanding of the mechanisms of action of biocides, the bacterial resistance mechanisms encompassing both intrinsic and acquired resistance and the influence of bacterial biofilms on resistance. We also consider the impact of bacteria that survive biocide exposure in environmental and clinical contexts.

The effects of didodecyl dimethyl ammonium chloride on microbial communities and resistance genes in floc, granular and biofilm denitrification sludge

As a type of quaternary ammonium compounds, didodecyl dimethyl ammonium chloride (DADMAC C12) was frequently detected in wastewater treatment plants. Here, floc-based sequencing batch reactor (FSBR), granule-based SBR (GSBR) and biofilm SBR (BSBR) were fed with 0.5, 5 and 10 mg/L of DADMAC C12 for 120 d. Compared with floc sludge and granule sludge, biofilm had the strongest ability to resist the impact of DADMAC C12. Notably, in both FSBR and GSBR systems, 5 mg/L DADMAC C12 promoted denitrification sludge to become hydrophobic and compact due to an increase in α-Helix/(β-Sheet+Random coil), consequently enhancing sludge granulation. Besides，high concentration of DADMAC C12 generally increased the abundances of MGEs in three denitrification systems, except extracellular MGEs in water. The variation of efflux pump ARGs was basically consistent with that of MGEs. The stimulation of DADMAC C12 also increased significantly the abundance of extracellular antibiotics deactivation ARGs in water in three denitrification systems. Besides, DADMAC C12 induced co-selection among various ARGs and promoted the proliferation and spread of sulfonamide ARGs in water.

Quaternary Ammonium Compounds (QACs) in Wastewater Influent and Effluent Throughout the COVID-19 Pandemic

Quaternary ammonium compounds (QACs) are used in consumer and industrial products, including disinfectants. Due to the COVID-19 pandemic, disinfectant use has increased, purportedly increasing loads to wastewater treatment plants and the environment. To understand how the increased usage has affected QAC loadings to treatment plants and to determine how effectively plants remove QACs from liquid effluent that is discharged to surface and groundwaters, influent and effluent wastewater samples were collected from four treatment plants (treatment capacities < 5 MGD to > 100 MGD) for 21 months beginning in May 2020. Influent QAC concentrations were hundreds of μg/L and effluent QAC concentrations were < 1 μg/L, corresponding to an average removal of 98% from all four plants. The most prevalent QACs in influent were those used most commonly in disinfectants, specifically benzylalkyldimethylammonium compounds (BACs) and short-chain dialkyldimethylammonium compounds (DADMACs), and influent levels of these compounds were correlated with QAC sales. Prior to this study, ethylbenzylalkyldimethylammonium compounds (EtBACs) had not been studied, and they comprised 13 ± 6% of QACs in influent. While removal was high at all plants, low μg/L concentrations were still continuously discharged into the environment. For QACs with equivalent alkyl chain lengths, those with aromatic substituents (BACs and EtBACs) appear to be removed more effectively than those with only alkyl chains (DADMACs).

Risks of benzalkonium chlorides as emerging contaminants in the environment and possible control strategies from the perspective of ecopharmacovigilance

An unprecedented increase in the use of disinfection products triggered by the coronavirus disease 2019 (COVID-19) pandemic is resulting in aggravating environmental loads of disinfectants as emerging contaminants, which has been considered a cause for worldwide secondary disasters. This review analyzed the literature published in the last decade about occurrence, bioaccumulation, and possible environmental risks of benzalkonium chlorides (BKCs) as emerging contaminants. Results indicated that BKCs globally occurred in municipal wastewater, surface water, groundwater, reclaimed water, sludge, sediment, soil, roof runoff, and residential dust samples across 13 countries. The maximum residual levels of 30 mg/L and 421 μg/g were reported in water and solid environmental samples, respectively. Emerging evidences suggested possible bioaccumulation of BKCs in plants, even perhaps humans. Environmentally relevant concentrations of BKCs exert potential adverse impacts on aquatic and terrestrial species, including genotoxicity, respiratory toxicity, behavioural effects and neurotoxicity, endocrine disruption and reproductive impairment, phytotoxicity, etc. Given the intrinsic biocidal and preservative properties of disinfectants, the inductive effects of residual BKCs in environment in terms of resistance and imbalance of microorganisms have been paid special attention. Considering the similarities of disinfectants to pharmaceuticals, from the perspective of ecopharmacovigilance (EPV), a well-established strategy for pharmaceutical emerging contaminants, we use the control of BKC pollution as a case, and provide some recommendations for employing the EPV measures to manage environmental risks posed by disinfectant emerging contaminants.

A review of current antibiotic resistance and promising antibiotics with novel modes of action to combat antibiotic resistance

The emergence and transmission of antibiotic resistance is a global public health crisis with significant burden on healthcare systems, resulting in high mortality and economic costs. In 2019, almost five million deaths were associated with drug-resistant infections, and if left unchecked, the global economy could lose $100 trillion by 2050. To effectively combat this crisis, it is essential for all countries to understand the current situation of antibiotic resistance. In this review, we examine the current driving factors leading to the crisis, impact of critical superbugs in three regions, and identify novel mechanisms of antibiotic resistance. It is crucial to monitor the phenotypic characteristics of drug-resistant pathogens and describe the mechanisms involved in preventing the emergence of cross-resistance to novel antimicrobials. Additionally, maintaining an active pipeline of new antibiotics is essential for fighting against diverse antibiotic-resistant pathogens. Developing antibacterial agents with novel mechanisms of action is a promising way to combat increasing antibiotic-resistant pathogens.

Efficient degradation of benzalkonium chloride by FeMn-CA300 catalyst activated persulfate process: Surface hydroxyl potentiation mechanism and degradation pathway

The consumption of disinfectants increased dramatically with the outbreak of the COVID-19 epidemic. Benzalkonium chloride (DDBAC), a cationic surfactant disinfectant for import and export cargoes, is used for effective degradation method. For DDBAC effective degradation, polyhedral Fe-Mn bimetallic catalyst of Prussian blue analogue (FeMn-CA300) was novelty developed for rapid peroxymonosulfate (PMS) activation. Results showed that the Fe/Mn redox and surface hydroxyl groups in the catalyst played an important role in the DDBAC-enhanced degradation. The removal effectiveness of 10 mg L-1 DDBAC was up to 99.4% in 80 min under the initial pH = 7, catalyst dosage of 0.4 g L-1, and PMS concentration of 15 mmol L-1. In addition, FeMn-CA300 had a wide pH applicability range. The results indicated that hydroxyls, sulfate radicals, and singlet oxygen could effectively improve the degradation efficiency, where sulfate radicals played a crucial role. Finally, the corresponding degradation path of DDBAC was further provided according to GC-MS results. The results of this study provide new insights into the degradation of DDBAC, thereby highlighting the great potential of FeMnca300/PMS to control refractory organic compounds in the aqueous phase.

Adaptation mechanisms of Listeria monocytogenes to quaternary ammonium compounds

Listeria monocytogenes is ubiquitously found in nature and can easily enter food-processing facilities due to contaminations of raw materials. Several countermeasures are used to combat contamination of food products, for instance, the use of disinfectants that contain quaternary ammonium compounds, such as benzalkonium chloride (BAC) and cetyltrimethylammonium bromide (CTAB). In this study, we assessed the potential of the commonly used wild-type strain EGD-e to adapt to BAC and CTAB under laboratory growth conditions. All BAC-tolerant suppressors exclusively carried mutations in fepR, encoding a TetR-like transcriptional regulator, or its promoter region, likely resulting in the overproduction of the efflux pump FepA. In contrast, CTAB tolerance was associated with mutations in sugR, which regulates the expression of the efflux pumps SugE1 and SugE2. L. monocytogenes strains lacking either FepA or SugE1/2 could still acquire tolerance toward BAC and CTAB. Genomic analysis revealed that the overproduction of the remaining efflux system could compensate for the deleted one, and even in the absence of both efflux systems, tolerant strains could be isolated, which all carried mutations in the diacylglycerol kinase-encoding gene lmo1753 (dgkB). DgkB converts diacylglycerol to phosphatidic acid, which is subsequently reused for the synthesis of phospholipids, suggesting that alterations in membrane composition could be the third adaptation mechanism. IMPORTANCE Survival and proliferation of Listeria monocytogenes in the food industry are ongoing concerns, and while there are various countermeasures to combat contamination of food products, the pathogen still successfully manages to withstand the harsh conditions present in food-processing facilities, resulting in reoccurring outbreaks, subsequent infection, and disease. To counteract the spread of L. monocytogenes, it is crucial to understand and elucidate the underlying mechanism that permits their successful evasion. We present various adaptation mechanisms of L. monocytogenes to withstand two important quaternary ammonium compounds.

Prevention of horizontal transfer of laboratory plasmids to environmental bacteria: comparison of the effectiveness of a few disinfection approaches to degrade DNA

The routine work of any molecular biology laboratory includes the daily use of microorganisms, including strains of E. coli, transformed with a variety of plasmids expressing at least one antibiotic resistance gene (ARG). Therefore, to avoid the accidental release of ARGs into environmental water, methods for disinfection of liquid laboratory waste must be effective in destroying nucleic acids. In support of this recommendation, the origin of replication of Enterobacteriaceae plasmids has been detected in strains of non-Enterobacteriaceae bacteria isolated from wastewater from laboratories and research institutes, suggesting that interspecific transfer of laboratory plasmids had occurred. Using quantitative polymerase chain reaction, we determined the decimal reduction value (D value, expressed as concentration of disinfectant or length of physical treatment) of several decontamination methods for their DNA degradation effect on cultures of E. coli Top10 transformed with a kanamycin resistant plasmid (pET28A + or pEGFP-C2). The estimated D values were 0.7 M for sulfuric acid, 6.3% for a commercial P3 disinfectant, 25 min for steam sterilization at 121 °C, and 49 min for disinfection by UVC. A 20-min treatment of bacteria cultures with a final concentration of 1-10% sodium hypochlorite was found to be ineffective in completely destroying a bacteria plasmid gene marker (coding for the pBR322 origin of replication). Residual DNA from NaClO-treated cells was 60%, while it decreased under 10% using the commercial disinfectant P3 diluted at 5%. As the degradation was incomplete in both cases, we recommend avoiding discharge of disinfected liquid waste to wastewater (even after chemical neutralization) without additional plasmid destruction treatment, to prevent horizontal transfer of laboratory ARGs to environmental bacteria.

Association of resistance to quaternary ammonium compounds and organic acids with genetic markers and their relationship to Escherichia coli serogroup

Sanitizer resistance is being extensively investigated due to the potential for bacterial survival and cross-resistance with other antimicrobials. Similarly, organic acids are being used due to their microbial inactivation potential as well as being generally recognized as safe (GRAS). However, little is known about associations of genetic and phenotypic factors in Escherichia coli related to resistance to sanitizers and organic acids as well as differences between "Top 7" serogroups. Therefore, we investigated 746 E. coli isolates for resistance to lactic acid and two commercial sanitizers based on quaternary ammonium and peracetic acid. Furthermore, we correlated resistance to several genetic markers and investigated 44 isolates using Whole Genome Sequencing. Results indicate that factors related to motility, biofilm formation, and Locus of Heat Resistance played a role in resistance to sanitizers and lactic acid. In addition, Top 7 serogroups significantly differed in sanitizer and acid resistance, with O157 being the most consistently resistant to all treatments. Finally, mutations in rpoA, rpoC, and rpoS genes were observed, in addition to presence of a Gad gene with alpha-toxin formation in all O121 and O145 isolates, which may be related to increased resistance of these serogroups to the acids used in the present study.

Further Study of the Polar Group's Influence on the Antibacterial Activity of the 3-Substituted Quinuclidine Salts with Long Alkyl Chains

Quaternary ammonium compounds (QACs) are among the most potent antimicrobial agents increasingly used by humans as disinfectants, antiseptics, surfactants, and biological dyes. As reports of bacterial co- and cross-resistance to QACs and their toxicity have emerged in recent years, new attempts are being made to develop soft QACs by introducing hydrolyzable groups that allow their controlled degradation. However, the development of such compounds has been hindered by the structural features that affect the bioactivity of QACs, one of them being polarity of the substituent near the quaternary center. To further investigate the influence of the polar group on the bioactivity of QACs, we synthesized 3-aminoquinuclidine salts for comparison with their structural analogues, 3-acetamidoquinuclidines. We found that the less polar amino-substituted compounds exhibited improved antibacterial activity over their more polar amide analogues. In addition to their better minimum inhibitory concentrations, the candidates were excellent at suppressing Staphylococcus aureus biofilm formation and killing bacteria almost immediately, as shown by the flow cytometry measurements. In addition, two candidates, namely QNH2-C14 and QNH2-C16, effectively suppressed bacterial growth even at concentrations below the MIC. QNH2-C14 was particularly effective at subinhibitory concentrations, inhibiting bacterial growth for up to 6 h. In addition, we found that the compounds targeted the bacterial membrane, leading to its perforation and subsequent cell death. Their low toxicity to human cells and low potential to develop bacterial resistance suggest that these compounds could serve as a basis for the development of new QACs.

Quaternary ammonium disinfectants and antiseptics: tolerance, resistance and potential impact on antibiotic resistance

BACKGROUND

Due to the substantial increase in the use of disinfectants containing quaternary ammonion compounds (QACs) in healthcare and community settings during the COVID-19 pandemic, there is increased concern that heavy use might cause bacteria to develop resistance to QACs or contribute to antibiotic resistance. The purpose of this review is to briefly discuss the mechanisms of QAC tolerance and resistance, laboratory-based evidence of tolerance and resistance, their occurrence in healthcare and other real-world settings, and the possible impact of QAC use on antibiotic resistance.

METHODS

A literature search was conducted using the PubMed database. The search was limited to English language articles dealing with tolerance or resistance to QACs present in disinfectants or antiseptics, and potential impact on antibiotic resistance. The review covered the period from 2000 to mid-Jan 2023.

RESULTS

Mechanisms of QAC tolerance or resistance include innate bacterial cell wall structure, changes in cell membrane structure and function, efflux pumps, biofilm formation, and QAC degradation. In vitro studies have helped elucidate how bacteria can develop tolerance or resistance to QACs and antibiotics. While relatively uncommon, multiple episodes of contaminated in-use disinfectants and antiseptics, which are often due to inappropriate use of products, have caused outbreaks of healthcare-associated infections. Several studies have identified a correlation between benzalkonium chloride (BAC) tolerance and clinically-defined antibiotic resistance. The occurrence of mobile genetic determinants carrying multiple genes that encode for QAC or antibiotic tolerance raises the concern that widespread QAC use might facilitate the emergence of antibiotic resistance. Despite some evidence from laboratory-based studies, there is insufficient evidence in real-world settings to conclude that frequent use of QAC disinfectants and antiseptics has promoted widespread emergence of antibiotic resistance.

CONCLUSIONS

Laboratory studies have identified multiple mechanisms by which bacteria can develop tolerance or resistance to QACs and antibiotics. De novo development of tolerance or resistance in real-world settings is uncommon. Increased attention to proper use of disinfectants is needed to prevent contamination of QAC disinfectants. Additional research is needed to answer many questions and concerns related to use of QAC disinfectants and their potential impact on antibiotic resistance.

Quaternary ammonium compounds promoted anoxic sludge granulation and altered propagation risk of intracellular and extracellular antibiotic resistance genes

Surfactants could influence sludge morphology and disinfectants were linked to antibiotic resistance genes (ARGs). Thus, the response of activated sludge and ARGs to long-term quaternary ammonium compounds (QACs) exposure required further investigation, which is a popular surfactant and disinfectant. Here, three sequencing batch reactors were fed with 5 mg/L most frequently detected QACs (dodecyl trimethyl ammonium chloride (ATMAC C12), dodecyl benzyl dimethyl ammonium chloride (BAC C12) and didodecyl dimethyl ammonium chloride (DADMAC C12)) for 180 d. The long-term inhibitory effect on denitrification ranked: DADMAC C12 > BAC C12 > ATMAC C12. Besides, obvious granular sludge promoted by the increase of α-Helix/(β-Sheet + Random coil) appeared in DADMAC C12 system. Moreover, intracellular ARGs increased when denitrification systems encountered QACs acutely but decreased in systems chronically exposed to QACs. Although replication and repair metabolism in ATMAC C12 system was higher, ATMAC C12 significantly promoted proliferation of extracellular ARGs. It was noteworthy that the propagation risk of extracellular ARGs in sludge increased significantly during sludge granulation process, and intracellular sul2 genes in sludge and water both increased with the granular diameter in DADMAC C12 system. The universal utilization of QACs may enhance antibiotic resistance of bacteria in wastewater treatment plants, deserving more attention.

Resolving the "health vs environment" dilemma with sustainable disinfection during the COVID-19 pandemic

The overuse of disinfection during the COVID-19 pandemic leads to an emerging "health versus environment" dilemma that humans have to face. Irresponsible and unnecessary disinfection should be avoided, while comprehensive evaluation of the health and environmental impacts of different disinfectants is urgently needed. From this discussion, we reach a tentative conclusion that hydrogen peroxide is a green disinfectant. Its on-demand production enables a circular economy model to solve the storage issues. Water, oxygen, and electrons are the only feedstock to generate H2O2. Upon completion of disinfection, H2O2 is rapidly converted back into water and oxygen. This model adopts several principles of green chemistry to ensure overall sustainability along the three stages of its whole life cycle, i.e., production, disinfection, and decomposition. Physical methods, particularly UV irradiation, also provide sustainable disinfection with minimal health and environmental impacts.

Organic Compounds and Antibiotic-Resistant Bacteria Behavior in Greywater Treated by a Constructed Wetland

Laundry greywater is considered as an alternative source of non-potable water, as it is discharged in approximately 70% of homes. Because this water contains compounds such as biodegradable and recalcitrant organic matter, surfactants, and microbiological compounds, it must be treated prior to reuse. Therefore, the objective of this study was to assess the behavior of organic matter and antibiotic-resistant bacteria (ARB) in greywater treated by a constructed wetland (CW). The results show that the organic matter removal efficiencies were 67.19%, 50.15%, and 63.57% for biological oxygen demand (BOD5), chemical oxygen demand (COD) and total organic carbon (TOC), respectively; these efficiencies were not significant (p > 0.05). In addition, the CW allows the distribution of TOC and ionic compounds in the fractions below 1000 Da to increase by 5.03% and 13.05%, respectively. Meanwhile, the treatment of microbiological compounds generated non-significant removals (p > 0.05), along with increases in bacteria resistant to the antibiotics ciprofloxacin (CIP) and ceftriaxone (CTX) of 36.34%, and 40.79%, respectively. In addition, a strong association between ARB to CIP, CTX, cationic and non-ionic surfactants was determined, indicating the role of surfactants in ARB selection. It is suggested that disinfection systems should be employed prior to the reuse of the treated water.

Accelerated spread of antibiotic resistance genes (ARGs) induced by non-antibiotic conditions: Roles and mechanisms

The global spread of antibiotic resistance genes (ARGs) has wreaked havoc with the treatment efficiency of antibiotics and, ultimately, anti-microbial chemotherapy, and has been conventionally attributed to the abuse and misuse of antibiotics. However, the ancient ARGs have alterative functions in bacterial physiology and thus they could be co-regulated by non-antibiotic conditions. Recent research has demonstrated that many non-antibiotic chemicals such as microplastics, metallic nanoparticles and non-antibiotic drugs, as well as some non-antibiotic conditions, can accelerate the dissemination of ARGs. These results suggested that the role of antibiotics might have been previously overestimated whereas the effects of non-antibiotic conditions were possibly ignored. Thus, in an attempt to fully understand the fate and behavior of ARGs in the eco-system, it is urgent to critically highlight the role and mechanisms of non-antibiotic chemicals and related environmental factors in the spread of ARGs. To this end, this timely review assessed the evolution of ARGs, especially its function alteration, summarized the non-antibiotic chemicals promoting the spread of ARGs, evaluated the non-antibiotic conditions related to ARG dissemination and analyzed the molecular mechanisms related to spread of ARGs induced by the non-antibiotic factors. Finally, this review then provided several critical perspectives for future research.