Bacterial population changes in hospital effluent treatment plant in central India

Are hospital wastewater treatment plants a source of new resistant bacterial strains?

To understand which type of hospital waste may contain the highest amount of antibiotic resistant microorganisms that could be released into the environment, the bacterial strains entering and leaving a hospital wastewater treatment plant (HWTP) were identified and tested for their antibiotic susceptibility. To achieve this goal, samples were collected from three separate sites, inlet and outlet wastewater positions, and sludge generated in a septic tank. After microbiological characterization according to APHA, AWWA, and WEF protocols, the relative susceptibility of the bacterial strains to various antibiotic agents was assessed according to the Clinical and Laboratory Standards Institute guidelines, to determine whether there were higher numbers of resistant bacterial strains in the inlet wastewater sample than in the outlet wastewater and sludge samples. The results showed more antibiotic resistant bacteria in the sludge than in the inlet wastewater, and that the Enterobacteriaceae family was the predominant species in the collected samples. The most antibiotic-resistant families were found to be Streptococcacea and non-Enterobacteriaceae. Some bacterial strains were resistant to all the tested antibiotics. We conclude that the studied HWTP can be considered a source of resistant bacterial strains. It is suggested that outlet water and sludge generated in HWTPs should be monitored, and that efficient treatment to eliminate all bacteria from the different types of hospital waste released into the environment is adopted.

An overview on the prevalence and potential impact of antimicrobials and antimicrobial resistance in the aquatic environment of India

India at present is one of the leading countries in antimicrobial drug production and use, leading to increasing antimicrobial resistance (AMR) and public health problems. Attention has mainly been focused on the human and food animals' contribution to AMR neglecting the potential contribution of the perceptibly degraded aquatic environment in India. The paper reviews the available published literature in India on the prevalence of antimicrobial residues and their dissemination pathways in wastewater of pharmaceutical industries, sewage treatment plants, hospitals, riverine, community pond water, and groundwater. The prevalence of antimicrobial residue concentration, pathogenic and non-pathogenic bacteria antimicrobial resistant bacteria (ARB), their drug resistance levels, and their specific antimicrobial resistant genes (ARGs) occurring in various water matrices of India have been comprehensively depicted from existing literature. The concentration of some widely used antimicrobials recorded from the sewage treatment plants and hospital wastewater and rivers in India has been compared with other countries. The ecotoxicological risk posed by these antimicrobials in the various water matrices in India indicated high hazard quotient (HQ) values for pharmaceutical effluents, hospital effluents, and river water. The degraded aquatic environment exhibited the selection of a wide array of co-existent resistant genes for antibiotics and metals. The review revealed improper use of antibiotics and inadequate wastewater treatment as major drivers of AMR contaminating water bodies in India and suggestion for containing the challenges posed by AMR in India has been proposed.

Hospital wastewater treatment methods and its impact on human health and environments

The scientific development and economic advances have led to the identification of many pathogenic agents in hospital effluents. Hospital wastewaters are qualitatively similar to municipal wastewaters, with the difference that these wastewaters contain toxic and infectious substances and compounds that can be dangerous for the health of the environment, employees of these centers, and the entire community. Therefore, in the last few years, it has been emphasized that all hospitals and medical and health centers should have a treatment facility for their produced wastewater so that the health of the society and people is not threatened. An issue that is not paid attention to has become one of the environmental problems and concerns of the world today. The present study focused on the investigate hospital wastewater treatment methods and its impact on human health and the environment. In this narrative study, the first literature search was performed with four hundred and twenty-three articles were retrieved based on PubMed, Elsevier, Web of science, Spring, and Google Scholar databases. The results of this study showed that wastewater from hospitals and medical centers can play a significant impress in polluting soil and aquatic environments and spreading infectious diseases. According to the mentioned contents, collection and treatment of hospital wastewater is essential. In addition, if hospital wastewater enters the wastewater collection network without knowing its characteristics or with incomplete treatment and finally enters the municipal wastewater treatment plant. It causes many problems, including disturbing the balance of the biological system of the treatment plant. Purification and disposal of hospital wastewater is considered a vital action based on environmental standards. The results of this study also showed that the treatment methods of this type of hospital wastewater can play a significant role in reducing the spread of diseases caused by hospital wastewater treatment, including infectious diseases. The results of this study can be very useful for politicians, the managers of the Ministry of Energy and Health and the Environmental Organization in choosing the appropriate methods and process to reduce hospital wastewater and increase the efficiency of hospital wastewater treatment plants.

Antimicrobial photodynamic inactivation of wastewater microorganisms by halogenated indole derivative capped zinc oxide

Novel 5-bromoindole (5B)-capped zinc oxide (ZnO) nanoparticles (5BZN) were synthesized to improve the antibacterial, antibiofilm, and disinfection processes for the control of microorganisms in wastewater treatment. When exposed to 5BZN, the biofilm density and cell attachment were reduced dramatically, as measured by scanning electron microscopy (SEM). The 5BZN were also investigated for photodynamic treatment of multidrug-resistant (MDR) bacteria and toxicity. The combination of 5B and ZnO exhibited strong antibacterial and antibiofilm activities against MDR bacteria even at low doses (20 μg/mL). After 12.5 mW/cm² blue LED irradiation, the composite 5BZN showed superior photodynamic inactivation of two wastewater MDR, Enterobacter tabaci E2 and Klebsiella quasipneumoniae SC3, with cell densities reduced by 3.9 log CFU/mL and 4.7 log CFU/mL, respectively, after 120 min. The mechanism of bacterial inactivation was studied using a scavenging investigation, and H₂O₂ was identified mainly as the reactive species for bacterial inactivation. The 5BZN exhibited higher photodynamic inactivation towards the total coliform bacteria in wastewater effluents under a blue LED light intensity of 12.5 mW/cm² with almost complete inactivation of the coliform bacteria cells within 40 min. Furthermore, when 5BZN (100 mg/L) was added to the reactor, the level of tetracycline antibiotic degradation was increased by 63.6% after 120 min. The toxicity test, animal model nematode studies and seed germination assays, showed that 5BZN is harmless, highlighting its tremendous potential as a self-healing agent in large-scale photodynamic disinfection processes.

Occurrence and anti-microbial susceptibility pattern of extended spectrum beta-lactamase producing Enterobacteriaceae in governmental hospitals wastewater in Addis Ababa, Ethiopia

Background

Worldwide, come out and dissemination of extended-spectrum beta-lactamases (ESBLs) producing Enterobacteriaceae has been warning the efficacy of antibiotics to treat an infection. Hospital wastewaters were a reservoir of such kind of resistant bacteria. Currently, the predominant antibiotics used for the treatment of hospitalized patients infected by Gram-negative bacteria are the β-lactam antibiotics. Therefore, it is an important source to investigate the magnitude of ESBLs producing bacteria and their antimicrobial susceptibility pattern. This study aimed to determine the occurrence of ESBLs producing Enterobacteriaceae (ESBLs-pE) and their antibiotic susceptibility pattern in wastewater released from five governmental hospitals in Addis Ababa, Ethiopia.

Methods

A cross-sectional study was conducted from April 1 to May 31, 2020. A total of 100 wastewaters were collected from five governmental hospitals in Addis Ababa using a grap-sampling technique. All Enterobacteriaceae were screened for ESBLs production using cefotaxime and ceftazidime as per 29th CLSI guideline. Each screen positive for ESBLs production was confirmed by the combination disk method (CDT) and their antibiotic susceptibility pattern was done using the Kirby–Bauer disk diffusion method on Muller Hinton agar (MHA). Data were entered and summarized using SPSS version 20 software.

Results

Of all Enterobacteriaceae, 48.3% were confirmed ESBLs-pE. The highest ratio of ESBLs-PE was observed in the adult ward (66.7%) and laundry unit effluent (58.8%). The highest ESBL producers were E. coli (21.8%) and K. pneumoniae (4.8%). The most elevated resistance level of ESBL producers were observed to cefotaxime (95.8%) and amoxicillin/clavunalate (93%). 64% of tested Enterobacteriaceae isolates were multi drug resistant (MDR).

Conclusions

Higher magnitude of MDR and ESBLs-pE were present in the hospital wastewater. The majority of them were in the adult ward and laundry unit effluents. The most frequent ESBLs-pE was among E.coli and K. pneumoniae. Hence, Consistent infection prevention and control procedures should be in practice at each ward/unit.

Shotgun metagenomic analysis reveals the prevalence of antibiotic resistance genes and mobile genetic elements in full scale hospital wastewater treatment plants

Wastewater treatment plants are considered as hotspots of emerging antimicrobial genes and mobile genetic elements. We used a shotgun metagenomic approach to examine the wide-spectrum profiles of ARGs (antibiotic resistance genes) and MGEs (mobile genetic elements) in activated sludge samples from two different hospital trains at the wastewater treatment plants (WWTPs) in Daegu, South Korea. The influent activated sludge and effluent of two trains (six samples in total) at WWTPs receiving domestic sewage wastewater (SWW) and hospital wastewater (HWW) samples collected at multiple periods were subjected to high throughput 16S rRNA metagenome sequencing for microbial community diversity. Cloacibacterium caeni and Lewinella nigricans were predominant in SWW effluents, while Bacillus subtilis and Staphylococcus epidermidis were predominant in HWW effluents based on the Miseq platform. Totally, 20,011 reads and 28,545 metagenomic sequence reads were assigned to 25 known ARG types in the SWW2 and HWW5 samples, respectively. The higher abundance of ARGs, including multidrug resistance (>53%, MDR), macrolide-lincosamide-streptogramin (>9%, MLS), beta-lactam (>3.3%), bacitracin (>4.4%), and tetracycline (>3.4%), confirmed the use of these antibiotics in human medicine. In total, 190 subtypes belonging to 23 antibiotic classes were detected in both SWW2 and HWW5 samples. RpoB2, MacB, and multidrug (MDR) ABC transporter shared the maximum matched genes in both activated sludge samples. The high abundance of MGEs, such as a gene transfer agent (GTA) (four times higher), transposable elements (1.6 times higher), plasmid related functions (3.8 times higher), and phages (two times higher) in HWW5 than in SWW2, revealed a risk of horizontal gene transfer in HWW. Domestic wastewater from hospital patients also influenced the abundance of ARGs and MGEs in the activated sludge process.

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

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

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

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

Nanoparticles impact in biomedical waste management

Effectual management of biomedical waste is obligatory for healthy human beings and for a safe environment. Mismanagement of biomedical waste is a community health problem. Safe and persistent methods for the management of biomedical waste are of vital importance. This article reviews the classification of biomedical waste, sources, colour-coding system of biomedical waste and salient features of biomedical waste rules in 2016, and the future prospective of nanoparticles. The untreated disposal of biomedical waste is associated with a huge amount of risk, so the efficient treatment for biomedical waste is most imperative. The review also highlights the current methods for disposal of biomedical waste, biological treatments given to biomedical waste water in the effluent treatment plant, and impacts due to the current method. Management of biomedical waste is a great challenge in developed and developing countries. To manage the biomedical waste there is a need for cost-effective, ecofriendly and less contaminating approaches for a greener and safe environment. The awareness regarding waste management is of great interest not only for the community but also for associated employees.

Reduction of erythromycin resistance gene erm(F) and class 1 integron-integrase genes in wastewater by Bardenpho treatment

Wastewaters routinely contain antibiotic-resistant bacteria (ARB) and genes (ARG) that are removed to a varying degree during wastewater treatment. This study investigated the removal of the erythromycin ribosome methylase class F (erm(F)) and class 1 integron-integrase (intI1) genes at each stage from two water resource recovery facilities in southern Arizona. Although genes were significantly reduced by Bardenpho treatment, erm(F) and intI1 were still observed in ≥ 9 and 7 out of 12 secondary effluent samples. Primary processes via sedimentation or dissolved air flotation, as well as chlorine disinfection, did not significantly impact erm(F) and intI1 concentrations. Therefore, Bardenpho treatment was critical to reduce erm(F) and intI1. Concentrations of erm(F) and intI1 were compared with each other and other markers for anthropogenic pollution. Results from this study support intI1 as one suitable marker to measure erythromycin resistance genes in wastewater, as intI1 was found at higher concentrations, persisted more throughout treatment, and correlated with erm(F) at nearly every treatment stage. PRACTITIONER POINTS: Bardenpho treatment was the key process responsible for the reduction of intI1 and erm(F) genes during wastewater treatment. Primary treatment and chlorine disinfection did not impact erm(F) and intI1 gene concentrations. The intI1 gene is a suitable marker for measuring erm(F) genes in wastewater.

Treatment enhances the prevalence of antibiotic-resistant bacteria and antibiotic resistance genes in the wastewater of Sri Lanka, and India

Wastewater treatment plants (WWTPs) are being debated for being the hot spots for the development of antibiotic resistance in pathogenic microbial communities. We observed the prevalence of antibiotic-resistant bacteria (ARB), antibiotic resistance genes (ARG), and multidrug resistance (MDR) in two municipal WWTPs and one hospital WWTP in Western and Southern Sri Lanka, and compared the results with particular reference to Indian and the World scenario to trace the imprints of treatment on ARB and ARG. Result suggests that although wastewater treatment resulted in higher than 1.06 log Escherichia coli (E. coli) reduction at all WWTPs, yet the percent of E. coli resistant to most of the antibiotics increased from influent to effluent. Higher prevalence of ARB, ARG, and MDR were noted in hospital WWTP owing to the higher antibiotic concentrations used and excreted by the patients. With reference to India, the WWTPs in Sri Lanka showed more ARB and a consistent increase in its percentages after the treatment but were less resistant to Fluoroquinolone (FQ). E. coli strains isolated from each location of both countries showed multidrug resistance, which has increased after the treatment and was strongly correlated with FQ in every WWTP. Resistant genes for Fluoroquinolone (FQ) (aac-(6')-1b-cr, qnrB, qnrS), β-lactams (ampC), and sulphonamides (sul1) were common in all the wastewaters except additional parC gene in the hospital effluent of Sri Lanka, implying much higher resistance for quinolones, especially for Ciprofloxacin. Multivariate statistical treatments suggest that effluent showed higher loadings and association for MDR/ARB, where pH change and more extensive interaction with metals during the treatment processes seem to have profound effects.

Photo-inactivation of bacteria in hospital effluent via thiolated iron-doped nanoceria

Hospital wastewater is a major contributor of disease-causing microbes and the emergence of antibiotic resistant bacteria. In this study, thiolated iron-doped nanoceria was synthesised and tested for killing of microbes from hospital effluent. These particles were designed to inhibit the efflux pumps of the bacteria found in hospital effluent with further ability to activate in visible light via iron doping thus generating tunable amount of reactive oxygen species (ROS). The quantum yield of the ROS generated by the nanoceria was 0.67 while the ROS types produced were singlet oxygen (36%), hydroxyl radical (31%) and hydroxyl ions (32%), respectively. The particles were initially synthesised through green route using Foeniculum vulgare seeds extract and were annealed at 200°C and further coated with thiolated chitosan to enhance the solubility and efflux pump inhibition. X-ray diffraction confirmed the polycrystalline nature of nanoparticles and uniform spherical shape with 30 nm size, confirmed by scanning electron microscope. The nanoparticles exhibited 100% bactericidal activity at 100 µg/mL against all the isolated bacteria. The enhanced bactericidal effect of iron-doped nanoceria could be attributed to efflux inhibition via thiolated chitosan as well as the production of ROS upon illumination in visible light, causing oxidative stress against microbes found in hospital effluent.

Hospital wastewater treatment scenario around the globe

Wastewaters generated from hospitals contain pharmaceuticals residues, pathogens, chemical reagents, radionuclide, and other harmful matter. The wastewater characteristics, quantity, and handling methods have not only variations among countries but also within a country. Some hazardous substances of hospital wastewaters (HWWs) may have a regulatory status and should be treated accordingly while others have characteristics similar to that of domestic sewage. At a global level, guidelines do exist for treatment of these HWWs. But literatures have shown that legislation has various loopholes in implementation. This chapter outlines the current status of management and handling of HWWs around the major industrial hubs of worlds in two categories of developed (the United States, United Kingdom, and Europe) and developing (India, China, Iran, and Bangladesh) countries. Various literatures and guidelines of these countries have been referred which mainly highlight different treatment scenarios and status of coverage of HWW management guidelines.

Treatment of hospital laundry wastewater by UV/H2O2 process

Hospitals consume a large volume of water to carry out their activities and, hence, generate a large volume of effluent that is commonly discharged into the local sewage system without any treatment. Among the various sectors of healthcare facilities, the laundry is responsible for the majority of water consumption and generates a highly complex effluent. Although several advanced oxidation processes (AOPs) are currently under investigation on the degradation of a variety of contaminants, few of them are based on real wastewater samples. In this paper, the UV/H₂O₂ AOP was evaluated on the treatment of a hospital laundry wastewater, after the application of a physicochemical pretreatment composed of coagulation-flocculation and anthracite filtration. For the UV/H₂O₂ process, a photoreactor equipped with a low-pressure UV-C lamp was used and the effects of initial pH and [H₂O₂]/chemical oxygen demand (COD) ratio on COD removal were investigated through a randomized factorial block design that considered the batches of effluent as blocks. The results indicated that the initial pH had no significant effect on the COD removal, and the process was favored by the increase in [H₂O₂]/COD ratio. Color and turbidity were satisfactorily reduced after the application of the physicochemical pretreatment, and COD was completely removed by the UV/H₂O₂ process under suitable conditions. The results of this study show that the UV/H₂O₂ AOP is a promising candidate for hospital laundry wastewater treatment and should be explored to enable wastewater reuse in the washing process.

Review on fate and mechanism of removal of pharmaceutical pollutants from wastewater using biological approach

Due to research advancement and discoveries in the field of medical science, maintains and provides better human health and safer life, which lead to high demand for production of pharmaceutical compounds with a concomitant increase in population. These pharmaceutical (biologically active) compounds were not fully metabolized by the body and excreted out in wastewater. This micro-pollutant remains unchanged during wastewater treatment plant operation and enters into the receiving environment via the discharge of treated water. Persistence of pharmaceutical compounds in both surface and ground waters becomes a major concern due to their potential eco-toxicity. Pharmaceuticals (emerging micro-pollutants) deteriorate the water quality and impart a toxic effect on living organisms. Therefore, from last two decades, plenty of studies were conducted on the occurrence, impact, and removal of pharmaceutical residues from the environment. This review provides an overview on the fate and removal of pharmaceutical compounds via biological treatment process.

Survival of antibacterial resistance microbes in hospital-generated recycled wastewater

Hospital wastewater has the potential to be a threat to the hospital environment as it can contain pathogenic bacteria that may facilitate the resistant nature of organisms within effluent or water treatment plants. The recycling of hospital wastewater should have good quality. This study was carried out to highlight the incidence of antibiotic resistant bacteria in hospital-generated recycled water. This study was conducted in a tertiary care teaching hospital during June 2013-June 2014. One hundred and forty wastewater samples were aseptically collected at different stages in the recycling plant. The samples were processed within 2 hours following standard procedures for identification of bacteria and the pathogenic bacteria were isolated. The mostly identified pathogens were Staphylococcus aureus (11.42%), Pseudomonas aeruginosa (9.28%), Enterococcus faecalis (10%) and Bacillus subtilis (8.57%) which were removed by treatment, but Escherichia coli (16.42%), Klebsiella pneumonia (8.57%), and Proteus mirabilis (11.42%) survived in the final sedimentation tank (lagoon) from where this water will be used for gardening purposes. An antibiogram study showed these pathogens were resistant to first-line antibiotics. Effluent treatment plants in hospitals should be monitored for the fulfillment of the guidelines and quality control of treated water to stop the emergence of multi-drug resistant bacteria in the hospital environment.

Implementation of a multi-variable regression analysis in the assessment of the generation rate and composition of hospital solid waste for the design of a sustainable management system in developing countries

Forecasting of hospital solid waste generation is a critical challenge for future planning. The composition and generation rate of hospital solid waste in hospital units was the field where the proposed methodology of the present article was applied in order to validate the results and secure the outcomes of the management plan in national hospitals. A set of three multiple-variable regression models has been derived for estimating the daily total hospital waste, general hospital waste, and total hazardous waste as a function of number of inpatients, number of total patients, and number of beds. The application of several key indicators and validation procedures indicates the high significance and reliability of the developed models in predicting the hospital solid waste of any hospital. Methodology data were drawn from existent scientific literature. Also, useful raw data were retrieved from international organisations and the investigated hospitals' personnel. The primal generation outcomes are compared with other local hospitals and also with hospitals from other countries. The main outcome, which is the developed model results, are presented and analysed thoroughly. The goal is this model to act as leverage in the discussions among governmental authorities on the implementation of a national plan for safe hospital waste management in Palestine.

What have we learned from worldwide experiences on the management and treatment of hospital effluent? - an overview and a discussion on perspectives

This study overviews lessons learned from experimental investigations on dedicated treatment systems of hospital effluent carried out worldwide in the last twenty years. It includes 48 peer reviewed papers from 1995 to 2015 assessing the efficacy of different treatment levels (preliminary, primary, secondary and polishing) of hospital wastewater in removing a wide spectrum of pharmaceutical compounds as well as conventional contaminants. Moreover, it highlights the rationale and the reasons for each study: reducing the discharge of micropollutants in surface water, improving existing wastewater treatment technologies and reducing the risk of spread of pathogens causing endemic diseases and finally, it offers a critical analysis of the conclusions and suggestions of each study. The most investigated technologies are membrane bioreactors equipped with ultrafiltration membranes in the secondary step, ozonation followed by activated carbon filtration (in powder and in granules) in the polishing step. Interesting research projects deal with photo-Fenton processes acting as primary treatments to enhance biodegradation before biological treatment, and as a polishing step, thus further reducing micro-contaminant occurrence. Investment and operational costs are also presented and discussed for the different treatment technologies tested worldwide, in particular membrane bioreactors and various advanced oxidation processes. This study also discusses the need for further research to evaluate toxicity resulting from advanced oxidation processes as well as the need to develop an accurate feasibility study that encompasses technical, ecotoxicological and economic aspects to identify the best available treatment in the different situations from a global view point.

Extended-spectrum β-lactamase producing Escherichia coli in hospital wastewaters and sewage treatment plants in Queensland, Australia

We investigated the prevalence of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli in untreated hospital wastewaters and 2 sewage treatment plants (STPs). A collection of 252 ESBL-producing E. coli isolates from hospital wastewater and STPs were typed and tested for resistance to 17 antimicrobial agents and for the presence of integron-associated integrases (intI gene) and ESBL genes. Eighty-nine percent (n = 176) of the ESBL-producing E. coli strains from hospital wastewater were found in more than 1 sample (common types), with 1 common type accounting for 35% of isolates, found in all samples. These strains were also resistant to up to 9 non-β-lactam antibiotics and showed the same pattern of resistance in all samples. More than 73% of the hospital wastewater isolates possessed SHV-type ESBL as opposed to isolates from STPs that carried only CTX-M-type ESBL genes. The prevalence of the intI gene did not differ between the sources of the isolates. Certain ESBL-producing E. coli were dominant in hospital wastewaters. These strains possessed β-lactamase genes that were different from isolates found in STPs. From a public health point of view, the presence of such a high level of ESBL-producing E. coli strains in hospital wastewaters is of great importance.

Dynamic assessment of the floc morphology, bacterial diversity, and integron content of an activated sludge reactor processing hospital effluent

The treatment of hospital effluents (HE) is a major concern, as they are suspected of disseminating drugs and antibiotic resistance determinants in the environment. In order to assess HE influence on wastewater treatment plant biomass, lab-scale conventional activated sludge systems (CAS) were continuously fed with real HE or urban effluent as a control. To gain insights into the main hurdles linked to HE treatment, we conducted a multiparameter study using classical physicochemical characterization, phase contrast and confocal laser scaning microscopy, and molecular biology (i.e., pyrosequencing) tools. HE caused erosion of floc structure and the production of extracellular polymeric substances attributed to the development of floc-forming bacteria. Adaptation of the sludge bacterial community to the HE characteristics, thus maintaining the purification performance of the biomass, was observed. Finally, the comparative metagenomic analysis of the CAS showed that HE treatment resulted in an increase of class 1 resistance integrons (RIs) and the introduction of Pseudomonas spp. into the bacterial community. HE treatment did not reduce the CAS process performance; nevertheless it increases the risk of dissemination into the environment of bacterial species and genetic determinants (RIs) involved in antibiotic resistance acquisition.

Detection and fate of antibiotic resistant bacteria in wastewater treatment plants: a review

Antibiotics are among the most successful group of pharmaceuticals used for human and veterinary therapy. However, large amounts of antibiotics are released into municipal wastewater due to incomplete metabolism in humans or due to disposal of unused antibiotics, which finally find their ways into different natural environmental compartments. The emergence and rapid spread of antibiotic resistant bacteria (ARB) has led to an increasing concern about the potential environmental and public health risks. ARB and antibiotic resistant genes (ARGs) have been detected extensively in wastewater samples. Available data show significantly higher proportion of antibiotic resistant bacteria contained in raw and treated wastewater relative to surface water. According to these studies, the conditions in wastewater treatment plants (WWTPs) are favourable for the proliferation of ARB. Moreover, another concern with regards to the presence of ARB and ARGs is their effective removal from sewage. This review gives an overview of the available data on the occurrence of ARB and ARGs and their fate in WWTPs, on the biological methods dealing with the detection of bacterial populations and their resistance genes, and highlights areas in need for further research studies.

Entrapped cell system for decentralized hospital wastewater treatment: inhibitory effect of disinfectants

This study aims to improve decentralized hospital wastewater treatment inhibited by disinfectants by using calcium alginate cell entrapment technique. The effects of disinfectant types (glutaraldehyde, povidone iodine (PI) and a potassium hydroxide solution) and disinfectant concentrations, cell entrapment conditions (cell-to-matrix ratios) and cell loadings were investigated. The batch experiments were conducted using synthetic wastewater with initial chemical oxygen demand (COD) of approximately 370 mg/L and acclimated activated sludge. Among three disinfectants, PI substantially affected the wastewater treatment efficiency (inhibition of 40%) while other disinfectants exhibited inhibition effects of less than 9%. The results also indicated that the entrapped cells obviously performed better than the free cells. The cell-to-matrix ratio of 1:20 (v/v) provided the highest treatment efficiency of 86% (inhibition of 9%) while the free cell system had inhibition of 47%. The system at the entrapped cell loading of 2000 mg/L performed the highest COD removal of 62% for ten-cycle sequencing batch operation. A scanning electron microscope image provided information on entrapped cell structure subjected to the disinfectant.

Pilot study of antimicrobial-resistant Escherichia coli in herring gulls (Larus argentatus) and wastewater in the northeastern United States

Wildlife may be an important reservoir of antibiotic-resistant bacteria and resistance genes. In this pilot study, the prevalence and patterns of antimicrobial resistance in Escherichia coli cultured from wild herring gull (Larus argentatus) feces and human wastewater at Cape Cod, Massachusetts, USA, was compared. Antimicrobial susceptibility was tested using Kirby-Bauer disk diffusion with seven antimicrobial agents. A high proportion of antimicrobial agent-resistant E. coli isolates (59.2%) were detected in wastewater samples compared with a lower prevalence of 17.5% in gull feces. In addition, there was a large proportion of isolates with intermediate susceptibility (93.0%) in gull feces. Although similar resistance patterns and shared resistance genes suggest possible wastewater contamination of the local environment, the relatively low frequency of resistance and high prevalence of intermediate susceptibility detected in E. coli cultured from gull feces depict a complex model of antimicrobial resistance among E. coli strains of wildlife origin.

Waste management in small hospitals: trouble for environment

Small hospitals are the grassroots for the big hospital structures, so proper waste management practices require to be initiated from there. Small hospitals contribute a lot in the health care facilities, but due to their poor waste management practices, they pose serious biomedical waste pollution. A survey was conducted with 13 focus questions collected from the 100 hospital present in Dehradun. Greater value of per day per bed waste was found among the small hospitals (178 g compared with 114 g in big hospitals), indicating unskilled waste management practices. Small hospitals do not follow the proper way for taking care of segregation of waste generated in the hospital, and most biomedical wastes were collected without segregation into infectious and noninfectious categories.

Decreased aztreonam susceptibility among Pseudomonas aeruginosa isolates from hospital effluent treatment system and clinical samples

The aim of this study was to evaluate the antimicrobial resistance patterns of Pseudomonas aeruginosa isolates from hospital wastewater treatment system (HWTS) and clinical specimens in a hospital of Rio de Janeiro city, Brazil. Forty-three isolates obtained from four of the five steps of the HWTS (n = 27) and clinical samples (n = 16) from patients were analyzed regarding their susceptibility profiles to 12 antibiotics. Clinical isolates exhibited higher resistance profiles to antibiotics than wastewater isolates. However, out of 27 isolates from sewage, 62.9% showed decreased susceptibility to aztreonam while 50% of clinical isolates were resistant to this antibiotic. Isolates were not detected at the chlorination stage but they were obtained from the following stage of the treatment revealing the capacity of regrowth after chlorinated sewage effluent. To our knowledge, this is the first study reporting decreased aztreonam susceptibility among P. aeruginosa isolates from a hospital wastewater treatment system. Further investigations are being conducted by our laboratory including a larger sampling program in order to obtain more data.

Medical Waste Management (MWM) in Dhaka, Bangladesh

This study reviews the current situation of medical waste management (MWM) and practices in Dhaka, Bangladesh, and examines possible solutions for further study. We collected existing information through an Internet survey using the keywords “Medical Waste Management,” “Health Hazards,” and “Bangladesh.” Medical wastes that are disposed in open places in the city are hazardous and toxics. Moreover, waste management and practices were found to be quite unsafe. Poor people collect the waste and sell it for recycling. Almost 85.0% of sharp injuries are caused between their usage and subsequent disposal. More than 20.0% of those who handle them encounter “stick” injuries. Another study showed that people use an average of 3.4 injections per year, in which 39.3% were administered with reused equipment for low level of management. There is no initiative for present MWM system by government or INGOs, and no concrete regulation has been established yet. Few researchers and INGOs have done little. Women and children are more vulnerable because they handle the waste with bare hands; exposing them to contamination with HIV or hepatitis B and other diseases. Therefore, it is essential to follow sound medical waste management system and take actions for this public health problem.

Count, identification and antimicrobial susceptibility of bacteria recovered from dental solid waste in Brazil

In Brazil, few studies on microbial content of dental solid waste and its antibiotic susceptibility are available. An effort has been made through this study to evaluate the hazardous status of dental solid waste, keeping in mind its possible role in cross-infection chain. Six samples of solid waste were collected at different times and seasons from three dental health services. The microbial content was evaluated in different culture media and atmospheric conditions, and the isolates were submitted to antibiotic susceptibility testing. A total of 766 bacterial strains were isolated and identified during the study period. Gram-positive cocci were the most frequent morphotype isolated (48.0%), followed by Gram-negative rods (46.2%), Gram-positive rods (5.0%), Gram-negative-cocci (0.4%), and Gram-positive coccobacillus (0.1%). Only two anaerobic bacteria were isolated (0.3%). The most frequently isolated species was Staphylococcus epidermidis (29.9%), followed by Stenotrophomonas maltophilia (8.2%), and Enterococcus faecalis (6.7%). High resistance rate to ampicillin was observed among Gram-negative rods (59.4%) and Gram-positive cocci (44.4%). For Gram-negative rods, high resistance was also noted to aztreonam (47.7%), cefotaxime (47.4%), ceftriaxone and cefazolin (43.7%), and ticarcillin-clavulanic acid (38.2%). Against Gram-positive cocci penicillin exhibit a higher resistance rate (45.0%), followed by ampicillin, erythromycin (27.2%), and tetracycline (22.0%). The present study demonstrated that several pathogenic bacteria are present in dental solid waste and can survive after 48 h from the waste generation time and harbor resistance profiles against several clinical recommended antibiotics.

Enumeration and characterization of antimicrobial-resistant Escherichia coli bacteria in effluent from municipal, hospital, and secondary treatment facility sources

We describe a modification of the most probable number (MPN) method for rapid enumeration of antimicrobial-resistant Escherichia coli bacteria in aqueous environmental samples. E. coli (total and antimicrobial-resistant) bacteria were enumerated in effluent samples from a hospital (n = 17) and municipal sewers upstream (n = 5) and downstream (n = 5) from the hospital, effluent samples from throughout the treatment process (n = 4), and treated effluent samples (n = 13). Effluent downstream from the hospital contained a higher proportion of antimicrobial-resistant E. coli than that upstream from the hospital. Wastewater treatment reduced the numbers of E. coli bacteria (total and antimicrobial resistant); however, antimicrobial-resistant E. coli was not eliminated, and E. coli resistant to cefotaxime (including extended-spectrum beta-lactamase [ESBL] producers), ciprofloxacin, and cefoxitin was present in treated effluent samples.

Application of MBR for hospital wastewater treatment in China

In China, the number of hospitals has increased to 19,712 in 2008, with the production of hospital wastewater reaching 1.29 × 10⁶ m³/d. Membrane bioreactor (MBR) technology presents a more efficient system at removing pathological microorganism compared with existing wastewater treatment systems. In the past 8 yr, over 50 MBR plants have been successfully built for hospital wastewater treatments, with the capacity ranging from 20 to 2000 m³/d. MBR can effectively save disinfectant consumption (chlorine addition can decrease to 1.0 mg/L), shorten the reaction time (approximately 1.5 min, 2.5-5% of conventional wastewater treatment process), and attain a good effect of inactivation of microorganism. Higher disinfection efficacy is achieved in MBR effluents at lower dose of disinfectant with less disinfection by-products (DBPs). Moreover, when capacity of MBR plants increases from 20 to 1000 m³/d, their operating cost decreases sharply.

Quantitative assessment of medical waste generation in the capital city of Bangladesh

There is a concern that mismanagement of medical waste in developing countries may be a significant risk factor for disease transmission. Quantitative estimation of medical waste generation is needed to estimate the potential risk and as a basis for any waste management plan. Dhaka City, the capital of Bangladesh, is an example of a major city in a developing country where there has been no rigorous estimation of medical waste generation based upon a thorough scientific study. These estimates were obtained by stringent weighing of waste in a carefully chosen, representative, sample of HCEs, including non-residential diagnostic centres. This study used a statistically designed sampling of waste generation in a broad range of Health Care Establishments (HCEs) to indicate that the amount of waste produced in Dhaka can be estimated to be 37+/-5 ton per day. The proportion of this waste that would be classified as hazardous waste by World Health Organisation (WHO) guidelines was found to be approximately 21%. The amount of waste, and the proportion of hazardous waste, was found to vary significantly with the size and type of HCE.

Comparison of antimicrobial resistance patterns between clinical and sewage isolates in a regional hospital in Taiwan

AIMS

To compare bacterial populations and antimicrobial resistance patterns between clinical and sewage isolates from a regional hospital in northern Taiwan. The dissemination of antibiotic-resistant bacteria from hospital compartments to the hospital sewage treatment plant was examined.

METHODS AND RESULTS

A total of 1020 clinical isolates and 435 sewage isolates were collected between July and September 2005. The percentages of Gram-negative bacteria from the clinical and sewage isolates were 87.2% and 91.0%, respectively (P = 0.033). Escherichia coli were the leading bacterial isolates in both groups. Antimicrobial susceptibility testing showed a significant difference (P < 0.001) in resistance to ampicillin (85.6% vs 94.1%), ampicillin/sulbactam (31.7% vs 55.4%), cefazolin (29.2% vs 71.5%) and cefuroxime (20.7% vs 61.9%) between clinical and sewage coliform isolates, respectively.

CONCLUSIONS

The sewage isolates had higher antimicrobial resistance rates than the clinical isolates from the same hospital.

SIGNIFICANCE AND IMPACT OF THE STUDY

The low efficacy of the hospital sewage treatment may contribute to the dissemination of multidrug resistant bacteria from this hospital compartments to the environment. Practices which limit the disposal of antimicrobial agents into the wastewater system may be the possible measure to prevent the selection of multidrug-resistant bacteria from sewage treatment plants.

Daily physicochemical, microbiological and ecotoxicological fluctuations of a hospital effluent according to technical and care activities

The problem of hospital effluents falls into the framework of hazardous substances due to the specific substances used and discharged for the most part into urban drainage networks without prior treatment. This in-depth study has led to greater understanding of the effluents discharged by hospitals. The experimental program implemented consisted in carrying out parallel sampling of the effluents of one hospital: a 24 h-average sample and 5 periodic samples corresponding to fractions of times and hospital activities. The samples were characterized by physicochemical, microbiological and ecotoxicological analyses. The results highlight that the effluents contained very little bacterial flora and a moderate organic pollution. However, a numerous of specific pollutants were detected: AOX, glutaraldehyde, free chlorine, detergents, Freon 113 as well as alcohols, acetone, formaldehyde, acetaldehyde, ammonium, phenols and several metals. The battery of bioassays showed that the effluents had a high level of ecotoxicity partly linked to particles in suspension and, that pollution fluctuated greatly during the day in connection with hospital activities. Finally, the PNEC values compared to the concentrations of pollutants dosed in the effluents highlighted that their toxicity was mainly due to several major pollutants, in particular free chlorine. Some hypotheses require additional experiments to be carried out. They concern: reactions of fermentations likely to occur in the drainage network and to form secondary toxic compounds, retention of chlorine by particles and physicochemical characterization of suspended solids.

Occurrence, fate and antibiotic resistance of fluoroquinolone antibacterials in hospital wastewaters in Hanoi, Vietnam

Occurrence and behavior of fluoroquinolone antibacterial agents (FQs) were investigated in hospital wastewaters in Hanoi, Vietnam. Hospital wastewater in Hanoi is usually not treated and this untreated wastewater is directly discharged into one of the wastewater channels of the city and eventually reaches the ambient aquatic environment. The concentrations of the FQs, ciprofloxacin (CIP) and norfloxacin (NOR) in six hospital wastewaters ranged from 1.1 to 44 and from 0.9 to 17 micrgl(-1), respectively. Total FQ loads to the city sewage system varied from 0.3 to 14 g d(-1). Additionally, the mass flows of CIP and NOR were investigated in the aqueous compartment in a small wastewater treatment facility of one hospital. The results showed that the FQ removal from the wastewater stream was between 80 and 85%, probably due to sorption on sewage sludge. Simultaneously, the numbers of Escherichia coli (E. coli) were measured and their resistance against CIP and NOR was evaluated by determining the minimum inhibitory concentration. Biological treatment lead to a 100-fold reduction in the number of E. coli but still more than a thousand E. coli colonies per 100ml of wastewater effluent reached the receiving water. The highest resistance was found in E. coli strains of raw wastewater and the lowest in isolates of treated wastewater effluent. Thus, wastewater treatment is an efficient barrier to decrease the residual FQ levels and the number of resistant bacteria entering ambient waters. Due to the lack of municipal wastewater treatment plants, the onsite treatment of hospital wastewater before discharging into municipal sewers should be considered as a viable option and consequently implemented.

Are antibiotic-resistant Pseudomonas aeruginosa isolated from hospitalised patients recovered in the hospital effluents?

Previous reports have studied the presence of antibiotic-resistant Pseudomonas aeruginosa strains in hospital wastewater without determination of their clonal relationship with the clinical strains of this species. The objectives of this study were to quantify the presence of P. aeruginosa in wastewater of our hospital, to determine their antibiotic-resistance profile and to potentially trace clinical antibiotic-resistant strains from patients to wastewater. Specimens were taken at the end of the wastewater network of our hospital just before the reject in the collective network of the town. Two specimens were taken each Monday during 12 weeks. All P. aeruginosa isolates recovered from hospitalised patients during the study period were collected. Genotyping of both clinical and wastewater isolates was determined by using pulsed-field gel electrophoresis (PFGE). The antibiotic-resistance profile of wastewater isolates was different from that of clinical isolates. The mechanisms involved in antibiotic resistance were different according to the origin of the isolates (wastewater versus human isolates). There was no common PFGE pattern in antibiotic-resistant P. aeruginosa from humans and wastewater. This study suggests that the risk of spread of antibiotic resistance in hospital wastewater is limited.

Pattern of medical waste management: existing scenario in Dhaka City, Bangladesh

Background

Medical waste is infectious and hazardous. It poses serious threats to environmental health and requires specific treatment and management prior to its final disposal. The problem is growing with an ever-increasing number of hospitals, clinics, and diagnostic laboratories in Dhaka City, Bangladesh. However, research on this critical issue has been very limited, and there is a serious dearth of information for planning. This paper seeks to document the handling practice of waste (e.g. collection, storage, transportation and disposal) along with the types and amount of wastes generated by Health Care Establishments (HCE). A total of 60 out of the existing 68 HCE in the study areas provided us with relevant information.

Methods

The methodology for this paper includes empirical field observation and field-level data collection through inventory, questionnaire survey and formal and informal interviews. A structured questionnaire was designed to collect information addressing the generation of different medical wastes according to amount and sources from different HCE. A number of in-depth interviews were arranged to enhance our understanding of previous and existing management practice of medical wastes. A number of specific questions were asked of nurses, hospital managers, doctors, and cleaners to elicit their knowledge. The collected data with the questionnaire survey were analysed, mainly with simple descriptive statistics; while the qualitative mode of analysis is mainly in narrative form.

Results

The paper shows that the surveyed HCE generate a total of 5,562 kg/day of wastes, of which about 77.4 per cent are non-hazardous and about 22.6 per cent are hazardous. The average waste generation rate for the surveyed HCE is 1.9 kg/bed/day or 0.5 kg/patient/day. The study reveals that there is no proper, systematic management of medical waste except in a few private HCE that segregate their infectious wastes. Some cleaners were found to salvage used sharps, saline bags, blood bags and test tubes for resale or reuse.

Conclusion

The paper reveals that lack of awareness, appropriate policy and laws, and willingness are responsible for the improper management of medical waste in Dhaka City. The paper also shows that a newly designed medical waste management system currently serves a limited number of HCE. New facilities should be established for the complete management of medical waste in Dhaka City.

Fluorochrome and flow cytometry to monitor microorganisms in treated hospital wastewater

Flow cytometry with a fluorescent technique (FCM/FL), epifluorescence microscopy with a fluorescent technique (EFM/FL), and a culture method were used and compared to study the microorganism population profiles in wastewater treatment. In the two non-culture methods (FCM/FL and EFM/FL), four fluorescent dyes [acridine orange (AO), 4',6-diamino-2-phenylindole dihydrochloride (DAPI), propidium iodide (PI), and YOPRO-1] were used to determine the total concentration and viability of microorganisms in the wastewater samples. Results showed that the total cell concentrations (both the bacteria and fungi) determined by using the non-culture-based methods were 18 to 67 times higher than those by the culture method (p = 0.036): the total cell concentration ranged from 1.10 x 10(7) to 2.44 x 10(8) cells/mL determined by both FCM and EFM with AO-staining method, and from 1.02 x 10(7) to 2.00 x 10(8) cells/mL by EFM with DAPI-staining method, whereas the culturable concentration of bacteria and fungi ranged from 0 to 3.22 x 10(6) CFU/mL and from 0 to 4.13 x 10(5) CFU/mL, respectively. No difference in total concentrations between dyes (AO and DAPI) and methods (FCM and EFM) were observed. By using EFM method, the microorganism viability ranged from 0.24 to 0.86 with PI staining and from 0.09 to 0.74 with YOPRO-1 staining. In the FCM analysis, the microorganism viability ranged from 0.23 to 0.87 with PI staining and from 0.18 to 0.73 with YOPRO-1 staining. In addition, the cultivability of microorganism ranged from 0 to 0.105 by the culture method. The total concentrations and viabilities of microorganisms were highly underestimated by the culture method. Results also showed that the viabilities determined by using either EFM/FL or FCM/FL were significantly higher than the cultivabilities. In addition, significant difference in viability between PI and YOPRO-1 for both EFM and FCM analysis was observed. However, the difference in viability between EFM and FCM depended on dyes. In regard to the difference between bacteria and fungi, significant difference in total concentration, viability, and cultivability was observed. In conclusion, the EFM/FL and FCM/FL methods can effectively assess total concentration and viability of microorganisms in environmental samples.

Virus removal performance and mechanism of a submerged membrane bioreactor

Responding to the worldwide outbreak of SARS in 2003, virus removal performance and mechanism of a SMBR were investigated by employing phage T4 as a model virus. Two membrane modules were compared in continuous operation for about 75 days. During stable operation, SMBR achieved almost complete phage removal for both membrane modules. For the 0.22 μm module, the cake layer, the gel layer and the membrane contributed 6.3 log, 3.1 log and 1.7 log, respectively to phage removal, confirming the importance of the cake/gel layer formed on the surface of membrane. The damage of the cake/gel layer resulted in the decrease of phage removal. As for the 0.1 μm one, the membrane alone played a major role in phage removal. Inactivation by activated sludge and adsorption by cake/gel layer contributed about 3.6 log to phage removal everyday so that there was no phage accumulation in bulk solution. The results demonstrated that SMBR was an efficient system and recommended for treatment of virus-bearing wastewater.