Quantitative Microbial Risk Assessment of Antimicrobial Resistant and Susceptible Staphylococcus aureus in Reclaimed Wastewaters

Protective masks reduced gastrointestinal risks of antibiotic-resistant E. coli for hospital wastewater treatment plant workers: A quantitative microbial risk assessment

Antibiotic-resistant bacteria (ARB) in hospital wastewater present significant but under-researched risks for wastewater treatment plant (WWTP) workers. This study evaluated annual infection risks (Py) from exposure to ESBL-producing Escherichia coli (ESBL E. coli) and the effectiveness of protective masks. Wastewater samples from 25 hospitals in Thailand revealed 88 % of untreated samples were positive for ESBL E. coli (6.25 × 102 to 1.83 × 107 CFU/100 mL, mean 2.22 × 106), while 40 % of treated samples tested positive (1.00 × 102 to 1.97 × 105 CFU/100 mL, mean 2.45 × 104). Using quantitative microbial risk assessment and data from 917 workers, risks were calculated under three scenarios: non-resistant, antibiotic-resistant, and highly virulent E. coli. Ingestion of aerosols and droplets posed a higher infection risk than hand-to-mouth contact, with Py often exceeding the U.S. EPA benchmark of 10-4 per person per year. Mask use, particularly surgical and FFP2 masks, significantly reduced risks, bringing treated wastewater exposure below the benchmark. However, highly virulent E. coli risks remained high across all mask types. These findings highlight the need for effective protective measures and disinfection strategies to safeguard WWTP workers and mitigate ARB dissemination, protecting public health and environmental safety.

Population Ecology-Quantitative Microbial Risk Assessment (QMRA) Model for Antibiotic-Resistant and Susceptible E. coli in Recreational Water

Understanding and predicting the role of waterborne environments in transmitting antimicrobial-resistant (AMR) infections are critical for public health. A population ecology-quantitative microbial risk assessment (QMRA) model is proposed to evaluate urinary tract infection (UTI) development due to recreational waterborne exposures to Escherichia coli (E. coli) and antibiotic-resistant extended-spectrum β-lactamase-producing (ESBL) E. coli. The horizontal gene transfer (HGT) mechanism of conjugation and other evolutionary factors were modeled separately in the environment and the gut. Persistence/dilution dominated HGT in the environment; however, HGT highly impacted predicted ESBL populations in the body. Predicted disability life year (DALY) risks from exposure to ESBL E. coli at concentrations consistent with US recreational water criteria were less than the 10-6 pppy benchmark value but greater than the susceptible E. coli DALY risks associated with a UTI health outcome. However, the prevailing susceptible dose-response relationship may underestimate ESBL risk if HGT rates in vivo approach those reported in vitro. A sensitivity analysis demonstrated that DALY values, E. coli/ESBL concentrations, and exposure parameters were influential on predicted risks. The model is a preliminary tool to begin the expansion of the QMRA paradigm to explore the impacts of evolutionary changes in AMR risk assessment.

Estimating nosocomial transmission of micro-organisms in hospital settings using patient records and culture data

Pathogenic bacteria are a major threat to patient health in hospitals. Here we leverage electronic health records from a major New York City hospital system collected during 2020-2021 to support simulation inference of nosocomial transmission and pathogenic bacteria detection using an agent-based model (ABM). The ABM uses these data to inform simulation of importation from the community, nosocomial transmission, and patient spontaneous decolonization of bacteria. We additionally use patient clinical culture results to inform an observational model of detection of the pathogenic bacteria. The model is coupled with a Bayesian inference algorithm, an iterated ensemble adjustment Kalman filter, to estimate the likelihood of detection upon testing and nosocomial transmission rates. We evaluate parameter identifiability for this model-inference system and find that the system is able to estimate modelled nosocomial transmission and effective sensitivity upon clinical culture testing. We apply the framework to estimate both quantities for seven prevalent bacterial pathogens: Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus (both sensitive, MSSA, and resistant, MRSA, phenotypes), Enterococcus faecium and Enterococcus faecalis. We estimate that nosocomial transmission for E. coli is negligible. While bacterial pathogens have different importation rates, nosocomial transmission rates were similar among organisms, except E. coli. We also find that estimated likelihoods of detection are similar for all pathogens. This work highlights how fine-scale patient data can support inference of the epidemiological properties of micro-organisms and how hospital traffic and patient contact determine epidemiological features. Evaluation of the transmission potential for different pathogens could ultimately support the development of hospital control measures, as well as the design of surveillance strategies.

Determinants of antimicrobial resistance in biosolids: A systematic review, database, and meta-analysis

Biosolids can provide a nutrient rich soil amendment, particularly for poor soils and semi-arid or drought-prone areas. However, there are concerns that sludge and biosolids could be a source of propagation and exposure to AMR determinants such as antibiotic resistant bacteria (ARB), and antibiotic resistance genes (ARGs). To inform risk assessment efforts, a systematic literature review was performed to build a comprehensive spreadsheet database of ARB and ARG concentrations in biosolids (and some sludges specified as intended for land application), along with 69 other quantitative and qualitative meta-data fields from 68 published studies describing sampling information and processing methods that can be used for modeling purposes. Mean ARG concentrations per gram in positive samples of biosolids ranged from -5.7 log10(gene copies [gc]/g) to 12.92 log10(gc/g) (with these range values reported per dry weight), and aqueous concentrations ranged from 0.9 log10(gc/L) to 14.6 log10(gc/L). Mean ARB concentrations per gram of biosolids ranged from 2.02 log10 (colony forming units [CFU]/g) to 9.00 log10 (CFU/g) (dry weight), and aqueous concentrations ranged from 3.23 log10 (CFU/L) to 12.0 log10 (CFU/L). ARG log removal values (LRVs) during sewage sludge stabilization were calculated from a meta-analysis of mean concentrations before and after stabilization from 31 studies, ranging from -2.05 to 5.52 logs. The classes of resistance most relevant for a risk assessment corresponded to sulfonamide (sul1 and sul2), tetracycline (tetZ, tetX, tetA and tetG), beta-lactam (blaTEM), macrolide (ermB and ermF), aminoglycoside (strA and aac(6')-Ib-cr), and integron-associated (intI1). The resistance classes most relevant for ARB risk assessment included sulfonamides (sulfamethoxazole and sulfamethazine), cephalosporin (cephalothin and cefoxitin), penicillin (ampicillin), and ciprofloxin (ciprofloxacin). Considerations for exposure assessment are discussed to highlight risk assessment needs relating to antimicrobial resistance (AMR) associated with biosolids application. This study aids in prioritization of resources for reducing the spread of AMR within a One Health framework.

Quantitative distribution of antibiotic resistance genes and crAssphage in a tropical urbanized watershed

As antimicrobial resistance continues to pose a significant threat to global health, this study provided a focused examination of the prevalence and behavior of key antibiotic resistance genes in aquatic environments. We investigated the quantitative distribution of intI1, sul1, blaTEM, blaNDM, blaVIM, mcr-1, tetQ, and crAssphage within wastewater influents (n = 12), effluents (n = 12) and river water samples (n = 12), from three municipal wastewater treatment plants and three river locations in an urbanized watershed in Central Thailand over dry and wet seasons. The qPCR method demonstrated that intI1, sul1, blaTEM, and tetQ were the most abundant in all samples (2.71-7.89 mean log10 copies/100 mL), with all genes exhibiting consistently uniform levels across diverse locations, suggesting the potential for any site to act as a monitoring sentinel. Although there is a significant reduction of ARG concentrations by WWTPs (0.62 - >4.05 LRV), the persistence of these genes in effluents points to the limited effectiveness of existing treatment methodologies. Temporal data indicated stable ARG concentrations over time, but tetQ levels rose during the wet season, in alignment with the monsoonal climate in Thailand. Additionally, we identified crAssphage, a marker of human sewage contamination, exhibited strong correlations with the more abundant ARGs (rho 0.65 - 0.81), implying that human waste contributes significantly to the environmental burden of ARGs. The results of this research highlight the widespread nature of ARGs in water systems and the need for improved treatment and sanitation strategies to mitigate the public health threat posed by antimicrobial resistance.

MetaCompare 2.0: differential ranking of ecological and human health resistome risks

While numerous environmental factors contribute to the spread of antibiotic resistance genes (ARGs), quantifying their relative contributions remains a fundamental challenge. Similarly, it is important to differentiate acute human health risks from environmental exposure, versus broader ecological risk of ARG evolution and spread across microbial taxa. Recent studies have proposed various methods for achieving such aims. Here, we introduce MetaCompare 2.0, which improves upon original MetaCompare pipeline by differentiating indicators of human health resistome risk (potential for human pathogens of acute resistance concern to acquire ARGs) from ecological resistome risk (overall mobility of ARGs and potential for pathogen acquisition). The updated pipeline's sensitivity was demonstrated by analyzing diverse publicly-available metagenomes from wastewater, surface water, soil, sediment, human gut, and synthetic microbial communities. MetaCompare 2.0 provided distinct rankings of the metagenomes according to both human health resistome risk and ecological resistome risk, with both scores trending higher when influenced by anthropogenic impact or other stress. We evaluated the robustness of the pipeline to sequence assembly methods, sequencing depth, contig count, and metagenomic library coverage bias. The risk scores were remarkably consistent despite variations in these technological aspects. We packaged the improved pipeline into a publicly-available web service (http://metacompare.cs.vt.edu/) that provides an easy-to-use interface for computing resistome risk scores and visualizing results.

On-Site Inactivation for Disinfection of Antibiotic-Resistant Bacteria in Hospital Effluent by UV and UV-LED

The problem of antimicrobial resistance (AMR) is not limited to the medical field but is also becoming prevalent on a global scale in the environmental field. Environmental water pollution caused by the discharge of wastewater into aquatic environments has caused concern in the context of the sustainable development of modern society. However, there have been few studies focused on the treatment of hospital wastewater, and the potential consequences of this remain unknown. This study evaluated the efficacy of the inactivation of antimicrobial-resistant bacteria (AMRB) and antimicrobial resistance genes (AMRGs) in model wastewater treatment plant (WWTP) wastewater and hospital effluent based on direct ultraviolet (UV) light irradiation provided by a conventional mercury lamp with a peak wavelength of 254 nm and an ultraviolet light-emitting diode (UV-LED) with a peak emission of 280 nm under test conditions in which the irradiance of both was adjusted to the same intensity. The overall results indicated that both UV- and UV-LED-mediated disinfection effectively inactivated the AMRB in both wastewater types (>99.9% after 1-3 min of UV and 3 min of UV-LED treatment). Additionally, AMRGs were also removed (0.2-1.4 log10 for UV 254 nm and 0.1-1.3 log10 for UV 280 nm), and notably, there was no statistically significant decrease (p < 0.05) in the AMRGs between the UV and UV-LED treatments. The results of this study highlight the importance of utilizing a local inactivation treatment directly for wastewater generated by a hospital prior to its flow into a WWTP as sewage. Although additional disinfection treatment at the WWTP is likely necessary to remove the entire quantity of AMRB and AMRGs, the present study contributes to a significant reduction in the loads of WWTP and urgent prevention of the spread of infectious diseases, thus alleviating the potential threat to the environment and human health risks associated with AMR problems.

Quantitative Microbial Risk Assessment of Antibiotic-Resistant E. coli, Legionella pneumophila, and Mycobacteria in Nonpotable Wastewater Reuse Applications

Antibiotic-resistant bacteria (ARB) have become a major threat to public health and modern medicine. A simple death kinetics-based dose-response model (SD-DRM) was incorporated into a quantitative microbial risk assessment (QMRA) to assess the risks of exposure to reclaimed wastewater harboring antibiotic-resistant E. coli, Legionella pneumophila, and Mycobacterium avium for multiple exposure scenarios. The fractions of ARB and trace antibiotics present in the body were incorporated to demonstrate their impact on infection risks. Both ARB and antibiotic susceptible bacteria, ASB, are assumed to have the same dose-response in the absence of antibiotics but behave differently in the presence of residual antibiotics in the body. Annual risk of L. pneumophila infection exceeded the EPA 10-4 pppy (per person per year) benchmark at concentrations in reclaimed water greater than 103-104 CFU/L, depending on parameter variation. Enteropathogenic E. coli infection risks meet the EPA annual benchmark at concentrations around 105-106 total E. coli. The results illustrated that an increase in residual antibiotics from 0 to 40% of the minimum inhibitory concentration (MIC) reduced the risk by about 1 order of magnitude for E. coli but was more likely to result in an untreatable infection.

Development of a High-Throughput Analytical Method for Antimicrobials in Wastewater Using an Automated Pipetting and Solid-Phase Extraction System

Antimicrobial resistance (AMR) has emerged and spread globally. Recent studies have also reported the presence of antimicrobials in a wide variety of aquatic environments. Conducting a nationwide monitoring survey of AMR in the environment to elucidate its status and to assess its impact on ecosystems and human health is of social importance. In this study, we developed a novel high-throughput analysis (HTA) system based on a 96-well plate solid-phase extraction (SPE), using automated pipetting and an SPE pre-treatment system. The effectiveness of the system as an HTA for antimicrobials in environmental water was verified by comparing it with a conventional manual analytical system in a domestic hospital over a period of two years and four months. The results of the manual analysis and HTA using a combination of automated pipetting and SPE systems were generally consistent, and no statistically significant difference was observed (p > 0.05) between the two systems. The agreement ratios between the measured concentrations based on the conventional and HTA methods were positively correlated with a correlation coefficient of r = 0.99. These results indicate that HTA, which combines automated pipetting and an SPE pre-treatment system for rapid, high-volume analysis, can be used as an effective approach for understanding the environmental contamination of antimicrobials at multiple sites. To the best of our knowledge, this is the first report to present the accuracy and agreement between concentrations based on a manual analysis and those measured using HTA in hospital wastewater. These findings contribute to a comprehensive understanding of antimicrobials in aquatic environments and assess the ecological and human health risks associated with antimicrobials and antimicrobial-resistant bacteria to maintain the safety of aquatic environments.

Quantitative microbial risk assessment for ingestion of antibiotic resistance genes from private wells contaminated by human and livestock fecal sources

We used quantitative microbial risk assessment to estimate ingestion risk for intI1, erm(B), sul1, tet(A), tet(W), and tet(X) in private wells contaminated by human and/or livestock feces. Genes were quantified with five human-specific and six bovine-specific microbial source-tracking (MST) markers in 138 well-water samples from a rural Wisconsin county. Daily ingestion risk (probability of swallowing ≥1 gene) was based on daily water consumption and a Poisson exposure model. Calculations were stratified by MST source and soil depth over the aquifer where wells were drilled. Relative ingestion risk was estimated using wells with no MST detections and >6.1 m soil depth as a referent category. Daily ingestion risk varied from 0 to 8.8 × 10-1 by gene and fecal source (i.e., human or bovine). The estimated number of residents ingesting target genes from private wells varied from 910 (tet(A)) to 1,500 (intI1 and tet(X)) per day out of 12,000 total. Relative risk of tet(A) ingestion was significantly higher in wells with MST markers detected, including wells with ≤6.1 m soil depth contaminated by bovine markers (2.2 [90% CI: 1.1-4.7]), wells with >6.1 m soil depth contaminated by bovine markers (1.8 [1.002-3.9]), and wells with ≤6.1 m soil depth contaminated by bovine and human markers simultaneously (3.1 [1.7-6.5]). Antibiotic resistance genes (ARGs) were not necessarily present in viable microorganisms, and ingestion is not directly associated with infection. However, results illustrate relative contributions of human and livestock fecal sources to ARG exposure and highlight rural groundwater as a significant point of exposure.IMPORTANCEAntibiotic resistance is a global public health challenge with well-known environmental dimensions, but quantitative analyses of the roles played by various natural environments in transmission of antibiotic resistance are lacking, particularly for drinking water. This study assesses risk of ingestion for several antibiotic resistance genes (ARGs) and the class 1 integron gene (intI1) in drinking water from private wells in a rural area of northeast Wisconsin, United States. Results allow comparison of drinking water as an exposure route for antibiotic resistance relative to other routes like food and recreational water. They also enable a comparison of the importance of human versus livestock fecal sources in the study area. Our study demonstrates the previously unrecognized importance of untreated rural drinking water as an exposure route for antibiotic resistance and identifies bovine fecal material as an important exposure factor in the study setting.

Inactivation of antibiotic-resistant bacteria in hospital wastewater by ozone-based advanced water treatment processes

The emergence and spread of antimicrobial resistance (AMR) continue on a global scale. The impacts of wastewater on the environment and human health have been identified, and understanding the environmental impacts of hospital wastewater and exploring appropriate forms of treatment are major societal challenges. In the present research, we evaluated the efficacy of ozone (O3)-based advanced wastewater treatment systems (O3, O3/H2O2, O3/UV, and O3/UV/H2O2) for the treatment of antimicrobials, antimicrobial-resistant bacteria (AMRB), and antimicrobial resistance genes (AMRGs) in wastewater from medical facilities. Our results indicated that the O3-based advanced wastewater treatment inactivated multiple antimicrobials (>99.9%) and AMRB after 10-30 min of treatment. Additionally, AMRGs were effectively removed (1.4-6.6 log10) during hospital wastewater treatment. The inactivation and/or removal performances of these pollutants through the O3/UV and O3/UV/H2O2 treatments were significantly (P < 0.05) better than those in the O3 and O3/H2O2 treatments. Altered taxonomic diversity of microorganisms based on 16S rRNA gene sequencing following the O3-based treatment showed that advanced wastewater treatments not only removed viable bacteria but also removed genes constituting microorganisms in the wastewater. Consequently, the objective of this study was to apply advanced wastewater treatments to treat wastewater, mitigate environmental pollution, and alleviate potential threats to environmental and human health associated with AMR. Our findings will contribute to enhancing the effectiveness of advanced wastewater treatment systems through on-site application, not only in wastewater treatment plants (WWTPs) but also in medical facilities. Moreover, our results will help reduce the discharge of AMRB and AMRGs into rivers and maintain the safety of aquatic environments.

Mitigating risks and maximizing sustainability of treated wastewater reuse for irrigation

Scarcity of freshwater for agriculture has led to increased utilization of treated wastewater (TWW), establishing it as a significant and reliable source of irrigation water. However, years of research indicate that if not managed adequately, TWW may deleteriously affect soil functioning and plant productivity, and pose a hazard to human and environmental health. This review leverages the experience of researchers, stakeholders, and policymakers from Israel, the United-States, and Europe to present a holistic, multidisciplinary perspective on maximizing the benefits from municipal TWW use for irrigation. We specifically draw on the extensive knowledge gained in Israel, a world leader in agricultural TWW implementation. The first two sections of the work set the foundation for understanding current challenges involved with the use of TWW, detailing known and emerging agronomic and environmental issues (such as salinity and phytotoxicity) and public health risks (such as contaminants of emerging concern and pathogens). The work then presents solutions to address these challenges, including technological and agronomic management-based solutions as well as source control policies. The concluding section presents suggestions for the path forward, emphasizing the importance of improving links between research and policy, and better outreach to the public and agricultural practitioners. We use this platform as a call for action, to form a global harmonized data system that will centralize scientific findings on agronomic, environmental and public health effects of TWW irrigation. Insights from such global collaboration will help to mitigate risks, and facilitate more sustainable use of TWW for food production in the future.

Risk assessment of Enterococcus faecium, Klebsiella pneumoniae, and Pseudomonas aeruginosa in environmental water sources: Development of surrogate models for antibiotic resistance genes

The presence of Enterococcus faecium (E. faecium), Klebsiella pneumoniae (K. pneumoniae), Pseudomonas aeruginosa (P. aeruginosa), and the aminoglycoside resistance genes, aac(6')-Ib and aac(6')-aph(2″), was investigated in environmental water sources obtained from informal settlements in the Western Cape (South Africa). Using ethidium monoazide bromide quantitative polymerase chain reaction (EMA-qPCR) analysis, E. faecium, K. pneumoniae, and P. aeruginosa were detected in 88.9 %, 100 %, and 93.3 % of the samples (n = 45), respectively, with a significantly higher mean concentration recorded for K. pneumoniae (7.83 × 104 cells/100 mL) over the sampling period. The aac(6')-Ib gene was detected in 95.6 % (43/45) of the environmental water samples [mean concentration of 7.07 × 106 gene copies (GC)/100 mL], while the aac(6')-aph(2″) gene was detected in 100 % (n = 45) of the samples [mean concentration of 6.68 × 105 GC/100 mL]. Quantitative microbial risk assessment (QMRA) subsequently indicated that the risks posed by K. pneumoniae and P. aeruginosa were linked to intentional drinking, washing/bathing, cleaning of the home, and swimming, in the samples collected from the various sampling sites. Surrogate risk assessment models were then designed and applied for Gram-positive [aac(6')-aph(2″) gene] and Gram-negative [aac(6')-Ib gene] pathogens that may exhibit aminoglycoside resistance. The results indicated that only the Gram-negative pathogens posed a risk (>10-4) in all the samples for cleaning of the home and intentional drinking, as well as for washing laundry by hand, garden hosing, garden work, washing/bathing, accidental consumption, and swimming at the stream and marsh sites. Thus, while environmental waters may pose a health risk of exposure to pathogenic bacteria, the results obtained indicate that screening for antibiotic resistant genes, associated with multiple genera/species, could serve as a surrogate model for estimating risks with the target group under investigation.

Assessing the additional health burden of antibiotic resistant Enterobacteriaceae in surface waters through an integrated QMRA and DALY approach

Antibiotic resistant Enterobacteriaceae pose a significant threat to public health. However, limited studies have evaluated the health risks associated with exposure to antibiotic-resistant bacteria (ARB), especially in natural environments. While quantitative microbial risk assessment (QMRA) assesses microbial risks in terms of the probability of infection, it does not account for the severity of health outcomes. In this study, a QMRA-DALY model was developed to integrate QMRA with health burden (disability-adjusted life years (DALY)) from infections caused by ARB. The model considers uncertainties in probability of infection and health burden assessment using Monte Carlo simulations. The study collected antimicrobial resistance (AMR) surveillance data from surface waters with different land uses. Results revealed water bodies with agricultural land use to be the main AMR hotspots, with the highest additional health burden observed in infections caused by meropenem-resistant E. coli (∆DALY = 0.0105 DALY/event) compared to antibiotic-susceptible E. coli. The estimated ∆DALY for antibiotic-resistant K. pneumoniae was lower than for antibiotic-resistant E. coli (highest ∆DALY = 0.00048 DALY/event). The study highlights the need for better evaluation of AMR associated health burden, and effective measures to mitigate the risks associated with antibiotic-resistant bacteria in natural environments.

Shift of human pathogen community composition and their potential human health risk after supply suspension in tap water

Water supply suspension-restoration can occur frequently due to the overhauling of civil infrastructure in developing countries and the shutdown of commercial buildings during the pandemic. For comprehensive insights into the effects of water supply suspension-restoration, this study characterized the variations of the pathogen community composition of the tap water and their infection risk under different water supply scenarios. Metagenomic sequencing revealed a significant change of the human pathogen profiles, among which the most dominant pathogen changed from Pseudomonas aeruginosa (4.91%) to Acinetobacter johnsonii (0.59%). Furthermore, absolute quantification of pathogens by propidium-monoazide-qPCR revealed that the abundance of the three typical pathogens (Pseudomonas aeruginosa, Mycobacterium avium and Salmonella sp.) showed an increase of 2.44 log to 3.60 log immediately after water supply suspension-restoration and did not return to the normal level even after 2-h supply restoration, except for Pseudomonas aeruginosa. Quantitative microbial risk assessment suggested the infection risks of the three pathogens arising from direct utilization of tap water under stable water supply, including dermal exposure and oral intake, were all above the threshold of 10^-4, and evidently increased after water supply suspension-restoration. This study warns us against the risk induced by the pathogens in tap water, especially after water supply suspension-restoration.

Performance of a Pilot-Scale Continuous Flow Ozone-Based Hospital Wastewater Treatment System

Antimicrobial resistance (AMR) is becoming a global concern. Recently, research has emerged to evaluate the human and environmental health implications of wastewater from medical facilities and to identify acceptable wastewater treatment methods. In this study, a disinfection wastewater treatment system using an ozone-based continuous flow system was installed in a general hospital located in Japan. The effectiveness of antimicrobial-resistant bacteria (ARB) and antimicrobials in mitigating the environmental impact of hospital wastewater was evaluated. Metagenomic analysis was conducted to characterize the microorganisms in the wastewater before and after treatment. The results demonstrated that ozone treatment enables effective inactivation of general gut bacteria, including Bacteroides, Prevotella, Escherichia coli, Klebsiella, DNA molecules, and ARGs, as well as antimicrobials. Azithromycin and doxycycline removal rates were >99% immediately after treatment, and levofloxacin and vancomycin removal rates remained between 90% and 97% for approximately one month. Clarithromycin was more readily removed than the other antimicrobials (81-91%), and no clear removal trend was observed for ampicillin. Our findings provide a better understanding of the environmental management of hospital wastewater and enhance the effectiveness of disinfection wastewater treatment systems at medical facilities for mitigating the discharge of pollutants into aquatic environments.

Quantitative microbial risk assessment with nasal/oral breathing pattern for S. aureus bioaerosol emission from aeration tanks and residual sludge storage yard in a wastewater treatment plant

A large number of pathogenic bioaerosols are generated during the treatment process of wastewater treatment plants (WWTPs), and they can pose potential risks to human health. Therefore, this study systematically analyzed the emission characteristics of Staphylococcus aureus bioaerosols released from an inverted umbrella aeration tank, a microporous aeration tank, and a residual sludge storage yard in a WWTP, and quantitatively evaluated the health risks of four kinds of exposed populations with nasal/oral breathing patterns under optimistic and conservative estimations. The results displayed that the bioaerosol concentration in inverted umbrella aeration tank was higher than that in microporous aeration tank and residual sludge storage yard. Aerosolization ratio in residual sludge storage yard was an order of magnitude lower than that in aeration tanks. Sludge workers were at higher health risks than the other three exposed populations. The health risks of nasal breathers (infection risk: 1.62 × 10^-5-2.56 × 10^-3 pppy; disease burden: 4.24 × 10^-8-6.72 × 10^-6 DALYs pppy) were 0.61-0.63 times higher than those of oral breathers (infection risk: 9.95 × 10^-6-1.59 × 10^-3 pppy; disease burden: 2.61 × 10^-8-4.18 × 10^-6 DALYs pppy). For female field engineers using oral breathing, laboratory technicians, and researchers without personal protective equipment (PPE), infection risk and disease burden had the opposite results, which indicated that satisfying one certain benchmark did not mean absolute safety. In addition, health risks of exposed populations were reduced by an order of magnitude after wearing PPE. This study can provide a reliable theoretical basis for the risk prevention of bioaerosols and supply data support for the strategies of health risk control perspectives for local sewage utilities.

Occurrence and Quantitative Microbial Risk Assessment of Methicillin-Resistant Staphylococcus aureus (MRSA) in a Sub-Catchment of the Yodo River Basin, Japan

The occurrence of Staphylococcus aureus (S. aureus) and methicillin-resistant S. aureus (MRSA) in a sub-catchment of the Yodo River Basin, a representative water system of a drinking water source in Japan, was investigated. The chromogenic enzyme-substrate medium method was used for the detection of S. aureus and MRSA by the presence or absence of antimicrobials in the medium for viable bacteria in a culture-based setting. The contributions of S. aureus and MRSA from wastewater to the rivers were estimated based on mass flux-based analysis, and quantitative microbial risk assessment (QMRA) was further conducted for S. aureus and MRSA in river environments. The mean abundance of S. aureus and MRSA was 31 and 29 CFU/mL in hospital effluent, 124 and 117 CFU/mL in sewage treatment plant (STP) influent, 16 and 13 CFU/mL in STP effluent, and 8 and 9 CFU/mL in river water, respectively. Contribution of the pollution load derived from the target STP effluent to river water ranged from 2% to 25%. The QMRA showed that to achieve the established health benchmarks, the drinking water treatment process would need to yield 1.7 log10 and 2.9 log10 inactivation in terms of infection risk and disability-adjusted life year (DALY) indexes, respectively. These findings highlight the link between medical environment and the importance of environmental risk management for antimicrobial-resistant bacteria in aquatic environments.

Distribution and characteristics of carbapenem-resistant and extended-spectrum β-lactamase (ESBL) producing Escherichia coli in hospital effluents, sewage treatment plants, and river water in an urban area of Japan

Occurrence of profiles of the carbapenem-resistant Escherichia coli (CRE-E) and extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (ESBL-E) in an urban river in a sub-catchment of the Yodo River Basin, one of the representative water systems of Japan was investigated. We conducted seasonal and year-round surveys for the antimicrobial-resistant bacteria (AMRB) and antimicrobial-resistance genes (AMRGs) in hospital effluents, sewage treatment plant (STP) wastewater, and river water; subsequently, contributions to wastewater discharge into the rivers were estimated by analyses based on the mass flux. Furthermore, the characteristics of AMRB in the water samples were evaluated on the basis of antimicrobial susceptibility tests. CRE-E and ESBL-E were detected in all water samples with mean values 11 and 1900 CFU/mL in the hospital effluent, 58 and 4550 CFU/mL in the STP influent, not detected to 1 CFU/mL in the STP effluent, and 1 and 1 CFU/mL in the STP discharge into the river, respectively. Contributions of the pollution load derived from the STP effluent discharged into the river water were 1 to 21%. The resistome profiles for bla_IMP, bla_TEM, and bla_CTX-M genes in each water sample showed that AMRGs were not completely removed in the wastewater treatment process in the STP, and the relative abundances of bla_IMP, bla_TEM, and bla_CTX-M genes were almost similar (P<0.05). Susceptibility testing of antimicrobial-resistant E. coli isolates showed that CRE-E and ESBL-E detected in wastewaters and river water were linked to the prevalence of AMRB in clinical settings. These results suggest the importance of conducting environmental risk management of AMRB and AMRGs in the river environment. To our knowledge, this is the first detailed study that links the medical environment to CRE-E and ESBL-E for evaluating the AMRB and AMRGs in hospital effluents, STP wastewater, and river water at the basin scale on the basis of mass flux as well as the contributions of CRE-E and ESBL-E to wastewater discharge into the river.

Prevalence of ESKAPE pathogens in the environment: Antibiotic resistance status, community-acquired infection and risk to human health

The ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.) pathogens are characterised by increased levels of resistance towards multiple classes of first line and last-resort antibiotics. Although these pathogens are frequently isolated from clinical environments and are implicated in a variety of life-threatening, hospital-associated infections; antibiotic resistant ESKAPE strains have been isolated from environmental reservoirs such as surface water, wastewater, food, and soil. Literature on the persistence and subsequent health risks posed by the ESKAPE isolates in extra-hospital settings is however, limited and the current review aims to elucidate the primary reservoirs of these pathogens in the environment, their antibiotic resistance profiles, and the link to community-acquired infections. Additionally, information on the current state of research regarding health-risk assessments linked to exposure of the ESKAPE pathogens in the natural environment, is outlined.