Does Chlorination Promote Antimicrobial Resistance in Waterborne Pathogens? Mechanistic Insight into Co-Resistance and Its Implication for Public Health

Chlorination-induced spread of antibiotic resistance genes in drinking water systems

Chlorine, the most widely utilized disinfectant for drinking water globally, has recently been implicated in facilitating the spread of antibiotic resistance genes (ARGs), raising concerns about its underestimated environmental and ecological risks. However, given the current fragmented research focus and results, a comprehensive understanding of the potential mechanisms and influencing factors behind chlorination-promoted ARGs transmission in drinking water systems is crucial. This work is the first to systematically review the variations in abundance, transmission mechanisms, influencing factors, and mitigation strategies related to ARGs during the chlorination process. The results indicated that chlorination could induce genetic mutations and promote horizontal gene transfer through multiple pathways, including increased reactive oxygen species, enhanced membrane permeability, stimulation of the SOS response, and activation of efflux pumps. In addition, this work delves into significant discoveries regarding the factors affecting ARG transmission in drinking water, such as chlorine concentration, reaction time, disinfection byproducts, pipe materials, biofilms, and the water matrix. A series of effective strategies from water source to point-of-use were proposed aimed at mitigating ARGs transmission risks in the drinking water system. Finally, we address existing challenges and outline future research directions to overcome these bottlenecks. Overall, this review aims to advance our understanding of the role of chlorination in the dissemination of ARGs and to inspire innovative research ideas for optimizing disinfection techniques, minimizing the risks of antibiotic resistance transmission, and enhancing the safety of drinking water.

Coaggregation dynamics in drinking water biofilms and implications for chlorine disinfection

Biofilms in drinking water (DW) systems persistently challenge traditional disinfection methods due to intricate microbial interactions, with coaggregation playing a crucial role in forming multispecies biofilms. This study examined the implications of coaggregation on tolerance towards sodium hypochlorite (NaOCl) disinfection. Dual-species biofilms were formed for seven days on polyvinyl chloride coupons, comprising a strain of the emerging pathogen Stenotrophomonas maltophilia and the coaggregating strain Delftia acidovorans 005 P. For comparison, dual-species biofilms were also formed with a non-coaggregation strain (D. acidovorans 009 P). The minimum bactericidal concentration (MBC) for each planktonic strain varied (D. acidovorans: 1 mg/L, S. maltophilia: 1.5 mg/L) below the safe DW treatment limits. However, high NaOCl doses (10 ×MBC and 100 ×MBC,) showed low efficacy against dual-species biofilms, indicating significant biofilm tolerance to disinfection. Membrane damage occurred at sub-MBC without culturability loss, underscoring biofilm resilience. The biofilm analysis revealed a complex interplay between the composition of extracellular polymeric substances and the architecture, which was influenced by the presence of the coaggregating strain. Overall, coaggregation significantly influenced biofilm formation and resilience, impacting NaOCl disinfection. These findings underscore the challenges of microbial interactions in biofilms, emphasizing the need for improved disinfection strategies to control biofilms in drinking water systems.

Combating chlorine-resistant marine Klebsiella pneumoniae biofilms with chlorine-tolerant bacteriophages

Biofilm formation presents a significant challenge in health care, food industries, water distribution systems, etc. In addition to their inherent resistance to various stresses and biocides, emerging resistance against widely used biocides like chlorine is a growing concern. The strong link between chlorine resistance and the development of antibiotic resistance among microbes further exacerbates this issue. Therefore, it is highly desirable to devise a method to mitigate the problems associated with biofilms formed by Chlorine Resistant Bacteria (CRB). In this study, a highly chlorine resistant, biofilm-forming Klebsiella pneumoniae was isolated from the cooling water system of a nuclear power plant employing continuous chlorination for biofilm control. Interestingly, K. pneumoniae was found to enhance biofilm formation under the influence of increasing concentrations of chlorine, highlighting the limitations of chlorination-based biofilm control measures. As a remedial measure, chlorine resistant bacteriophages specific to K. pneumoniae were successfully isolated from the same water sample. These bacteriophages effectively inhibited planktonic growth biofilm formation and removed preformed biofilms. Whole-genome sequencing of two of the promising bacteriophages confirmed their identity as novel bacteriophages specific to K. pneumoniae. The absence of any antibiotic-resistant gene, virulent factor(s), or gene associated with the lysogenic life cycle further supports their suitability for environmental applications. This study provides valuable insights into the prevalence of chlorine resistant, pathogenic bacteria in cooling water distribution systems. It also highlights the promising application of bacteriophages to mitigate chlorine resistant bacteria and their biofilms.

The fate of antibiotic resistance genes in wastewater containing microalgae treated by chlorination, ultra-violet, and Fenton reaction

Antibiotic resistance genes (ARGs) and bacteria (ARBs) in the effluent of wastewater treatment plants (WWTPs) are of utmost importance for the dissemination of ARGs in natural aquatic environments. Therefore, there is an urgent need for effective technologies to eliminate WWTP ARGs/ARBs and mitigate the associated risks posed by the discharged ARG in aquatic environments. To test the effective technology for eliminating ARGs/ARBs, we compared the removal of ARGs and ARBs by three different tertiary treatments, namely ultra-violet (UV) disinfection, chlorination disinfection, and Fenton oxidation. Then, the treated wastewater was co-cultured with Chlorella vulgaris (representative of aquatic biota) to investigate the fate of discharged ARGs into the aquatic environment. The results demonstrated that chlorination (at a chlorine concentration of 15 mg/L) and Fenton (at pH 2.73, with 0.005 mol/L Fe2+ and 0.0025 mol/L H2O2) treatment showed higher efficacy in ARG removal (1.8 - 4.17 logs) than UV treatment (15 min) (1.29 - 3.87 logs). Moreover, chlorine at 15 mg/L and Fenton treatment effectively suppressed ARB regeneration while UV treatment for 15 min could not. Regardless of treatments tested in this study, the input of treated wastewater to the Chlorella system increased the number of ARGs and mobile genetic elements (MGEs), indicating the potential risk of ARG dissemination associated with WWTP discharge. Among the wastewater-Chlorella co-culture systems, chlorination resulted in less of an increase in the number of ARGs and MGEs compared to Fenton and UV treatment. When comparing the wastewater systems to the co-culture systems, it was observed that Chlorella vulgaris reduced the number of ARGs and MGEs in chlorination and UV-treated wastewater; however, Chlorella vulgaris promoted ARG survival in Fenton-treated water, suggesting that aquatic microalgae might act as a barrier to ARG dissemination. Overall, chlorination treatment not only effectively removes ARGs and inhibits ARB regeneration but also shows a lower risk of ARG dissemination. Therefore, chlorination is recommended for practical application in controlling the spread of discharged ARGs from WWTP effluent in natural aquatic environments.

Insights into microbial contamination and antibiotic resistome traits in pork wholesale market: An evaluation of the disinfection effect of sodium hypochlorite

Chlorine and its derivatives, such as sodium hypochlorite (NaClO) and chlorine dioxide, are frequently employed as disinfectants throughout the pork supply chain in China. Nevertheless, the extensive use of NaClO has the potential to cause the creation of 'chlorine-tolerant bacteria' and accelerate the evolution of antibiotic resistance. This study evaluated the efficacy of NaClO disinfection by examining alterations in the microbiome and resistome of a pork wholesale market (PWM), and bacteria isolation and analysis were performed to validate the findings. As expected, the taxonomic compositions of bacteria was significantly different before and after disinfection. Notably, Salmonella enterica (S. enterica), Salmonella bongori (S. bongori), Escherichia coli (E. coli), Klebsiella pneumoniae (K. pneumoniae), and Pseudomonas aeruginosa (P. aeruginosa) were observed on all surfaces, indicating that the application of NaClO disinfection treatment in PWM environments for pathogenic bacteria is limited. Correlations were identified between antibiotic resistance genes (ARGs) associated with aminoglycosides (aph(3'')-I, aph(6')-I), quinolone (qnrB, abaQ), polymyxin (arnA, mcr-4) and disinfectant resistance genes (emrA/BD, mdtA/B/C/E/F). Furthermore, correlations were found between risk Rank I ARGs associated with aminoglycoside (aph(3')-I), tetracycline (tetH), beta_lactam (TEM-171), and disinfectant resistance genes (mdtB/C/E/F, emrA, acrB, qacG). Importantly, we found that Acinetobacter and Salmonella were the main hosts of disinfectant resistance genes. The resistance mechanisms of the ARGs identified in PWM were dominated by antibiotic deactivation (38.7%), antibiotic efflux (27.2%), and antibiotic target protection (14.4%). The proportion of genes encoding efflux pumps in the PWM resistome increased after disinfection. Microbial cultures demonstrated that the traits of microbial contamination and antibiotic resistane were consistent with those observed by metagenomic sequencing. This study highlights the possibility of cross-resistance between NaClO disinfectants and antibiotics, which should not be ignored.

Antimicrobial resistance expansion in pathogens: a review of current mitigation strategies and advances towards innovative therapy

The escalating problem of antimicrobial resistance (AMR) proliferation in clinically important pathogens has become one of the biggest threats to human health and the global economy. Previous studies have estimated AMR-associated deaths and disability-adjusted life-years (DALYs) in many countries with a view to presenting a clearer picture of the global burden of AMR-related diseases. Recently, several novel strategies have been advanced to combat resistance spread. These include efflux activity inhibition, closing of mutant selection window (MSW), biofilm disruption, lytic bacteriophage particles, nanoantibiotics, engineered antimicrobial peptides, and the CRISPR-Cas9 gene-editing technique. The single or integrated deployment of these strategies has shown potentialities towards mitigating resistance and contributing to valuable therapeutic outcomes. Correspondingly, the new paradigm of personalized medicine demands innovative interventions such as improved and accurate point-of-care diagnosis and treatment to curtail AMR. The CRISPR-Cas system is a novel and highly promising nucleic acid detection and manipulating technology with the potential for application in the control of AMR. This review thus considers the specifics of some of the AMR-mitigating strategies, while noting their drawbacks, and discusses the advances in the CRISPR-based technology as an important point-of-care tool for tracking and curbing AMR in our fight against a looming 'post-antibiotic' era.

Bacterial-Nanocellulose-Based Biointerfaces and Biomimetic Constructs for Blood-Contacting Medical Applications

Understanding the interaction between biomaterials and blood is critical in the design of novel biomaterials for use in biomedical applications. Depending on the application, biomaterials can be designed to promote hemostasis, slow or stop bleeding in an internal or external wound, or prevent thrombosis for use in permanent or temporary medical implants. Bacterial nanocellulose (BNC) is a natural, biocompatible biopolymer that has recently gained interest for its potential use in blood-contacting biomedical applications (e.g., artificial vascular grafts), due to its high porosity, shapeability, and tissue-like properties. To promote hemostasis, BNC has been modified through oxidation or functionalization with various peptides, proteins, polysaccharides, and minerals that interact with the coagulation cascade. For use as an artificial vascular graft or to promote vascularization, BNC has been extensively researched, with studies investigating different modification techniques to enhance endothelialization such as functionalizing with adhesion peptides or extracellular matrix (ECM) proteins as well as tuning the structural properties of BNC such as surface roughness, pore size, and fiber size. While BNC inherently exhibits comparable mechanical characteristics to endogenous blood vessels, these mechanical properties can be enhanced through chemical functionalization or through altering the fabrication method. In this review, we provide a comprehensive overview of the various modification techniques that have been implemented to enhance the suitability of BNC for blood-contacting biomedical applications and different testing techniques that can be applied to evaluate their performance. Initially, we focused on the modification techniques that have been applied to BNC for hemostatic applications. Subsequently, we outline the different methods used for the production of BNC-based artificial vascular grafts and to generate vasculature in tissue engineered constructs. This sequential organization enables a clear and concise discussion of the various modifications of BNC for different blood-contacting biomedical applications and highlights the diverse and versatile nature of BNC as a natural biomaterial.

The impact of chlorine, ultraviolet-C, and microwave treatment on the survivability of Blastocystis sp. cysts

Blastocystis sp. is a common widely distributed gut protozoan, with water transmission identified as one of its transmission routes. This study aimed to investigate the effect of chlorine, ultraviolet (UV)-C, and microwave (MW) treatments on the in vitro viability of cysts of Blastocystis sp. Purified Blastocystis sp. cysts were molecularly subtyped. Viable cysts were subjected to different free chlorine concentrations (1, 2, and 4 ppm), different doses of UV-C (5.13, 10.26, 20.52, and 40.47 mJ/cm2), and MW irradiation times (10, 15, 30, and 45 s). Viability reduction percentage, log10 inactivation, and micrometre-based optical microscopy examined cyst number and appearance after each disinfection trial. The three disinfectants' efficacy and application conditions were assessed. The analysed isolates of Blastocystis cysts were subtype 3, possessed varying sizes and shapes, but two identical genomes. The cysts of Blastocystis sp. were resistant to chlorine at all doses and exposure durations tested. UV-C at a dose of 40 mJ/cm2 and MW treatment for 15 s were able to completely disinfect the cysts. The MW was the most effective disinfectant against Blastocystis cysts based on all evaluated factors. MW irradiation is the most efficient water treatment method for eradicating Blastocystis cysts in an easy and safe manner.

Antibacterial Activity of Solvothermal Obtained ZnO Nanoparticles with Different Morphology and Photocatalytic Activity against a Dye Mixture: Methylene Blue, Rhodamine B and Methyl Orange

In this paper, we report the synthesis of ZnO nanoparticles (NPs) by forced solvolysis of Zn(CH3COO)2·2H2O in alcohols with a different number of –OH groups. We study the influence of alcohol type (n-butanol, ethylene glycol and glycerin) on the size, morphology, and properties of the obtained ZnO NPs. The smallest polyhedral ZnO NPs (<30 nm) were obtained in n-butanol, while in ethylene glycol the NPs measured on average 44 nm and were rounded. Polycrystalline particles of 120 nm were obtained in glycerin only after water refluxing. In addition, here, we report the photocatalytic activity, against a dye mixture, of three model pollutants: methyl orange (MO), methylene blue (MB), and rhodamine B (RhB), a model closer to real situations where water is polluted with many chemicals. All samples exhibited good photocatalytic activity against the dye mixture, with degradation efficiency reaching 99.99%. The sample with smallest nanoparticles maintained a high efficiency >90%, over five catalytic cycles. Antibacterial tests were conducted against Gram-negative strains Salmonella enterica serovar Typhimurium, Pseudomonas aeruginosa, and Escherichia coli, and Gram-positive strains Enterococcus faecalis, Bacillus subtilis, Staphylococcus aureus, and Bacillus cereus. The ZnO samples presented strong inhibition of planktonic growth for all tested strains, indicating that they can be used for antibacterial applications, such as water purification.

The Impact of Chlorine Disinfection of Hospital Wastewater on Clonal Similarity and ESBL-Production in Selected Bacteria of the Family Enterobacteriaceae

Hospitals are regarded as ecological niches of antibiotic-resistant bacteria (ARB). ARB can spread outside the hospital environment via hospital wastewater (HWW). Therefore, HWW is often disinfected in local stations to minimize that risk. Chlorine-based treatment is the most popular method of HWW disinfection around the world, however, recent research has suggested that it can contribute to the spread of antimicrobial resistance (AMR). The aim of this study is to determine the impact of HWW disinfection on the clonal similarity of Enterobacteriaceae species and their ability to produce extended-spectrum beta-lactamases (ESBLs). The study was conducted in a hospital with a local chlorine-based disinfection station. Samples of wastewater before disinfection and samples of disinfected wastewater, collected in four research seasons, were analyzed. Bacteria potentially belonging to the Enterobacteriaceae family were isolated from HWW. The Enterobacterial Repetitive Intergenic Consensus Polymerase Chain Reaction (ERIC-PCR) method was used to generate DNA fingerprints of all bacterial isolates. The isolates were phenotypically tested for the production of ESBLs. Antibiotic resistance genes (bla_SHV, bla_TEM, and bla_OXA, bla_{CTX-M-1-group}, bla_{CTX-M-2-group}, bla_CTX-9-group and bla_{CTX-M-8/25-group}) were detected by PCR in strains with confirmed phenotypic ability to produce ESBLs. The ESBL+ isolates were identified by the sequencing of 16S rDNA. In the present study, the same bacterial clones were isolated from HWW before and after disinfection and HWW was sampled in different seasons. Genetic and phenotypic variations were observed in bacterial clones. ESBL+ strains were isolated significantly more often from disinfected than from non-disinfected HWW. The bla_OXA gene was significantly more prevalent in isolates from disinfected than non-disinfected HWW. Enterobacter hormaechei and Klebsiella pneumoniae were the dominant species in ESBL+ strains isolated from both sampling sites. The results of this study indicate that chlorine-based disinfection promotes the survival of ESBL-producing bacteria and/or the transmission of genetic determinants of antimicrobial resistance. As a result, chlorination increases the proportion of ESBL-producing Enterobacteriaceae in disinfected wastewater. Consequently, chlorine-based disinfection practices may pose a risk to the environment and public health by accelerating the spread of antimicrobial resistance.