The occurrence of antimicrobial substances in toilet, sink and shower drainpipes of clinical units: A neglected source of antibiotic residues

Voigt, Alexander; Faerber, H.A.; Wilbring, Gero; Skutlarek, Dirk; Felder, Carsten; Mahn, Robert; Wolf, Dominik; Brossart, Peter; Hornung, Thorsten; Engelhart, Steffen; Exner, Martin; Schmithausen, Ricarda Maria

doi:10.1016/j.ijheh.2018.12.013

Cited by 44 publications

(33 citation statements)

References 58 publications

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“…A study conducted in German hospitals with high antibiotic consumption regularly detected antibiotic residues in toilets, sink siphons and shower drains [29]. Subsequent flushing of wastewater was successful in removing antibiotic residues, but after temporal stagnation, antibiotics were again detected [29]. This confirms the ability of biofilm to rapidly reform on wet surfaces, and act as a reservoir for accumulation and reoccurrence of antibiotics in hospital sanitary units [29].…”

Section: Biofilm In Healthcare Facilitiesmentioning

confidence: 93%

“…An antibiotic-resistant strain of Klebsiella pneumoniae was reported to efficiently transfer its extended-spectrum β-lactamase-encoding plasmid amongst bacteria within biofilm, and survive in a hospital environment [28]. A study conducted in German hospitals with high antibiotic consumption regularly detected antibiotic residues in toilets, sink siphons and shower drains [29]. Subsequent flushing of wastewater was successful in removing antibiotic residues, but after temporal stagnation, antibiotics were again detected [29].…”

Section: Biofilm In Healthcare Facilitiesmentioning

confidence: 99%

“…Subsequent flushing of wastewater was successful in removing antibiotic residues, but after temporal stagnation, antibiotics were again detected [29]. This confirms the ability of biofilm to rapidly reform on wet surfaces, and act as a reservoir for accumulation and reoccurrence of antibiotics in hospital sanitary units [29]. The combination of high antibiotic use and environmental biofilms in intensive care units has been recognised as a mechanism enabling increased genetic exchange amongst associated bacteria, leading to persistence of antibiotic-resistant bacteria despite terminal cleaning [30].…”

Section: Biofilm In Healthcare Facilitiesmentioning

confidence: 99%

See 2 more Smart Citations

Biofilm exacerbates antibiotic resistance: Is this a current oversight in antimicrobial stewardship?

Bowler

Murphy

Wolcott

2020

Antimicrob Resist Infect Control

159

125

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Objective To raise awareness of the role of environmental biofilm in the emergence and spread of antibiotic resistance and its consideration in antimicrobial stewardship. Background Antibiotic resistance is a major threat to public health. Overuse of antibiotics, increased international travel, and genetic promiscuity amongst bacteria have contributed to antibiotic resistance, and global containment efforts have so far met with limited success. Antibiotic resistance is a natural mechanism by which bacteria have adapted to environmental threats over billions of years and is caused either by genetic mutations or by horizontal gene transfer. Another ancient survival strategy involves bacteria existing within a self-produced polymeric matrix, which today is termed biofilm. Biofilm similarly enables bacterial tolerance to environmental threats, and also encourages the transfer of antibiotic resistance genes between bacterial species. This natural and ubiquitous mode of bacterial life has not been considered amongst strategies to tackle antibiotic resistance in healthcare facilities, despite its ability to significantly enhance bacterial survival and persistence, and to encourage antibiotic resistance. Conclusion Biofilm must be considered synonymously with antibiotic resistance because of its proficiency in transferring resistance genes as well as its innate phenotypic tolerance to antibiotics. Although biofilm falls outside of the current definition of antimicrobial stewardship, greater awareness of the existence, ubiquity, and consequences of environmental biofilm amongst healthcare practitioners is crucial to improving hygiene practices and controlling the emergence and spread of antibiotic resistance in healthcare facilities.

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Section: Biofilm In Healthcare Facilitiesmentioning

confidence: 93%

Section: Biofilm In Healthcare Facilitiesmentioning

confidence: 99%

Section: Biofilm In Healthcare Facilitiesmentioning

confidence: 99%

See 1 more Smart Citation

Biofilm exacerbates antibiotic resistance: Is this a current oversight in antimicrobial stewardship?

Bowler

Murphy

Wolcott

2020

Antimicrob Resist Infect Control

159

125

View full text Add to dashboard Cite

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“…The abundance of carbapenem resistance genes especially in Gram-negative bacteria from hospital-influenced wastewater was also previously described 19 , and was mentioned by the WHO to be one of the most important challenges in modern medicine 1 . Another reason for the increased abundance of carbapeneme resistance in FPB in hospital wastewaters can be attributed to an antibiotic reservoir phenomenon in the www.nature.com/scientificreports www.nature.com/scientificreports/ drainpipes in clinics 20 . Here, the persistance of high concentrations of antibiotics in biofilms is documented to promote the selection of carbapeneme-resistant FPB.…”

Section: Calculation Of the Pearson Coefficient Of Single Bacterial Gmentioning

confidence: 99%

Evaluation of antibiotic resistance dissemination by wastewater treatment plant effluents with different catchment areas in Germany

Alexander

Hembach

Schwartz

2020

Sci Rep

107

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The study quantified the abundances of antibiotic resistance genes (ARGs) and facultative pathogenic bacteria (FPB) as well as one mobile genetic element in genomic DNA via qPCR from 23 different wastewater treatment plant (WWTP) effluents in Germany. 12 clinically relevant ARGs were categorized into frequently, intermediately, and rarely occurring genetic parameters of communal wastewaters. Taxonomic PCR quantifications of five FPB targeting Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Acinetobacter baumannii, and enterococci were performed. The WWTPs differed in their catchment areas being impacted by hospitals, food processing companies, or housing areas only. The total discharges of the analyzed ARGs and FPB were found to cluster independently of the sizes of the WWTPs with a maximum difference of two log units within one cluster. Initially, quantitative data evaluations revealed no significant difference between ARG categories and WWTP catchment areas. More distinct correlations became obvious with a Pearson correlation approach, where each single taxonomic marker is compared to each ARG target. Here, increased correlation of FPB (i.e. E. coli, K. pneumoniae, P. aeruginosa, and enterococci) with clinically relevant ARGs of the category of rarely occurring resistance genes (bla NDM-1 , vanA) was found in WWTP effluents being influenced by hospital wastewaters.

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“…Selective pressure from antibiotic excretion in the urine and feces has been proposed as a potential contributor to the success of multidrug-resistant organisms in hospital plumbing. While studies have demonstrated higher levels of antibiotic residues and relative abundance of antimicrobial resistance genes in hospital wastewater (11)(12)(13), studies investigating associations between antibiotic concentrations and specific resistance phenotypes have produced mixed results (14)(15)(16)(17).…”

mentioning

confidence: 99%

Risk Factors Associated with Carbapenemase-Producing Enterobacterales (CPE) Positivity in the Hospital Wastewater Environment

Park

Parikh

Vegesana

et al. 2020

Appl Environ Microbiol

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Background: Hospital wastewater is an increasingly recognized reservoir for resistant Gramnegative organisms. Factors involved in establishment and persistence of Klebsiella pneumoniae carbapenemase-producing organisms (KPCO) in hospital wastewater plumbing are unclear. Methods: This study was conducted at a hospital with endemic KPCO linked to wastewater reservoirs and robust patient perirectal screening for silent KPCO carriage. Over five months, both rooms occupied and not occupied by KPCO-positive patients were sampled at three wastewater sites within each room (sink drain, sink P-trap, and toilet or hopper). Risk factors for KPCO positivity were assessed using logistic regression. Whole genome sequencing (WGS) identified environmental seeding by KPCO-positive patients. Findings: 219/475(46%) room sampling events were KPCO-positive in at least one wastewater site. KPCO-positive patient exposure was associated with increased risk of environmental positivity for the room and toilet/hopper. Previous positivity and intensive care unit room type were consistently associated with increased risk. Tube feeds were associated with increased risk for the drain, while exposure to patients with Clostridioides difficile was associated with decreased risk. Urinary catheter exposure was associated with increased risk of P-trap positivity. P-trap heaters reduced risk of P-trap and sink drain positivity. WGS identified genomically linked environmental seeding in six of 99 room occupations by 40 KPCO-positive patients. Interpretation: KPCO-positive patients seed the environment in at least 6% of opportunities; once positive for KPCO, wastewater sites are at greater risk of being positive subsequently. Increased nutrient exposure, e.g. due to tube food disposal down sinks, may increase risk; frequent flushing may be protective. IMPORTANCE: Klebsiella pneumoniae carbapenemase-producing organisms (KPCOs) are bacteria that are resistant to most antibiotics and thus are challenging to treat when they cause infections in patients. These organisms can be acquired by patients who are hospitalized for other reasons, complicating their hospital stay and even leading to death. Hospital wastewater sites, such as sink drains and toilets, have played a role in many reported outbreaks over the past decade. The significance of our research is in identifying risk factors for environmental positivity for KPCOs, which will facilitate further work to prevent transmission of these organisms to patients from the hospital environment.

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The occurrence of antimicrobial substances in toilet, sink and shower drainpipes of clinical units: A neglected source of antibiotic residues

Cited by 44 publications

References 58 publications

Biofilm exacerbates antibiotic resistance: Is this a current oversight in antimicrobial stewardship?

Biofilm exacerbates antibiotic resistance: Is this a current oversight in antimicrobial stewardship?

Evaluation of antibiotic resistance dissemination by wastewater treatment plant effluents with different catchment areas in Germany

Risk Factors Associated with Carbapenemase-Producing Enterobacterales (CPE) Positivity in the Hospital Wastewater Environment

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