Carriage of ESBL-producing Enterobacterales in wastewater treatment plant workers and surrounding residents - the AWARE Study

To investigate whether wastewater treatment plant (WWTP) workers and residents living in close proximity to a WWTP have elevated carriage rates of ESBL-producing Enterobacterales, as compared to the general population. From 2018 to 2020, we carried out a cross-sectional study in Germany, the Netherlands, and Romania among WWTP workers (N = 344), nearby residents (living ≤ 300~m away from WWTPs; N = 431) and distant residents (living ≥ 1000~m away = reference group; N = 1165). We collected information on potential confounders via questionnaire. Culture of participants' stool samples was performed with ChromID®-ESBL agar plates and species identification with MALDI-TOF-MS. We used logistic regression to estimate the odds ratio (OR) for carrying ESBL-producing E. coli (ESBL-EC). Sensitivity analyses included stratification by country and interaction models using country as secondary exposure. Prevalence of ESBL-EC was 11% (workers), 29% (nearby residents), and 7% (distant residents), and higher in Romania (28%) than in Germany (7%) and the Netherlands (6%). Models stratified by country showed that within the Romanian population, WWTP workers are about twice as likely (aOR = 2.34, 95% CI: 1.22-4.50) and nearby residents about three times as likely (aOR = 3.17, 95% CI: 1.80-5.59) to be ESBL-EC carriers, when compared with distant residents. In stratified analyses by country, we found an increased risk for carriage of ESBL-EC in Romanian workers and nearby residents. This effect was higher for nearby residents than for workers, which suggests that, for nearby residents, factors other than the local WWTP could contribute to the increased carriage

Wastewater treatment plants, an “escape gate” for ESCAPE pathogens

Antibiotics are an essential tool of modern medicine, contributing to significantly decreasing mortality and morbidity rates from infectious diseases. However, persistent misuse of these drugs has accelerated the evolution of antibiotic resistance, negatively impacting clinical practice. The environment contributes to both the evolution and transmission of resistance. From all anthropically polluted aquatic environments, wastewater treatment plants (WWTPs) are probably the main reservoirs of resistant pathogens. They should be regarded as critical control points for preventing or reducing the release of antibiotics, antibiotic-resistant bacteria (ARB), and antibiotic-resistance genes (ARGs) into the natural environment. This review focuses on the fate of the pathogens Enterococcus faecium, Staphylococcus aureus, Clostridium difficile, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacteriaceae spp. (ESCAPE) in WWTPs. All ESCAPE pathogen species, including high-risk clones and resistance determinants to last-resort antibiotics such as carbapenems, colistin, and multi-drug resistance platforms, were detected in wastewater. The whole genome sequencing studies demonstrate the clonal relationships and dissemination of Gram-negative ESCAPE species into the wastewater via hospital effluents and the enrichment of virulence and resistance determinants of S. aureus and enterococci in WWTPs. Therefore, the efficiency of different wastewater treatment processes regarding the removal of clinically relevant ARB species and ARGs, as well as the influence of water quality factors on their performance, should be explored and monitored, along with the development of more effective treatments and appropriate indicators (ESCAPE bacteria and/or ARGs). This knowledge will allow the development of quality standards for point sources and effluents to consolidate the WWTP barrier role against the environmental and public health AR threats

A membrane filtration method for the enumeration of Escherichia coli in bathing water and other waters with high levels of background bacteria

The presence and level of faecal indicator bacteria are important factors in estimating the microbiological quality of surface water and the risk of human infection upon exposure to this water. Until 2014, ISO 9308-1:2000 was available and used to enumerate faecal indicator Escherichia coli in bathing water. In 2014, this ISO was technically revised and replaced by ISO 9308-1:2014. This ISO introduced a less selective method for enumeration of E. coli that allows non-specific growth from waters containing high levels of bacteria, such as surface waters. This implies that currently there is no suitable reference membrane filtration method for the compliance monitoring of official bathing sites for E. coli according to the European Bathing Water Directive. Here, the performance characteristics of three chromogenic culture media, namely Tryptone Bile X-glucuronide (TBX) agar, Chromogenic Coliform Agar (CCA), and CHROMagar E. coli/Coliform (ECC) were investigated at 44 °C for water with varying levels of bacteria according to ISO 13843:2017. Based on performance characteristics, colony counts, and practical usage, TBX appeared the most suitable culture medium for the enumeration of E. coli in bathing water and other waters with high levels of background bacteria, such as surface water in agricultural areas and wastewater discharge points. HIGHLIGHTS Performance characteristics at 44 °C, after resuscitation at 36 °C, were comparable for the tested chromogenic culture media TBX, CCA, and ECC.; Based on performance characteristics, colony counts, and practical usage, TBX was selected as the preferential culture medium.

Nationwide surveillance reveals frequent detection of carbapenemase-producing Enterobacterales in Dutch municipal wastewater

Carbapenemase-producing Enterobacterales (CPE) pose a threat to public health necessitating restriction of further spread. Tools to efficiently monitor the prevalence of these still relatively rare resistant bacteria and insight in routes of dissemination are pivotal for the development of prevention strategies. By analysis of untreated and treated wastewater from 100 municipal wastewater treatment plants (WWTPs) together serving over 40% of the Dutch population, this study investigated both the distribution of CPE in the Dutch population, and WWTPs as a source of CPE in the aquatic environment. CPE were detected at 89% of the WWTPs, in 87 influents and 53 effluents. Overall, 15 different CPE-types were detected based on species and carbapenemase gene. The most widely distributed were E. coli carrying blaOXA-48-like genes, which were detected at 88 WWTPs including small WWTPs without connected health care institutions (HCI). BlaOXA-48-like-positive-K. pneumoniae, blaNDM- or blaKPC-positive E. coli, and blaNDM- or blaKPC-positive K. pneumoniae were detected at 33, 20, and 14 WWTPs, respectively. Mean influent and effluent CPE concentrations were 7.9×102 cfu/l and 11 cfu/l. The total daily number of CPE discharged by the 100 WWTPs was estimated to be 2.2×1011 cfu. In multivariate analysis, CPE concentrations in untreated wastewater were positively associated with WWTP size and E. coli concentrations, but not with the presence of HCI. Based on the total number of CPE (9.7×1012 cfu) and ESBL-E. coli (2.41015 cfu) in influents, and a prevalence of approximately 5% in the Dutch population for ESBL-E. coli, the prevalence of CPE in the Dutch population was roughly estimated to be 0.02%. Wastewater surveillance is an efficient tool to monitor the distribution of CPE in the population at a national level and may supplement human surveillance data. CPE are emitted to the aquatic environment with treated wastewater and associated public health risks need to be determined

Nationwide surveillance reveals frequent detection of carbapenemase-producing Enterobacterales in Dutch municipal wastewater

Carbapenemase-producing Enterobacterales (CPE) pose a threat to public health necessitating restriction of further spread. Tools to efficiently monitor the prevalence of these still relatively rare resistant bacteria and insight in routes of dissemination are pivotal for the development of prevention strategies. By analysis of untreated and treated wastewater from 100 municipal wastewater treatment plants (WWTPs) together serving over 40% of the Dutch population, this study investigated both the distribution of CPE in the Dutch population, and WWTPs as a source of CPE in the aquatic environment. CPE were detected at 89% of the WWTPs, in 87 influents and 53 effluents. Overall, 15 different CPE-types were detected based on species and carbapenemase gene. The most widely distributed were E. coli carrying blaOXA-48-like genes, which were detected at 88 WWTPs including small WWTPs without connected health care institutions (HCI). BlaOXA-48-like-positive-K. pneumoniae, blaNDM- or blaKPC-positive E. coli, and blaNDM- or blaKPC-positive K. pneumoniae were detected at 33, 20, and 14 WWTPs, respectively. Mean influent and effluent CPE concentrations were 7.9×102 cfu/l and 11 cfu/l. The total daily number of CPE discharged by the 100 WWTPs was estimated to be 2.2×1011 cfu. In multivariate analysis, CPE concentrations in untreated wastewater were positively associated with WWTP size and E. coli concentrations, but not with the presence of HCI. Based on the total number of CPE (9.7×1012 cfu) and ESBL-E. coli (2.41015 cfu) in influents, and a prevalence of approximately 5% in the Dutch population for ESBL-E. coli, the prevalence of CPE in the Dutch population was roughly estimated to be 0.02%. Wastewater surveillance is an efficient tool to monitor the distribution of CPE in the population at a national level and may supplement human surveillance data. CPE are emitted to the aquatic environment with treated wastewater and associated public health risks need to be determined

Nationwide surveillance reveals frequent detection of carbapenemase-producing Enterobacterales in Dutch municipal wastewater

Carbapenemase-producing Enterobacterales (CPE) pose a threat to public health necessitating restriction of further spread. Tools to efficiently monitor the prevalence of these still relatively rare resistant bacteria and insight in routes of dissemination are pivotal for the development of prevention strategies. By analysis of untreated and treated wastewater from 100 municipal wastewater treatment plants (WWTPs) together serving over 40% of the Dutch population, this study investigated both the distribution of CPE in the Dutch population, and WWTPs as a source of CPE in the aquatic environment. CPE were detected at 89% of the WWTPs, in 87 influents and 53 effluents. Overall, 15 different CPE-types were detected based on species and carbapenemase gene. The most widely distributed were E. coli carrying blaOXA-48-like genes, which were detected at 88 WWTPs including small WWTPs without connected health care institutions (HCI). BlaOXA-48-like-positive-K. pneumoniae, blaNDM- or blaKPC-positive E. coli, and blaNDM- or blaKPC-positive K. pneumoniae were detected at 33, 20, and 14 WWTPs, respectively. Mean influent and effluent CPE concentrations were 7.9×102 cfu/l and 11 cfu/l. The total daily number of CPE discharged by the 100 WWTPs was estimated to be 2.2×1011 cfu. In multivariate analysis, CPE concentrations in untreated wastewater were positively associated with WWTP size and E. coli concentrations, but not with the presence of HCI. Based on the total number of CPE (9.7×1012 cfu) and ESBL-E. coli (2.41015 cfu) in influents, and a prevalence of approximately 5% in the Dutch population for ESBL-E. coli, the prevalence of CPE in the Dutch population was roughly estimated to be 0.02%. Wastewater surveillance is an efficient tool to monitor the distribution of CPE in the population at a national level and may supplement human surveillance data. CPE are emitted to the aquatic environment with treated wastewater and associated public health risks need to be determined

International Travel as a Risk Factor for Carriage of Extended-Spectrum β-Lactamase-Producing Escherichia coli in a Large Sample of European Individuals-The AWARE Study

Antibiotic resistance (AR) is currently a major threat to global health, calling for a One Health approach to be properly understood, monitored, tackled, and managed. Potential risk factors for AR are often studied in specific high-risk populations, but are still poorly understood in the general population. Our aim was to explore, describe, and characterize potential risk factors for carriage of Extended-Spectrum Beta-Lactamase-resistant Escherichia coli (ESBL-EC) in a large sample of European individuals aged between 16 and 67 years recruited from the general population in Southern Germany, the Netherlands, and Romania. Questionnaire and stool sample collection for this cross-sectional study took place from September 2018 to March 2020. Selected cultures of participants' stool samples were analyzed for detection of ESBL-EC. A total of 1183 participants were included in the analyses: 333 from Germany, 689 from the Netherlands, and 161 from Romania. Travels to Northern Africa (adjusted Odds Ratio, aOR 4.03, 95% Confidence Interval, CI 1.67-9.68), Sub-Saharan Africa (aOR 4.60, 95% CI 1.60-13.26), and Asia (aOR 4.08, 95% CI 1.97-8.43) were identified as independent risk factors for carriage of ESBL-EC. Therefore, travel to these regions should continue to be routinely asked about by clinical practitioners as possible risk factors when considering antibiotic therapy

Wastewater treatment plants, an "escape gate" for ESCAPE pathogens.

Antibiotics are an essential tool of modern medicine, contributing to significantly decreasing mortality and morbidity rates from infectious diseases. However, persistent misuse of these drugs has accelerated the evolution of antibiotic resistance, negatively impacting clinical practice. The environment contributes to both the evolution and transmission of resistance. From all anthropically polluted aquatic environments, wastewater treatment plants (WWTPs) are probably the main reservoirs of resistant pathogens. They should be regarded as critical control points for preventing or reducing the release of antibiotics, antibiotic-resistant bacteria (ARB), and antibiotic-resistance genes (ARGs) into the natural environment. This review focuses on the fate of the pathogens Enterococcus faecium, Staphylococcus aureus, Clostridium difficile, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacteriaceae spp. (ESCAPE) in WWTPs. All ESCAPE pathogen species, including high-risk clones and resistance determinants to last-resort antibiotics such as carbapenems, colistin, and multi-drug resistance platforms, were detected in wastewater. The whole genome sequencing studies demonstrate the clonal relationships and dissemination of Gram-negative ESCAPE species into the wastewater via hospital effluents and the enrichment of virulence and resistance determinants of S. aureus and enterococci in WWTPs. Therefore, the efficiency of different wastewater treatment processes regarding the removal of clinically relevant ARB species and ARGs, as well as the influence of water quality factors on their performance, should be explored and monitored, along with the development of more effective treatments and appropriate indicators (ESCAPE bacteria and/or ARGs). This knowledge will allow the development of quality standards for point sources and effluents to consolidate the WWTP barrier role against the environmental and public health AR threats

International Travel as a Risk Factor for Carriage of Extended-Spectrum β-Lactamase-Producing in a Large Sample of European Individuals-The AWARE Study.

Antibiotic resistance (AR) is currently a major threat to global health, calling for a One Health approach to be properly understood, monitored, tackled, and managed. Potential risk factors for AR are often studied in specific high-risk populations, but are still poorly understood in the general population. Our aim was to explore, describe, and characterize potential risk factors for carriage of Extended-Spectrum Beta-Lactamase-resistant Escherichia coli (ESBL-EC) in a large sample of European individuals aged between 16 and 67 years recruited from the general population in Southern Germany, the Netherlands, and Romania. Questionnaire and stool sample collection for this cross-sectional study took place from September 2018 to March 2020. Selected cultures of participants' stool samples were analyzed for detection of ESBL-EC. A total of 1183 participants were included in the analyses: 333 from Germany, 689 from the Netherlands, and 161 from Romania. Travels to Northern Africa (adjusted Odds Ratio, aOR 4.03, 95% Confidence Interval, CI 1.67-9.68), Sub-Saharan Africa (aOR 4.60, 95% CI 1.60-13.26), and Asia (aOR 4.08, 95% CI 1.97-8.43) were identified as independent risk factors for carriage of ESBL-EC. Therefore, travel to these regions should continue to be routinely asked about by clinical practitioners as possible risk factors when considering antibiotic therapy