Open access peer-reviewed chapter
Prevalence of MRSA in wastewater from healthcare facilities from different countries.
Abstract
In most developing countries of the world and few advanced ones, wastewater are discharged into the environment without any form of treatment, thus exposing the general public to hazardous chemicals, residual antibiotics, heavy metals and so many antimicrobial compounds. This chapter deals with the threat posed by methicillin resistant Staphylococcus aureus (MRSA) introduced into the aquatic ecosystem via wastewater generated from the operations of healthcare facilities. It focuses more on the microbiology and composition of wastewater from the hospital environment, and the role they played as a stimulant for the development of resistance in bacteria, while also emphasizing their roles as important reservoirs of MRSA in the aquatic environment. The epidemiology of MRSA in wastewater discharge from low-middle and high -income countries was examined, with another dig at the public health significance of these organisms in the water environment. The concluding part dwells heavily on the management and control strategies from the authors’ perspective, and this includes the one-health approach and the enactment of Government policies to control the indiscriminate discharge of untreated wastewater from the healthcare settings into receiving water bodies.
Keywords
- wastewater
- hospital wastewater (HWW)
- healthcare facilities
- methicillin resistant Staphylococcus aureus (MRSA)
- aquatic environment
1. Introduction
Wastewater is any water whose quality has been lowered as a result of anthropogenic influence, and could be from several sources including agricultural, domestic, pharmaceutical, and hospitals. Wastewater from the hospital environment comes from various places hence the composition could vary. These places include the surgical areas, administrative blocks, laundries, laboratories, wards and the kitchens [1]. These wastewater contain a lot of hazardous and potentially dangerous chemicals compared to the urban wastewater. Most of these compounds are persistent and potentially toxic and could include radionuclides, disinfectants, antiseptics, quaternary ammonium compounds (QAC), solvents, remnants of drugs, and some antimicrobial compounds at various concentrations [2, 3, 4]. Verlicchi et al. [5] in a review, reported that the concentrations of antibiotics, analgesics and metals (micro-pollutants) in HWW are between 4 and 150 times higher than in urban wastewater, making HWW a hub of several toxic agents. In addition to this, hospital wastewater (HWW) is also a repository of antibiotic resistant organisms and resistance genes, as reported in a study by Adekanmbi et al. [6] on the diversity of resistant
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2. Wastewater from healthcare systems (composition and microbiology)
Wastewater is any water from different processing and manufacturing operations such as pharmaceuticals, agriculture, domestic sources, and healthcare centres, whose quality have been tainted by a high level of anthropogenic influence [7]. The hospital wastewater is however quite different from wastewater from other sources because it contains a vast number of micro- and macro- pollutants, which have been discharged from the different departments of hospitals including laboratories, theaters, laundries, research units and other notable sections [8]. Most of the pollutants in questions range from pharmaceuticals, chemical compounds, metals, media remnants, antibiotics, disinfectants, radioactive isotopes, and stock cultures [9]. In some instances, some pharmaceuticals present in hospital wastewater have been implicated in causing the disruption of the endocrine system, impairment of the reproductive system and sex reversal in some aquatic species [10]. The discharge of this wastewater has led to the build-up of nutrients in the receiving aquatic ecosystem, leading to eutrophication [7].
In many countries of the world, wastewater from the healthcare settings are discharged into sewage channels without any form of pre-treatment, after which it undergoes treatment in the municipal wastewater treatment plants, but in most instances, the treatment is not sufficient to remove these pollutants from the wastewater [11]. Another worrisome situation is the fact that pharmaceutical compounds present in the wastewater could undergo transformation and form conjugates, whose toxicity could be higher than that of the parent metabolite [12].
The HWW can act as an ideal medium for the proliferation of various classes of microorganisms e.g. viruses, bacteria, fungi and other parasites. Wastewater generated from the operations of the healthcare facilities is also a hub of bacteria showing resistance to several classes of antibiotics and antibiotic residues, which could cause an inhibition of the sensitive bacteria, thereby causing an elevation of the population of the resistance bacteria in the receiving water channels. These resistant bacteria could also act as vectors for the transmission of genes, or serve as vehicles and reservoirs for the proliferation of antibiotic resistance genes (ARG), that could pose a potential threat to public health [13].
HWW poses a very challenging threat to humans, society, hospital employees, patients, public health and the environment at large, as it has been implicated in the spread of infective diseases, and could also be a vehicle in terms of contagiousness [14]. A very worrisome constituent of HWW are the residual drugs. When medications are consumed by patients, the drugs are not fully metabolized by the human body, and residual concentrations are excreted into sewage or other receiving water sources via urine and feces. These residual quantities of these antimicrobial compounds act as stimulants for the onset of resistance in the microflora of the water or wastewater, thus leading to an increase in the population of potentially pathogenic strains of organisms [15]. These pathogenic organisms, which could be viruses, bacteria, algae, yeasts, protozoa, parasites and sometimes bacteriophages could survive for a long time in the receiving soils or water, and could eventually find their way into the food chain, causing infectious diseases and so many health risks to humans [16].
2.1 Wastewater from the healthcare facilities: a stimulant for antibiotic resistance
The treatment procedures for wastewater do not completely remove antibiotics, which increases the amount of antibiotics in aquatic ecosystems [17, 18]. The observed amounts of many antibiotics in surface water range from 0.001 to 484 g/L globally [19]. According to studies, the use of antibiotics in aquatic environments is linked to an increase in the number of antibiotic resistant bacteria (ARB) and the emergence of resistance genes [20]. Horizontal gene transfer (HGT) and mutagenesis in bacteria are influenced to a large extent by sub-inhibitory doses/concentration of antibiotics in aquatic systems [21]. As a result, a number of pathogenic microorganisms have developed resistance to the most potent medicines, and it is unclear how quickly new antibiotic resistant microorganisms emerge. Antibiotic resistant microorganisms disseminate resistance genes in the environment and transmit them to the following generation [22].
Clinical sewages have long served as important sources of antibiotic resistance determinants in aquatic ecosystems due to the usage of antibiotics in hospitals, particularly due to the excretion of their powerful forms into the environment [23]. Previous research revealed that HWW contains significant amounts of microorganisms and antibiotic drug residues, which has the ability to exert selective pressure on the spread of antibiotic resistant bacteria [24]. Consequently, compared to other wastewater systems, such as urban sewage systems, HWW is likely to pose greater hazards of the spread of ARGs [25, 26]. Therefore, hospitals and other healthcare settings are considered as one of the leading polluting sectors around the world [27]. Hospital wastewater treatment facilities in particular are regarded and best defined as the epicenter and major location for the spread of antibiotic resistance that could endanger public health if water is reused [28, 29].
Large amounts of antibiotics and other substances can impose selective pressure at low concentrations (below therapeutic levels) in pharmaceutical wastewaters from pharmaceuticals and healthcare wastewater [30, 31]. Studies have demonstrated that wastewaters produced during the manufacture of pharmaceuticals are reservoirs of antibiotic resistant bacteria (ARB) and antibiotic resistance genes (ARGs), and they may hasten the potential horizontal transfer of environmental resistance determinants across the endogenous microbial community [30, 32, 33].
Antibiotic-resistant bacteria (ARB) and their functional metabolites, as well as resistance genes (ARG), are frequent and pervasive pollutants in many ecosystems as a result of years of antibiotic misuse and overuse [34, 35]. Excreta from people and animals, as well as wastewater, are acknowledged and documented as primary sources of the microorganisms and chemicals mentioned above [34]. Despite the fact that treatment methods can lower pathogen concentrations in wastewater, wastewater treatment plant effluents do not generally show a significant reduction of ARB and ARG, and a lot of these pathogens, possibly from hospitals, are released into the recipient waterways [28, 36].
According to recent reports, the environment contains other key sources of antibiotic resistance, such as animal farms, wastewater treatment facilities [WWTPs] [32, 37, 38]. Since antibiotic resistance genes are now regarded as environmental contaminants, it is evident that their future dissemination must be prevented [39, 40]. To enable this, it is necessary to clarify their potential reservoirs, particularly those found in the environment. A major global public health concern is the prevalence of antibiotic resistance genes (ARGs) in the environment due to the extensive use of antibiotics in healthcare systems, agriculture, and breeding [41, 42]. Long-term trends show that the use of antibiotics is increasing, thus stagnation or decline is not anticipate [43]. To prevent the establishment of resistance, research is already pointing to the potential use of novel medications in combination with nanotechnologies. Different nanomaterials having antibacterial properties based on carbon, titanium, silver, or gold are used in several new technologies [44].
In low- and middle-income countries (LMIC), where many hospitals either lack wastewater treatment plants or have inadequate ones, the hazards of such clinical illnesses may be more serious. To make matters worse, surface water is frequently used for home and agricultural uses, or even ingested untreated, especially in rural regions [23]. Antibiotic resistance genes are disseminated in such waters and have been reported to be more widespread in environmental non-pathogenic microbial populations than was originally believed [45, 46]. According to reports, these resistances spread among bacterial populations in two main ways: vertical gene transfer (during bacterial cell division) and horizontal gene transfer, or conjugation, transformation, and transduction, supported by mobile genetic elements (MGEs) [47]. The diversity, distribution, and future of ARGs in urban water systems are still unknown, despite the fact that antibiotic resistance is widely acknowledged as a major danger to human public health [48].
Regulations on sludge/sewage emission criteria have been adopted globally since the 1980s in an effort to reduce the harm caused by effluent after it is discharged [49]. However, only a few countries (such as France and Italy) have set up laws governing hospital wastewater (HWW) treatment before release [50]. Unfortunately, no emission standard for wastewater has required the biological safety assessment of ARGs [51]. The current condition results in a significant biosafety risk of ARGs from HWW, which has been largely disregarded by legislation and contemporary wastewater treatment facilities [51].
2.2 Wastewater from healthcare facilities: a reservoir for the introduction of MRSA into the aquatic ecosystem
Hospital wastewater poses a significantly greater environmental threat than urban effluent [52]. The hospitals use an enormous quantity of water each day, ranging from 400 to 1200 liters, and produce a sizeable amount of wastewater each day in their operations [53]. These facilities are also renowned for the wide range and high rates of wastewater pollution in aquatic environments [54]. Hospitals are well known for their excessive and ongoing usage of antibiotics [55]. According to Bui
Most antibiotics used are excreted into wastewater, where they may sustain or impose selective pressure on microorganisms culminating in resistance development [58]. In wastewater, antibiotic resistant bacteria and genes are frequently found in more significant numbers and concentrations than in surface water [59]. Additionally, wastewater can foster the development of a diverse bacterial community that serves as a breeding ground for bacteria that are resistant to antibiotics. As a result, it has been hypothesized that wastewater treatment facilities contribute to the spread and evolution of antibiotic-resistant microorganisms. Methicillin-resistant
2.3 Epidemiology of MRSA in wastewater from healthcare facilities in low-middle- and high-income countries
Antimicrobial-resistant bacteria are increasingly causing environmental water pollution issues on a global scale [65]. In addition to making antibiotic treatment challenging, the appearance and spread of Antimicrobial-resistant bacteria have become a significant issue for hospitals and other healthcare facilities [66]. This is because it increases the danger of epidemics and severe outbreaks of infectious illnesses. The World Health Organization (WHO) released a list of 12 particular groups of antimicrobial resistant bacteria (AMRB). Methicillin-resistant
| Year of study | Prevalence | Source | Countries | Region | Reference |
|---|---|---|---|---|---|
| 2022 | 94–96% | Hospital effluent and Healthcare facility effluent | Japan | High-income country | [67] |
| 2021 | 97% | Hospital effluent | Japan | High-income country | [68] |
| 2013 | 70–81% | Regional hospital and Metropolitan hospital | Australia | High-income country | [69] |
| 2019 to 2020 | 37.5% | Hospital wastewater | Japan | High-income country | [70] |
| 2012 | 10% | Hospital wastewater | Ethiopia | Low-income country | [71] |
| 2020 | 100% | Hospital wastewater | Bangladesh | Low-middle-income country | [72] |
| 2015 | 90% | Hospital effluent | India | Low-middle-income country | [73] |
| 2017 | 11%, and 8% | Raw and Treated hospital sewage water | Iran | Low-middle-income country | [74] |
| 2019 to 2020 | 46.9% | Hospital wastewater | Portugal | High-income country | [75] |
| 2015 | 47% | Hospital wastewater | Iran | Low-middle-income country | [76] |
| 2015 | 53% | Hospital wastewater | Iran | Low-middle-income country | [76] |
Table 1.
2.4 Public health challenges of MRSA in the aquatic environment
The ubiquitous bacteria-
The treatment of bacterial illnesses relies heavily on antibiotics. As the number of bacteria that are resistant to antibiotics increases, there are less and fewer drugs that can effectively combat certain infections. Bacteria develop resistance mostly by horizontal gene transfer and genetic alterations, which allow infections to flourish in the environment while antibiotics are present [82, 83]. Hospitals and other settings are increasingly encountering multiple drug resistant strains, causing hazardous illnesses for people [84].
Within the next 30 years, the world’s population is expected to reach 10 billion, and agricultural production is expected to rise by 70%. This will further put pressure on freshwater supplies [85]. Nearly 50% of the world’s population use contaminated water sources to irrigate crops, and it is estimated that 20 million hectares are watered with wastewater [86]. Many cities throughout the world with historically low rainwater collection have used wastewater in agriculture for generations. It is also becoming a more important alternative source of water in nations mostly affected by water scarcity, particularly in those that depend on agriculture for a living. Re-using untreated wastewater is one of the few accessible options to the sophisticated procedures used in the majority of wastewater treatment facilities in high-income nations for many low-income countries [87]. High levels of pathogens, pharmaceuticals, heavy metals, plastic additives, and other contaminants can be found in wastewater, and these contaminants might negatively affect plant growth when wastewater is used for their irrigation [88].
Pharmaceuticals, personal care items, antibiotic residues, antimicrobial resistant bacteria (ARB), and antimicrobial resistance genes (ARGs) are contaminants of particular concern [89]. Antibiotics have been detected in treated wastewater effluent and ARB/ARGs can withstand or even proliferate at treatment plants [90, 91]. Wastewater irrigation can result in ongoing antibiotic exposure for the irrigated crops, which can cause the establishment of resistant bacteria. ARGs can be transferred between native soil communities and wastewater bacteria via irrigation-delivered ARB in wastewater [92].
The following vegetables can be eaten raw: carrot, radish, cucumber, tomato, cabbage, lettuce, coriander, and. Food-borne illnesses could occasionally develop from improper washing and peeling, which can act as a vehicle for several germs. Numerous microorganisms can infect people through the oral route [93]. For instance, since lettuce is not processed before consumption, all of the (resistant) bacteria that are present in it may be directly ingested by consumers [94]. Because they are necessary components of our diet and are frequently eaten raw or with minimal preparation, fruits and vegetables can be a major source of human pathogens [95]. Market garden items are frequently thought to be contaminated by irrigation water [96]. The fact that they come from market gardeners who have already engaged in self-medication by treating infections brought on by their working tools, can explain the presence of multidrug resistant
Surface waters have been noted as possible antibiotic and antibiotic resistance reservoirs [98, 99]. In numerous countries, research have found genes and pathogens associated with antibiotic resistance in lakes, rivers, streams, ponds, and estuaries. A possible risk of human exposure to resistant bacteria exists since some of the surface waters that contain antimicrobial resistance genes (ARGs) are used for recreational purposes [100]. Antibiotic residues, heavy metals, natural processes, and climate change are the causes of antibiotic resistance in surface waterways, whereas healthcare facilities, wastewater, agricultural settings, food, and wildlife populations are the main vehicles [101, 102]. For hospitals and other medical facilities, the formation and spread of antimicrobial resistance has become a critical issue since it makes antimicrobial treatment challenging and raises the danger of epidemics and severe outbreaks of infectious illnesses [103].
Penicillin provided temporary relief, but in the 1940s, resistance developed through the β-lactamase gene
Resistance to methicillin and oxacillin is caused by the acquisition of a gene that encodes a PBP2 homolog termed PBP2a that is resistant to drug activity [105, 106]. The peptidoglycan produced when an MRSA strain is cultured in the presence of β-lactams is not well cross-linked. If the MRSA strain is exposed to β-lactams, one outcome of this is that the peptidoglycan has higher proinflammatory effects, which may lead to pathology during infection [107]. The
Antibiotic-resistant
2.5 Management and control strategies
The World Health Organization (WHO) has urged countries to create a Global Action Plan on Antimicrobial Resistance, a framework for an action plan for AMRB, and has argued that comprehensive measures should be taken to assess and resolve the issues involving AMRB, taking into account their interactions among people, animals, and the environment based on the fundamental principle of One Health [116]. These countermeasures include Clarification of the pollution status and an evaluation of the environmental danger of MRSA in aquatic environments: For life to exist, there must be water. Additionally, more medicines and residues are discovered in the ambient compartment. Water pollution is one of the critical issues associated with water, along with water scarcity and floods. Drug residues and resistant microbes can be found in large quantities in hospital wastewater, but the situation is much more severe in numerous countries. In LMIC, where drug use is more prevalent, the Sustainable Development Goals are critical [117]. However, according to the United Nations [102], over 80% of the world’s wastewater is dispersed into the environment without sufficient treatment. Water recycling is likely necessary to address water shortages and advance a circular economy, but the quality of the recycled water must be ensured. As part of the Registration, Evaluation, Authorization, and Restriction of Chemicals Program (ECREARCP) of the European Commission, ecotoxicological evaluations based on bioaccumulation tests are crucial for determining the environmental risk of chemical compounds. In order to assess the risk that prospective water pollutants pose and, consequently, whether specific restrictions should be imposed, the Surface Water “Watch List” under the Water Framework Directive (WFD) is a system used in Europe. For the benefit of other regions of the world, especially the LMIC, this list should be updated every 2 years and made available.
2.5.1 Surveillance
As part of the hospital infection control program, surveillance must be conducted regularly and a recognized component of the clinical governance process. For bench-marking purposes, surveillance data should be gathered and published consistently, using agreed-upon case definitions and specialty activity denominators, with case mix stratification. Most hospital staff should easily understand surveillance data, which should be discussed often at hospital senior management committees and in regional infection control training. The results of microbiological tests conducted for clinical purposes, as well as the results of those investigations conducted for screening purposes, should all contain MRSA monitoring if there are any requirements in the hospital state rules.
2.5.2 Screening
MRSA carriage should be actively screened for in hospital wastewater and patient samples, and the findings should be connected to a focused strategy for isolation and facility cohorts. It is essential to routinely check hospital wastewater that poses a high MRSA risk. The infection control team must conduct local screening of the hospital wastewater, discuss it with the necessary clinical teams, and receive approval from the pertinent hospital management structure. This will affect the risk status of each hospital wastewater, the local prevalence of MRSA in the wastewater, and the propensity for MRSA to be present in the wastewater.
2.5.3 Antibiotic stewardship
Many hospital staff members need to be made aware of antibiotics’ use and side effects. Identifying key personnel in charge of monitoring antibiotic resistance and consumption, prescriber education, and the effects of antibiotics in wastewater on aquatic life and the community are critical elements of implementing antibiotic stewardship programs in healthcare facilities. The prevalence of MRSA in hospital wastewater can be decreased by avoiding inappropriate or excessive antibiotic therapy and prophylaxis, making sure that antibiotics are administered at the correct dosage and for the right amount of time, and only the proper antibiotics in cases of infection.
2.5.4 One health approach
One Health Approach is founded on the idea that treating each issue separately will prevent us from understanding the interconnectedness of human, animal, and environmental health. We need a comprehensive approach to grasp these domains’ interdependence to tackle complicated public health concerns. However, what impact would One Health have on our healthcare system? The community’s dynamic microbiological inputs from people and animals are included in hospitals as incubators. The use of antibiotics places selection pressure on these incoming microbial populations, causing a change to a more significant proportion of resistant organisms. Hospital-associated multidrug-resistant organisms (MDRO) can colonize people while they are in the hospital (both patients and staff). A feedback loop is initiated when they are released back into the community. The hospital serves as a surveillance site and a multiplier for resistant organisms and infections due to MDRO acquisition and infection, which further emphasizes the need to describe community- and hospital-based risk factors that affect the hospital environment. By considering the interaction between the patient, the hospital equipment, the hospital environment, and the role of the community, a One Health approach may help create unique research and multi-modal intervention approaches. This includes well-known local risk factors for MRSA colonization in hospital wastewater, such as patients, pet ownership, or residing in an area with an active livestock industry. The complexity of hospital infection control warrants a multidisciplinary approach. An integrated approach is required to direct research avenues and public policy mediation.
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3. Conclusion
This write-up further outlines the public health challenge associated with the discharge of untreated wastewater from healthcare facilities into the environment. This act not only introduce potentially pathogenic microorganisms into the environment, it also serve as a medium for the dissemination of the antibiotic resistant strains of which MRSA is a major threat. There is an urgent need to put mitigation protocols in place to prevent a potential public health breakdown as a result of the unwholesome act of discharging wastewater into receiving water bodies and the environment at large without any form of treatment. Relevant agencies in countries affected by this menace should wake up to their responsibilities and carry out enlightenment campaigns to educate hospitals and the populace on the danger inherent in such practices. A stitch in time saves nine.
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Acknowledgments
The authors would like to appreciate the authors whose work served as the reference point for this chapter.
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