Multidrug-Resistant Enterobacteriaceae in Lebanese Hospital Wastewater: Implication in the One Health Concept.

Extended-spectrum beta-lactamases (ESBL) and carbapenemase-producing organisms pose severe problems for hospitalized patients. In the absence of efficient sanitation and sewage disposal, the risks for transmission of hospital organisms into the community are high. Our objectives were to study the occurrence and mechanisms of resistance of multidrug-resistant gram-negative bacilli in two Lebanese hospital sewage treatment plants. Wastewater samples were collected, filtered, and cultivated on MacConckey+cefotaxime agars. ESBL, AmpC, metallo-β-lactamases (MBL), and Klebsiella pneumoniae Carbapenemases (KPC) production were phenotypically detected using plain Mueller Hinton agar plates, and plates impregnated with 5 mM EDTA, 10 mg/mL phenyl boronic acid, and 250 μg/mL cloxacillin (embedded). Temocillin discs were used for the presumptive detection of OXAs. ESBL, carbapenemase, outer membrane protein F (OMPF), and outer membrane protein C (OMPC) genes were detected using polymerase chain reaction. Pulsed-field gel electrophoresis (PFGE) was performed to study the clonality of Enterobacter cloacae isolates. In total, 32 and 38 Enterobacteriaceae were detected from Hospital 1 and Hospital 2, respectively. All Escherichia coli and Klebsiella spp. isolates were ESBL producers. AmpC reached 25% and 28.9% of all isolates. Only one Enterobacter cloacae isolate from one hospital showed full resistance to carbapenems. Molecular tests, however, detected NDM-1 in two strains of Enterobacter cloacae. PFGE results showed 80% similarity between these two strains. The isolation of NDM-1-producing Enterobacter cloacae from hospital wastewater occurred almost a year before the first case of carbapenem-resistant Enterobacter spp. was detected from a patient sample in the laboratory hospital. Understanding the local epidemiology of resistance in hospitals should include areas of potential resistance, such as wastewater and hospital environment.