Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel, HaAliya HaShniya St 8, Haifa 3109601, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Efron St 1, Haifa 3109601, Israel.
Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel, HaAliya HaShniya St 8, Haifa 3109601, Israel.
Sci Total Environ. 2020 Nov 15;743:140804. doi: 10.1016/j.scitotenv.2020.140804. Epub 2020 Jul 11.
Antibiotic-resistant bacteria (ARB) and antibiotic-resistance genes (ARGs) are constantly shed into the aquatic environment, with hospital wastewater potentially acting as an important source for resistance spread into the environment. A systematic review was conducted aiming to investigate the role of hospital wastewater on dissemination of antimicrobial resistance in the aquatic environment. Studies included in the review compared the prevalence of ARB and/or ARGs in hospital versus community wastewater. Data were extracted on ARB and/or ARG prevalence. Data on sampling techniques, microbiological methodology and risk of bias of included studies were recorded. Thirty-seven studies were included. Higher frequencies of antibiotic resistance determinants were found in hospital wastewater compared to community sources in 30/37 (81%) of included studies. However, trends for specific multi-drug-resistant bacteria differed. Antibiotic-resistant Gram-negative were more prevalent in hospital compared to community wastewaters, with higher concentrations of extended-spectrum-beta-lactamase-producing pathogens and carbapenemase-producing Enterobacteriaceae in hospital sources in 9/9 studies and 6/7 studies, respectively. Hospitals did not contribute consistently to the abundance of vancomycin-resistant Enterococci (VRE); 5/10 studies found higher abundance of VRE in hospital compared to community wastewaters. Reporting on sampling methods, wastewater treatment processes and statistical analysis were at high risk of bias. Extreme heterogeneity in study methods and outcome reporting precluded meta-analysis. Current evidence concurs that hospital wastewater is an important source for antibiotic resistance in aquatic environments, mainly multidrug-resistant Gram-negative bacteria. Future research is needed to assess the effect of wastewater treatment processes on overall antibiotic resistance in the aquatic environment.
耐抗生素细菌 (ARB) 和抗生素耐药基因 (ARGs) 不断排入水生环境，医院废水可能是抗生素耐药性向环境传播的重要来源。本系统综述旨在调查医院废水在水生环境中抗生素耐药性传播中的作用。纳入的研究比较了医院和社区废水中 ARB 和/或 ARG 的流行率。提取了 ARB 和/或 ARG 流行率的数据。记录了纳入研究的采样技术、微生物学方法和偏倚风险的数据。共纳入 37 项研究。在 37 项纳入研究中，有 30 项（81%）发现医院废水中抗生素耐药决定因素的频率高于社区来源。然而，特定多药耐药细菌的趋势不同。与社区废水相比，医院废水中耐抗生素的革兰氏阴性菌更为普遍，9/9 项研究和 6/7 项研究分别发现医院来源的产超广谱β-内酰胺酶病原体和产碳青霉烯酶肠杆菌科的浓度更高。医院废水并不始终导致万古霉素耐药肠球菌 (VRE) 的丰度增加；10 项研究中有 5 项发现医院废水中的 VRE 丰度高于社区废水。关于采样方法、废水处理过程和统计分析的报告存在高度偏倚风险。研究方法和结果报告的极端异质性排除了荟萃分析。目前的证据表明，医院废水是水生环境中抗生素耐药的重要来源，主要是多药耐药革兰氏阴性菌。需要进一步研究来评估废水处理过程对水生环境中总体抗生素耐药性的影响。
