Antimicrobials and antimicrobial resistance genes in a one-year city metabolism longitudinal study using wastewater-based epidemiology.

This longitudinal study tests correlations between antimicrobial agents (AA) and corresponding antimicrobial resistance genes (ARGs) generated by a community of >100 k people inhabiting one city (Bath) over a 13 month randomised monitoring programme of community wastewater. Several AAs experienced seasonal fluctuations, such as the macrolides erythromycin and clarithromycin that were found in higher loads in winter, whilst other AA levels, including sulfamethoxazole and sulfapyridine, stayed consistent over the study period. Interestingly, and as opposed to AAs, ARGs prevalence was found to be less variable, which indicates that fluctuations in AA usage might either not directly affect ARG levels or this process spans beyond the 13-month monitoring period. However, it is important to note that weekly positive correlations between individual associated AAs and ARGs were observed where seasonal variability in AA use was reported: ermB and macrolides CLR-clarithromycin and dmCLR-N-desmethyl clarithromycin, aSPY- N-acetyl sulfapyridine and sul1, and OFX-ofloxacin and qnrS. Furthermore, ARG loads normalised to 16S rRNA (gene load per microorganism) were positively correlated to the ARG loads normalised to the human population (gene load per capita), which indicates that the abundance of microorganisms is proportional to the size of human population and that the community size, and not AA levels, is a major driver of ARG levels in wastewater. Comparison of hospital and community wastewater showed higher number of AAs and their metabolites, their frequency of occurrence and concentrations in hospital wastewater. Examples include: LZD-linezolid (used only in severe bacterial infections) and AMX-amoxicillin (widely used, also in community but with very low wastewater stability) that were found only in hospital wastewater. CIP-ciprofloxacin, SMX-sulfamethoxazole, TMP-trimethoprim, MTZ-metronidazole and macrolides were found at much higher concentrations in hospital wastewater while TET-tetracycline and OTC-oxytetracycline, as well as antiretrovirals, had an opposite trend. In contrast, comparable concentrations of resistant genes were observed in both community and hospital wastewater. This supports the hypothesis that AMR levels are more of an endemic nature, developing over time in individual communities. Both hospital and community wastewater had AAs that exceeded PNEC values (e.g. CLR-clarithromycin, CIP-ciprofloxacin). In general, though, hospital effluents had a greater number of quantifiable AAs exceeding PNECs (e.g. SMX-sulfamethoxazole, ERY-erythromycin, TMP-trimethoprim). Hospitals are therefore an important consideration in AMR surveillance as could be high risk areas for AMR.

Quantifying community-wide antibiotic usage via urban water fingerprinting: Focus on contrasting resource settings in South Africa.

There has been a significant increase in antimicrobial agents (AAs) usage, globally - however the relative consumption is unevenly distributed between nations. Inappropriate use of antibiotics can harbour inherent antimicrobial resistance (AMR); therefore, it is important to understand and monitor community-wide prescribing and consumption behaviours throughout different communities around the world. Wastewater-Based Epidemiology (WBE) is a novel tool enabling low cost and large scale studies focussed on AA usage patterns. The back-calculation of community antimicrobial intake was performed from quantities measured in municipal wastewater and informal settlement discharge in the city of Stellenbosch, utilising WBE. Seventeen antimicrobials, and their human metabolites, were evaluated, in concordance with prescription records corresponding to the catchment region. The proportional excretion, biological/chemical stability, and method recovery of each analyte were all crucial factors in the efficacy of the calculation. Mass per day measurements were normalised to the catchment area via population estimates. Municipal wastewater treatment plant population estimates were used to normalise the wastewater samples and prescription data (mg/day/1000 inhabitants). Population estimates for the informal settlements were less accurate due to a lack of reliable sources that were relevant to the sampling time period. Both mass loads and normalised loads suggested higher than average usage throughout the settlements, relative to municipal wastewater. This was seen most prominently in emtricitabine and lamivudine; but also, sulfamethoxazole, trimethoprim, sulfadiazine, clindamycin, ciprofloxacin, ofloxacin, and doxycycline. Urban water fingerprinting (UWF) data triangulation with prescription datasets showed good correlations for several antimicrobial agents (AAs) (e.g., clindamycin, clarithromycin, ofloxacin, and doxycycline). It also revealed discrepancies in usage for some compounds (e.g., tetracycline and sulfapyridine). This might be linked with a lack of pharma compliance in prescription datasets; erroneous association of prescription boundaries with the sewerage catchment; and/or uncertainties within the sewerage catchment (e.g., population estimations). The UWF tool provided a comprehensive overview of multiclass AAs usage, both prescription and over-the counter. For example, tetracycline was not reported in available prescription statistics, but was detected at an average of 18.4 mg/day/1000inh; and no antiviral prescriptions were obtained, but emtricitabine and lamivudine were quantified at 2415.4 and 144.4 mg/day/1000inh, respectively. A lack of clarity regarding prescriptions and a lack of inclusion of several critical (often over-the-counter) medications in public health databases makes WBE a useful and comprehensive epidemiology tool for tracking pharma usage within a catchment.

Community infectious disease treatment with antimicrobial agents - A longitudinal one year study of antimicrobials in two cities via wastewater-based epidemiology.

Antimicrobial resistance (AMR) is one of the most significant global health threats. Inappropriate and over-usage of antimicrobial agents (AAs) is a major driver for AMR. Wastewater-based epidemiology (WBE) is a promising tool for monitoring AA usage in communities which is, for the first time, explored in this large scale, longitudinal study. Two contrasting urban catchment areas have been investigated: one city and one small town in the Southwest of the UK over a 13-month period in 2018-2019. Per capita daily intake of 17 AAs and metabolites has been estimated and obtained estimates were triangulated with catchment specific AA prescription data to understand AA usage patterns (both seasons driven prescription and AA prescription compliance). Results have demonstrated positive correlations for all quantifiable parent AAs and metabolites in wastewater, and spatial variability in AA usage was observed even in neighbouring urban areas. WBE and catchment specific prescription data showed similar seasonal trends but with low correlation in intake. The reasons might be variable prescribing patterns, prescription/intake outside the studied catchment, and/or lack of patient compliance. WBE proved useful in differentiating between consumption vs topical usage and/or direct disposal of unused AA. WBE is considered superior to prescription data as it provides information on AAs prescribed outside of the monitoring catchment, e.g. HIV antivirals and TB drugs. However, data triangulation, of both prescription data and wastewater data, provides the most comprehensive approach to understanding AA usage in communities.

In-situ multi-mode extraction (iMME) sampler for a wide-scope analysis of chemical and biological targets in water in urbanized and remote (off-the-grid) locations.

Chemical pollution (including chemicals of emerging concern - CECs) continues to gain increasing attention as a global threat to human health and the environment, with numerous reports on the adverse and sometimes devastating effects upon ecosystems the presence of these chemicals can have. Whilst many studies have investigated presence of CECs in aquatic environments, these studies have been often focused on higher income countries, leaving significant knowledge gaps for many low-middle income countries. This study proposes a new integrated powerless, in-situ multi-mode extraction (iMME) sampler for the analysis of chemicals (105 CECs) and biological (5 genes) markers in water in contrasting settings: an urbanized Avon River in the UK and remote Olifants River in Kruger National Park in South Africa. The overarching goal was to develop a sampling device that maintains integrity of a diverse range of analytes via analyte immobilization using polymeric and glass fibre materials, without access to power supply or cold chain (continuous chilled storage) for sample transportation. Chemical analysis was achieved using ultra-performance liquid chromatography coupled with tandem mass spectrometry. Several mobile CECs showed low stability in river water, at room temperature and typical 24 h sampling/transport time. It is therefore recommended that, in the absence of cooling, environmental water samples are spiked with internal standards on site, immediately after collection and analyte immobilization option is considered, in order to allow fully quantitative analysis. iMME has proven effective in immobilization, concentration and increased stability of CECs at room temperature (and at least 7 days storage) allowing for sample collection at remote locations. The results from the River Avon and Olifants River sampling indicate that the pristine environment of Olifants catchment is largely unaffected by CECs common in the urbanized River Avon in the UK with a few exceptions: lifestyle chemicals (e.g., caffeine, nicotine and their metabolites), paracetamol and UV filters due to tourism and carbamazepine due to its persistent nature. iMME equipped with an additional gene extraction capability provides an exciting new opportunity of comprehensive biochemical profiling of aqueous samples with one powerless in-situ device. Further work is required to provide full integration of the device and comprehensive assessment of performance in both chemical and biological targets.

Assessment of community-wide antimicrobials usage in Eastern China using wastewater-based epidemiology.

Wastewater-based epidemiology (WBE) has potential to identify the epidemiological links between people, animals, and the environment, as part of antimicrobial resistance (AMR) surveillance. In this study, we investigated six wastewater treatment plants (WWTPs) serving six communities located in two regions in Eastern China: Site A in Zhejiang and site B in Jiangsu province to assess the public use of antimicrobial agents (AA). Fifty antimicrobials and 24 of their metabolites were quantified using ultraperformance liquid chromatography coupled with triple quadrupole tandem mass spectrometry (UPLC-MS/MS). Spatiotemporal trends were established for measured concentrations, daily loads, and population-normalised daily loads. Daily AA mass loads varied between 1.6 g/day and 324.6 g/day reflecting the WWTP scales, with macrolides and ß-lactams showing the highest overall environmental burden at 223.7 g/day and 173.7 g/day, respectively. Emissions of antibiotic residues from manufacturing have been observed, with the peak daily load 12-fold higher than the overall load from a community serving a population of over 600,000. Community exposure levels of 225.2 ± 156.2 mg/day/1000 inhabitant and 351.9 ± 133.5 mg/day/1000 inhabitant were recorded in site A and B, respectively. Paired parent-metabolites analysis identified a large proportion (64-78%) of un-metabolised metronidazole and clindamycin at site B, indicating improper disposal of unused drugs either in the community or in livestock production. Consumption levels, calculated via WBE, suggested relatively low antimicrobial usage in Eastern China compared to other areas in China. This first application of WBE in Eastern China to assess the community-wide exposure to AAs has potential to inform regional antimicrobial stewardship.

Spatiotemporal urban water profiling for the assessment of environmental and public exposure to antimicrobials (antibiotics, antifungals, and antivirals) in the Eerste River Catchment, South Africa.

Antimicrobial agent (AA) usage, excretion, and persistence are all important factors in association with the occurrence and dissemination of antimicrobial resistance. Urban water profiling was utilised in the Eerste River catchment (South Africa) to establish AA usage in a region where comprehensive prescription records were not readily available and where portions of the community did not have sufficient access to sanitation. This technique enabled the environmental exposure to be quantified throughout the catchment area and the identification of contamination hotspots. Monitoring occurred over a 11-month period. 812 samples were processed using UPLC-MS/MS for the quantitation of 56 antimicrobials and 26 of their metabolites. Spatiotemporal trends were established, with consideration to community behaviour, seasonal changes, and physiochemical properties of the analytes. The Eerste River samples collected upstream from the town of Stellenbosch had the lowest AA loads (<4 g/day), unafflicted by industrial presence and with only small impact from farming activities. This was followed by sites downstream from a wastewater treatment plant (serving 178 K people). The measurement of low AA loads (influent: 500-800 g/day and effluent 50-100 g/day), indicates a high efficiency of wastewater treatment, allowing for an effective reduction of AA and a lower environmental burden. This is compared to river sites that receive untreated waste from communities in informal settlements (6-12 K people) that are not connected to the sewer infrastructure (with AA levels accounting for 100-600 g/day). Temporal trends exhibited reduced daily loads during the summer to early autumn (Nov-May). This is likely due to seasonal patterns in community health and/or notable changes in rainfall and temperatures at the sampling locations throughout the year. However, weather patterns are also important to consider - particularly for the river sites. South Africa has notable rainfall and temperature seasonality. Antiretrovirals (ARV), emtricitabine and lamivudine, were the most prevalent drugs throughout the monitoring campaign, followed by tuberculosis drugs and sulfonamides. ARVs were, however, effectively reduced via wastewater treatment processes (>97%). This was also the case for beta-lactams, nitrofurantoin, and trimethoprim. The treatment efficacy for other drugs was more variable, that did not appear to have temporal significance.

Quantifying community-wide antimicrobials usage via wastewater-based epidemiology.

Increasing usage of antimicrobials is a significant contributor to the emergence and dissemination of antimicrobial resistance. Wastewater-based epidemiology is a useful tool for evaluating public health, via the monitoring of chemical and biological markers in wastewater influent, such as antibiotics. Sixteen antimicrobials and their metabolites were studied: sulfonamides, trimethoprim, metronidazole, quinolones, nitrofurantoin, cyclines, and antiretrovirals. Correction factors (CFs) for human drug excretion, for various drug forms, were determined via a systematic literature review of pharmacokinetic research. Analyte stability was examined over a 24 h study. The estimation of community-wide drug intake was evaluated using the corresponding catchment prescription data. Overall, antimicrobials excreted in an unchanged form were often observed to over-estimate daily intake. This could be attributed to biotransformation, e.g., via glucuronide cleavage, or direct disposal of unused drugs. Acetyl-sulfonamides, trimethoprim, hydroxy-metronidazole, clarithromycin, ciprofloxacin, ofloxacin, tetracycline, and oxytetracycline generally performed well in the estimation of drug intake, relative to prescription records. The low prevalence of quinolone and trimethoprim metabolites, and the low stability of nitrofurantoin, limited the ability to evaluate these metabolites and their respective CFs.

Multiresidue antibiotic-metabolite quantification method using ultra-performance liquid chromatography coupled with tandem mass spectrometry for environmental and public exposure estimation.

This manuscript describes a new multiresidue method utilising ultra-performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) via multiple reaction monitoring (MRM), for the identification and quantification of 58 antibiotics and their 26 metabolites, in various solid and liquid environmental matrices. The method was designed with a 'one health' approach in mind requiring multidisciplinary and multisectoral collaborative efforts. It enables comprehensive evaluation of antibiotic usage in surveyed communities via wastewater-based epidemiology, as well as allowing for the assessment of potential environmental impacts. The instrumental performance was very good, demonstrating linearity up to 3000 µg L-1, and high accuracy and precision. The method accuracy in several compounds was significantly improved by dividing calibration curves into separate ranges. This was accompanied by applying a weighting factor (1/x). Microwave-assisted and/or solid-phase extraction of analytes from liquid and solid matrices provided good recoveries for most compounds, with only a few analytes underperforming. Method quantification limits were determined as low as 0.017 ng L-1 in river water, 0.044 ng L-1 in wastewater, 0.008 ng g-1 in river sediment, and 0.009 ng g-1 in suspended solids. Overall, the method was successfully validated for the quantification of 64 analytes extracted from aqueous samples, and 45 from solids. The analytes that underperformed are considered on a semi-quantitative basis, including aminoglycosides and carbapenems. The method was applied to both solid and liquid environmental matrices, whereby several antibiotics and their metabolites were quantified. The most notable antibiotic-metabolite pairs are three sulfonamides and their N-acetyl metabolites; four macrolides/lincomycins and their N-desmethyl metabolites; and five quinolone metabolites.

Characterisation of the protein corona using tunable resistive pulse sensing: determining the change and distribution of a particle's surface charge.

The zeta potential of the protein corona around carboxyl particles has been measured using tunable resistive pulse sensing (TRPS). A simple and rapid assay for characterising zeta potentials within buffer, serum and plasma is presented monitoring the change, magnitude and distribution of proteins on the particle surface. First, we measure the change in zeta potential of carboxyl-functionalised nanoparticles in solutions that contain biologically relevant concentrations of individual proteins, typically constituted in plasma and serum, and observe a significant difference in distributions and zeta values between room temperature and 37 °C assays. The effect is protein dependent, and the largest difference between the two temperatures is recorded for the γ-globulin protein where the mean zeta potential changes from -16.7 to -9.0 mV for 25 and 37 °C, respectively. This method is further applied to monitor particles placed into serum and/or plasma. A temperature-dependent change is again observed with serum showing a 4.9 mV difference in zeta potential between samples incubated at 25 and 37 °C; this shift was larger than that observed for samples in plasma (0.4 mV). Finally, we monitor the kinetics of the corona reorientation for particles initially placed into serum and then adding 5 % (V/V) plasma. The technology presented offers an interesting insight into protein corona structure and kinetics of formation measured in biologically relevant solutions, i.e. high protein, high salt levels, and its particle-by-particle analysis gives a measure of the distribution of particle zeta potential that may offer a better understanding of the behaviour of nanoparticles in solution. Graphical Abstract The relative velocity of a nanoparticle as it traverses a nanopore can be used to determine its zeta potential. Monitoring the changes in translocation speeds can therefore be used to follow changes to the surface chemistry/composition of 210 nm particles that were placed into protein rich solutions, serum and plasma. The particle-by-particle measurements allow the zeta potential and distribution of the particles to be characterised, illustrating the effects of protein concentration and temperature on the protein corona. When placed into a solution containing a mixture of proteins, the affinity of the protein to the particle's surface determines the corona structure, and is not dependent on the protein concentration.