Today was the inaugural Healthcare Cleaning Forum. The plan was to showcase some healthcare cleaning and disinfection science at the Interclean Conference in Amsterdam (which is a huge general cleaning show). I think we managed to create some awareness about the unique challenges of cleaning and disinfection in healthcare outside of the usual crowd.
There have been a few important updates on the prevention and control of MDR-GNR from ECCMID, here in Madrid. I thought I’d share a couple of key reflections.
Professor Joakim Larsson gave a frankly chilling lecture on antibiotic pollution and its impact on the environmental resistome. Antibiotic resistance genes are fairly common in soil bacteria, and indeed, pre-date the use of antibiotics. Furthermore, the reservoir of resistance genes in soil bacteria seems to have increased since the 1940s when we began using antibiotics. This creates a huge reservoir of resistance determinants to the tune of some 1030 bacteria, an unimaginably massive number that we can only begin to understand through analogy. Fortunately, there is not a free flow of antibiotic resistance genes from environmental to hospital bacteria. However, where there’s close contact and selective pressure, transfer of resistance genes from environmental bacteria to hospital pathogens does occur. Prof Larsson introduced the idea of ‘minimal selective concentration (MSC)’, the cost-benefit equation for bacteria carrying antibiotic resistance genes.
This problem is driven by the appropriate and inappropriate use of antibiotics in human medicine, agriculture and aquaculture. Indeed, we all know about the high rates of NDM-1 in the New Delhi water supply; the modern day John Snow’s water pump handle (although the solution is not as obvious)? Another important driver is antibiotic contaminated effluent from pharmaceutical factories producing antibiotics. A large amount of pharmaceutical production of antibiotics occurs in emerging markets, such as India. There are tight regulations on what factories are allowed to release into their surrounding environment in many countries, but some are largely unregulated. One plant in India released phenomenal amounts of one particular antibiotic, ciprofloxacin, in waste water: 44kg per day. To put this in context, that’s almost 5x the amount of the same antibiotic consumed by the whole of Sweden per day, and the concentration of the antibiotic in the waste water was higher than therapeutic levels of the drug in humans! Unsurprisingly, this provides a strong selective pressure for the development of antibiotic resistance in the bacteria surrounding the factories. There are special treatments available to reduce or eliminate antibiotic contamination of factory waste (e.g. active carbon filtration or ozone treatment). But incentives are required to ensure that these technologies are implemented in the resource-limited settings where the factories are based.
Prof Larsson is planning some research to help to understand the relationship between environmental bacteria and hospital pathogens, for example, through his ‘NoCURE’ (Novel Carbapenemases – UnRaveling the Environmental reservoir) project, and the BacMet database for registering biocide and metal resistance genes, which are both worth checking out. As we come towards the end of antibiotics, the last thing we need to be doing is polluting our planet with antibiotics, which provides a selective pressure for the development of resistant bacteria, some of which will find their way into hospitals sooner or later.
You can view some other ‘Perspectives from ECCMID’ here.
Image: ‘Effluent tank’ by Bob Shand.