Infection

, Volume 45, Issue 4, pp 479–491 | Cite as

Environmental pollution with antimicrobial agents from bulk drug manufacturing industries in Hyderabad, South India, is associated with dissemination of extended-spectrum beta-lactamase and carbapenemase-producing pathogens

  • Christoph Lübbert
  • Christian Baars
  • Anil Dayakar
  • Norman Lippmann
  • Arne C. Rodloff
  • Martina Kinzig
  • Fritz Sörgel
Original Paper

Abstract

Purpose

High antibiotic and antifungal concentrations in wastewater from anti-infective drug production may exert selection pressure for multidrug-resistant (MDR) pathogens. We investigated the environmental presence of active pharmaceutical ingredients and their association with MDR Gram-negative bacteria in Hyderabad, South India, a major production area for the global bulk drug market.

Methods

From Nov 19 to 28, 2016, water samples were collected from the direct environment of bulk drug manufacturing facilities, the vicinity of two sewage treatment plants, the Musi River, and habitats in Hyderabad and nearby villages. Samples were analyzed for 25 anti-infective pharmaceuticals with liquid chromatography–tandem mass spectrometry and for MDR Gram-negative bacteria using chromogenic culture media. In addition, specimens were screened with PCR for bla VIM, bla KPC, bla NDM, bla IMP-1, and bla OXA-48 resistance genes.

Results

All environmental specimens from 28 different sampling sites were contaminated with antimicrobials. High concentrations of moxifloxacin, voriconazole, and fluconazole (up to 694.1, 2500, and 236,950 µg/L, respectively) as well as increased concentrations of eight other antibiotics were found in sewers in the Patancheru–Bollaram industrial area. Corresponding microbiological analyses revealed an extensive presence of extended-spectrum beta-lactamase and carbapenemase-producing Enterobacteriaceae and non-fermenters (carrying mainly bla OXA-48, bla NDM, and bla KPC) in more than 95% of the samples.

Conclusions

Insufficient wastewater management by bulk drug manufacturing facilities leads to unprecedented contamination of water resources with antimicrobial pharmaceuticals, which seems to be associated with the selection and dissemination of carbapenemase-producing pathogens. The development and global spread of antimicrobial resistance present a major challenge for pharmaceutical producers and regulatory agencies.

Keywords

Antibiotics Antifungal agents Antimicrobial resistance Multidrug-resistant (MDR) pathogens Carbapenemase-producing Enterobacteriaceae (CPE) Non-fermenters Colonization Infection Selection pressure 

Notes

Author contributions

Study conception and design: CL, CB, ACR, and FS. Identification of sampling sites and acquisition of data: CL, CB, and AD. Provision of documentary images: CL and CB. Performance of the laboratory experiments: NL and MK. Data analysis and interpretation of the results: CL, CB, NL, TE, ACR, MK, and FS. Drafting of the manuscript: CL. Critical revision of the manuscript: CL, CB, AD, TE, NL, ACR, MK, and FS.

Compliance with ethical standards

Conflict of interest

All authors deny any potential conflicts of interest.

Funding

The authors did not receive any external funding.

Supplementary material

15010_2017_1007_MOESM1_ESM.pdf (1.4 mb)
Supplementary material 1 (PDF 1437 kb)

References

  1. 1.
    World Health Organization. Antimicrobial resistance 2014: global report on surveillance. Geneva: World Health Organization; 2014.Google Scholar
  2. 2.
    O’Neill J. The review on antimicrobial resistance 2014. Tackling drug-resistant infections globally: final report and recommendations. http://www.amr-review.org. Accessed 20 Jan 2017.
  3. 3.
    Bengtsson-Palme J, Larsson DGJ. Concentrations of antibiotics predicted to select for resistant bacteria: proposed limits for environmental regulation. Environ Int. 2016;86:140–9.CrossRefPubMedGoogle Scholar
  4. 4.
    Bengtsson-Palme J, Angelin M, Huss M, et al. The human gut microbiome as a transporter of antibiotic resistance genes between continents. Antimicrob Agents Chemother. 2015;59:6551–60.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Woodford N, Turton JF, Livermore DM. Multiresistant gram-negative bacteria: the role of high-risk clones in the dissemination of antibiotic resistance. FEMS Microbiol Rev. 2011;35:736–55.CrossRefPubMedGoogle Scholar
  6. 6.
    Molton JS, Tambyah PA, Ang BS, et al. The global spread of healthcare-associated multidrug-resistant bacteria: a perspective from Asia. Clin Infect Dis. 2013;56:1310–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Woerther PL, Burdet C, Chachaty E, Andremont A. Trends in human fecal carriage of extended-spectrum-ß-lactamases in the community: toward the globalization of CTX-M. Clin Microbiol Rev. 2013;26:744–58.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Lübbert C, Straube L, Stein C, et al. Colonization with extended-spectrum beta-lactamase-producing and carbapenemase-producing Enterobacteriaceae in international travelers returning to Germany. Int J Med Microbiol. 2015;305:148–56.CrossRefPubMedGoogle Scholar
  9. 9.
    Kantele A, Lääveri T, Mero S, et al. Antimicrobials increase travelers’ risk of colonization by extended-spectrum betalactamase-producing Enterobacteriaceae. Clin Infect Dis. 2015;60:837–46.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Arcilla MS, van Hattem JM, Haverkate MR, et al. Import and spread of extended-spectrum β-lactamase-producing Enterobacteriaceae by international travellers (COMBAT study): a prospective, multicentre cohort study. Lancet Infect Dis. 2017;17:78–85.CrossRefPubMedGoogle Scholar
  11. 11.
    Mutreja A. Bacterial frequent flyers. Nat Rev Microbiol. 2012;10:734.CrossRefPubMedGoogle Scholar
  12. 12.
    Fick J, Söderström H, Lindberg RH, et al. Contamination of surface, ground, and drinking water from pharmaceutical production. Environ Toxicol Chem. 2009;28:2522–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Larsson DG, de Pedro C, Paxeus N. Effluent from drug manufactures contains extremely high levels of pharmaceuticals. J Hazard Mater. 2007;148:751–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Rutgersson C, Fick J, Marathe N, et al. Fluoroquinolones and qnr genes in sediment, water, soil, and human fecal flora in an environment polluted by manufacturing discharges. Environ Sci Technol. 2014;48:7825–32.CrossRefPubMedGoogle Scholar
  15. 15.
    Ashbolt NJ, Amézquita A, Backhaus T, et al. Human health risk assessment (HHRA) for environmental development and transfer of antibiotic resistance. Environ Health Persp. 2013;121:993–1001.Google Scholar
  16. 16.
    Dang B, Mao D, Xu Y, Luo Y. Conjugative multi-resistant plasmids in Haihe River and their impacts on the abundance and spatial distribution of antibiotic resistance genes. Water Res. 2016;111:81–91.CrossRefPubMedGoogle Scholar
  17. 17.
    Bengtsson-Palme J, Boulund F, Fick J, et al. Shotgun metagenomics reveals a wide array of antibiotic resistance genes and mobile elements in a polluted lake in India. Front Microbiol. 2014;5:648.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Walsh TR, Weeks J, Livermore DM, Toleman MA. Dissemination of NDM-1 positive bacteria in the New Delhi environment and its implications for human health: an environmental point prevalence study. Lancet Infect Dis. 2011;11:355–62.CrossRefPubMedGoogle Scholar
  19. 19.
    Hsu LY, Apisarnthanarak A, Khan E, et al. Carbapenem-resistant Acinetobacter baumannii and Enterobacteriaceae in South and Southeast Asia. Clin Microbiol Rev. 2017;30:1–22.CrossRefPubMedGoogle Scholar
  20. 20.
    Marathe NP, Regina VR, Walujkar SA, et al. A treatment plant receiving waste water from multiple bulk drug manufacturers is a reservoir for highly multi-drug resistant integron-bearing bacteria. PLoS One. 2013;8:e77310.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Khan GA, Berglund B, Khan KM, et al. Occurrence and abundance of antibiotics and resistance genes in rivers, canal and near drug formulation facilities—a study in Pakistan. PLoS One. 2013;8:e62712.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Bengtsson-Palme J, Hammarén R, Pal C, et al. Elucidating selection processes for antibiotic resistance in sewage treatment plants using metagenomics. Sci Total Environ. 2016;572:697–712.CrossRefPubMedGoogle Scholar
  23. 23.
    Changing Markets. Superbugs in the Supply Chain, 2016: how pollution from antibiotics factories in India and China is fuelling the global rise of drug-resistant infections. http://www.mightyearth.org/wp-content/uploads/2016/10/changing-market-superbugs-in-the-supply-chain-guard-font-fin-print.pdf. Accessed 20 Jan 2017.
  24. 24.
    Investigators of the Delhi neonatal infection study. (DeNIS) collaboration. Characterisation and antimicrobial resistance of sepsis pathogens in neonates born in tertiary care centres in Delhi, India: a cohort study. Lancet Glob Health. 2016;4:e752–60.CrossRefGoogle Scholar
  25. 25.
    India online pages. Population of Hyderabad 2016. http://www.indiaonlinepages.com/population/hyderabad-population.html. Accessed 20 Jan 2017.
  26. 26.
    Central Pollution Control Board of India (CPCB). Final action plan for improvement of environmental parameters in critically polluted areas of Patancheru–Bollaram cluster, Andhra Pradesh, 2010. http://cpcb.nic.in/divisionsofheadoffice/ess/Patancheru-Bollaram.pdf. Accessed 20 Jan 2017.
  27. 27.
    Central Pollution Control Board of India (CPCB). Note on the implementation of the action plan and its compliance for the critically polluted area of Patancheru–Bollaram in Telangana, 2016. http://cpcb.nic.in/zonaloffice/banglore/CEPI_Bollaram.pdf. Accessed 20 Jan 2017.
  28. 28.
    The Hans India. Pharma still pollutes Patancheru, 2015. http://www.thehansindia.com/posts/index/Telangana/2015-11-28/Pharma-still-pollutes-Patancheru/189407. Accessed 20 Jan 2017.
  29. 29.
    Smith M, Diederen B, Scharringa J, et al. Rapid and accurate detection of carbapenemase genes in Enterobacteriaceae with the Cepheid Xpert Carba-R assay. J Med Microbiol. 2016;65:951–3.CrossRefPubMedGoogle Scholar
  30. 30.
    Munoz-Price LS, Poirel L, Bonomo RA, et al. Clinical epidemiology of the global expansion of Klebsiella pneumoniae carbapenemases. Lancet Infect Dis. 2013;13:785–96.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Kothari C, Gaind R, Singh LC, et al. Community acquisition of β-lactamase producing Enterobacteriaceae in neonatal gut. BMC Microbiol. 2013;13:136.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Saseedharan S, Sahu M, Pathrose EJ, Shivdas S. Act fast as time is less: high faecal carriage of carbapenem-resistant Enterobacteriaceae in critical care patients. J Clin Diagn Res. 2016;10:DC01–5.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Shafiq N, Praveen Kumar M, Gautam V, et al. Antibiotic stewardship in a tertiary care hospital of a developing country: establishment of a system and its application in a unit-GASP initiative. Infection. 2016;44:651–9.CrossRefPubMedGoogle Scholar
  34. 34.
    The Indian Express. India has 60.4 per cent people without access to toilet: study 2015. http://indianexpress.com/article/india/india-news-india/india-has-60-4-per-cent-people-without-access-to-toilet-study/. Accessed 20 January 2017.
  35. 35.
    Lübbert C, Rodloff AC, Laudi S, et al. Lessons learned from excess mortality associated with Klebsiella pneumoniae carbapenemase-2-producing K. pneumoniae in liver transplant recipients. Liver Transpl. 2014;20:736–8.CrossRefPubMedGoogle Scholar
  36. 36.
    Lübbert C, Lippmann N, Busch T, et al. Long-term carriage of Klebsiella pneumoniae carbapenemase-2-producing K. pneumoniae after a large single-center outbreak in Germany. Am J Infect Control. 2014;42:376–80.CrossRefPubMedGoogle Scholar
  37. 37.
    Martin RM, Cao J, Brisse S, et al. Molecular epidemiology of colonizing and infecting isolates of Klebsiella pneumoniae. mSphere. 2016;1:e00261–76.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Chandran SP, Diwan V, Tamhankar AJ, et al. Detection of carbapenem resistance genes and cephalosporin, and quinolone resistance genes along with oqxAB gene in Escherichia coli in hospital wastewater: a matter of concern. J Appl Microbiol. 2014;117:984–95.CrossRefPubMedGoogle Scholar
  39. 39.
    Marathe NP, Shetty SA, Shouche YS, Larsson DG. Limited bacterial diversity within a treatment plant receiving antibiotic-containing waste from bulk drug production. PLoS One. 2016;11:e0165914.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Gothwal R, Shashidar. Occurrence of high levels of fluoroquinolones in aquatic environment due to effluent discharges from bulk drug manufacturers. J Hazard Toxic Radioact Waste. 2016;28:2153–5. doi: 10.1061/(ASCE)HZ.2153-5515.0000346.Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  • Christoph Lübbert
    • 1
    • 2
  • Christian Baars
    • 3
  • Anil Dayakar
    • 4
  • Norman Lippmann
    • 2
    • 5
  • Arne C. Rodloff
    • 2
    • 5
  • Martina Kinzig
    • 6
  • Fritz Sörgel
    • 6
    • 7
  1. 1.Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and RheumatologyLeipzig University HospitalLeipzigGermany
  2. 2.Interdisciplinary Center for Infectious DiseasesLeipzig University HospitalLeipzigGermany
  3. 3.Ressort InvestigationNorth German Broadcasting Corporation (NDR)HamburgGermany
  4. 4.NGO GamanaMadhapurIndia
  5. 5.Institute for Medical Microbiology and Epidemiology of Infectious DiseasesLeipzig University HospitalLeipzigGermany
  6. 6.IBMP-Institute for Biomedical and Pharmaceutical ResearchNürnberg-HeroldsbergGermany
  7. 7.Institute of PharmacologyUniversity of Duisburg-EssenEssenGermany

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