Wastewater from healthcare centers in Burkina Faso is a source of ESBL, AmpC-β-lactamase and carbapenemase-producing Escherichia coli and Klebsiella pneumoniae
BMC Microbiology volume 23, Article number: 351 (2023)
Extended-spectrum β-lactamase (ESBL), plasmid-mediated AmpC-β-lactamase and carbapenemase-producing Escherichia coli and Klebsiella pneumoniae have spread into the environment worldwide posing a potential public health threat. However, the prevalence data for low- and middle-income countries are still scarce. The aim of this study was to evaluate the presence of ESBL, AmpC-β-lactamase and carbapenemase-producing and multidrug-resistant E. coli and K. pneumoniae in wastewaters from healthcare centers in Burkina Faso.
Eighty-four (84) wastewater samples were collected from five healthcare centers and plated on selective ESBL ChromAgar. E. coli and Klebsiella pneumoniae isolates were identified using API20E. ESBL-producing bacteria were detected in 97.6% of the samples and their average concentration per hospital ranged from 1.10 × 105 to 5.23 × 106 CFU/mL. Out of 170 putative ESBL-producing isolates (64% of them were E. coli) and 51 putative AmpC-β-lactamase-producing isolates, 95% and 45% were confirmed, respectively. Carbapenemase production was detected in 10 isolates, of which 6 were NDM producers, 3 were OXA-48 producers and 1 was NDM and OXA-48 producer. All isolates were multidrug resistant and, moreover, all of them were resistant to all tested β-lactams. Resistance to ESBL inhibitors was also common, up to 66% in E. coli and 62% in K. pneumoniae. Amikacin, fosfomycin and nitrofurantoin were the antibiotics to which the least resistance was detected.
This study showed that wastewater from healthcare centers constitutes a reservoir of multidrug-resistant bacteria in Burkina Faso, including carbapenemase producers. Untreated healthcare wastewater entering the environment exposes people and animals to infections caused by these multi-resistant bacteria, which are difficult to treat, especially in the resource-poor settings.
The emergence and spread of antimicrobial resistance (AMR) represent a serious threat to human and animal health. In 2019, the number of deaths associated with AMR was estimated at 4.95 million including 1.27 million directly attributable to multi-drug resistant bacteria . Therefore, if no action is taken against AMR, by 2050 this number could rise to 10 million per year [2, 3]. The economic cost of AMR has been estimated to vary from 1.1 to 3.8% of the global gross domestic product and the annual shortfall to reach $3.4 trillion by 2030 . Several reasons, such as unreasonable use or overuse of antibiotics, have been speculated to favor the emergence and spread of resistance genes and multidrug resistant bacteria [5,6,7,8,9,10]. Furthermore, in low- and middle-income countries (LMICs), socio-economic and behavioral factors, such as poverty, use of poor quality antibiotics, absence of diagnostic tools, absence of antibiotic stewardship policies and uncontrolled use of antibiotics in animals, have been indicated . The persistence of antibiotic residues, non-degraded antibiotics and disinfectants in wastewaters contribute to selection of resistant bacteria and their wide spread in environment [5,6,7, 11,12,13,14,15]. Multidrug resistant bacteria harboring extended-spectrum β-lactamase genes (blaTEM, blaSHV, blaCTX-M) and carbapenemase genes (blaOXA-48, blaKPC, blaNDM, blaVIM and blaIMP) have been detected in hospital wastewaters from several countries [16,17,18,19,20]. Management of healthcare center wastewaters in LMICs is highly insufficient and sometimes the wastewaters are directly discharged into the environment, drainage, rivers, or lakes without any treatment [21,22,23]. Use of this water for various human activities exposes the population to new infections by multidrug resistant bacteria [24, 25].
In Burkina Faso, information on wastewater contamination is patchy, but recent studies have revealed the abundant presence of resistant bacteria in healthcare center effluents [26, 27]. The present study aimed to assess healthcare center wastewater contamination specifically by ESBL, AmpC-β-lactamase and carbapenemase -producing Gram negative bacilli and to perform phenotypic characterization of ESBL-producing Escherichia coli (ESBL-Ec) and Klebsiella pneumoniae (ESBL-Kp) in wastewaters from hospitals at different levels of the healthcare system in Burkina Faso.
Bacterial concentration in healthcare center wastewaters
The average concentration of bacteria growing on ESBL-selective plates from wastewater of each healthcare center varied from 1.10 × 105 to 5.23 × 106 CFU/mL. The highest bacterial counts were obtained from wastewater drained from Yalgado Ouédraogo teaching hospital (tertiary level hospital), followed by Koudougou regional hospital center and El Fateh Suka clinic (both secondary level healthcare facilities) (Table 1).
Prevalence of ESBL
From the 84 healthcare center wastewater samples, ESBL E. coli or K. pneumoniae isolates were detected in 82 samples (97.62%). In total, 170 strains were isolated (109 E. coli and 61 K. pneumoniae). ESBL test confirmed 160 (95%) bacterial isolates (102 E. coli and 58 K. pneumoniae) to be ESBL positive. ESBL confirmation test was negative for ten isolates but they were resistant to all the β-lactam and ESBL inhibitors tested.
Prevalence of AmpC β-lactamase producers
Bacterial isolates with cefoxitin inhibition zone diameter less than 18 mm (37 ESBL-Ec and 14 ESBL-Kp) were tested to detect AmpC-β-lactamase production by the phenotypic method. In total, 23 out of 51 isolates tested (45%) were AmpC- β-lactamase producers (Table 2).
Prevalence of carbapenemase producers
Twenty-one bacterial isolates resistant to meropenem (15 ESBL-Ec and 6 ESBL-Kp) were tested to detect carbapenemase production (OXA-48, KPC, NDM, VIM, and IMP). Ten isolates (47.62%) were carbapenemase producers: 6 were NDM producers, 3 were OXA-48 producers, and 1 was NDM and OXA-48 producer. Carbapenemase-producing bacteria were detected among wastewaters collected from the tertiary and the secondary level healthcare facilities (Table 3).
Resistance to antibiotics
All the bacterial isolates from the ESBL selective plates (109 E. coli and 61 K. pneumoniae isolates) were tested against 31 antibiotics representing different antibiotic categories (Table 4). All the bacterial isolates were multidrug resistant. All the isolates (100%) were resistant to aminopenicillins (ampicillin, piperacillin) and cephalosporins except cefoxitin. In case of the ESBL-inhibiting combination antibiotics, 65.42% and 65.74% of E. coli and 61.67% and 45.76% of K. pneumoniae were resistant to amoxicillin + clavulanic acid and to piperacillin + tazobactam, respectively.
High resistance rates were detected against aminoglycoside, quinolone, and fluoroquinolone antibiotic categories. Indeed, in the aminoglycoside family, the detected resistance rates were up to 71.43% in E. coli and 77.77% in K. pneumoniae against kanamycin. Bacterial isolates were more susceptible to amikacin since only 6.93% of E. coli and 13.11% of K. pneumoniae were resistant (Table 4). The resistance rates against quinolones and fluoroquinolones varied from 67.05% to 100% in E. coli and from 24.44% to 93.44% in K. pneumoniae.
In case of the carbapenems, 17 E. coli (15.74%) and 5 K. pneumoniae (8.19%) isolates were resistant to meropenem (Table 4).
Other families of antibiotics commonly used in hospitals in Burkina Faso include cyclins; 86.02% E. coli and 78.26% K. pneumoniae isolates were resistant to tetracycline. In case of the sulfonamides, 88.14% of K. pneumoniae isolates were resistant to sulfamethoxazole + trimethoprim and 100% to sulfamethoxazole (Table 4).
Β-lactams are widely used in the treatment of patients in healthcare in Burkina Faso, but nowadays bacteria are often highly resistant to these antibiotics. Therefore, we isolated E. coli and Klebsiella pneumoniae strains from ESBL-selective ChromAgar plates inoculated with healthcare center wastewaters to determine their susceptibility to commonly used antibiotics. Over 97% of the 84 wastewater samples analyzed contained ESBL-producing E. coli and/or K. pneumoniae. The concentrations of ESBL-producing Gram-negative bacteria in the healthcare center wastewaters were high, but, our results are comparable to those published in previous studies in different parts of the world [16, 30,31,32]. For instance, concentrations up to 107 CFU/mL of ESBL, CARB and OXA-producing Enterobacteriaceae were reported from hospital wastewaters in Slovenia and Austria . Also in Burkina Faso’s neighboring countries, Ghana and Nigeria, ESBL-producers have been commonly isolated from hospital wastewater [33, 34] Among our samples, the wastewaters collected from the tertiary and secondary level healthcare centers were the most contaminated with ESBL producers, possibly because these hospitals receive more patients, generally referred from a district level healthcare. Also, antibiotics are used more in terms of both quantity and diversity in tertiary and secondary level hospitals.
In addition to being ESBL producers, many of the bacterial isolates characterized in this study were also AmpC-β-lactamase (23 positive out of 51 isolates tested) and carbapenemase (10 positive out of 21 isolates tested) producers. Two types of carbapenemases, (OXA-48 and NDM) were detected. Previously, using a metagenomics approach, presence of several carbapenemase genes (blaVIM, blaIMP, blaNDM and blaOXA-48) was reported in the wastewaters of some of the same hospitals in Burkina Faso . The resistance rate of our ESBL-producing E. coli and K. pneunomia isolates to carbapenems was 15.74% to meropenem, 20.75% to imipenem and 32.71% to ertapenem. Our results differ from those recently reported from Burkina Faso, where imipenem was the only carbapenem tested and no resistance to it was detected [26, 35]. Occurrence and eventual spread of the carbapenem resistant bacteria into the environment is of a particular concern since carbapenems are currently the antimicrobials of last resort in healthcare.
Wastewaters originating from healthcare centers present a public health concern in Burkina Faso and the other countries, where they are discharged directly into the environment or into municipality wastewater channels without any prior treatment [21, 23]. Furthermore, in LMICs, hospital wastewater may be used for irrigation of vegetable crops . Indeed, ESBL-producing bacteria have been isolated on lettuce in Burkina Faso . The common intestinal carriage of these bacteria may increase their prevalence in patients visiting healthcare centers, where the presence of these bacteria leads to complications of therapeutic treatment, prolonged patient hospitalizations and increased hospitalization costs, as well as higher mortality and morbidity .
High level of resistance to the commonly used antibiotics has been reported also by other research groups in West Africa [37, 38]. In Nigeria, full resistance to cefotaxime, cefpodoxime, sulfonamide and ertapenem was reported among ESBL-producing E. coli isolated from a healthcare facility wastewater . Likewise, in Côte d’Ivoire, ESBL-producing E. coli and K. pneumoniae isolated from hospital wastewaters were reported to be fully resistant to amoxicilline + clavulanic acid, cefotaxime, ceftriaxone and ceftazidime. In addition, E. coli were fully resistant to ciprofloxacin, nalidixic acid and cefepime and K. pneumoniae were highly resistant to ciprofloxacin (62.5%), nalidixic acid and cefepime (87%) . The high resistance level of bacteria in wastewaters from healthcare centers is a consequence of antimicrobial misuse in hospitals, the discharge at high concentrations of not metabolized antibiotics and antibiotic residues into hospital wastewater, and the fecal contamination by patients [8, 23, 39,40,41,42]. Furthermore, the high concentration of bacteria in these wastewaters offers an increased chance for horizontal transfer of resistance genes between bacteria [30,31,32, 37].
Amikacin, fosfomycin and nitrofurantoin were the antibiotics against which we recorded low resistance rates. Also in Mexico, a low resistance rate to amikacin among carbapenemase-producing Klebsiella spp. isolated from hospital wastewater was reported recently . These antibiotics, mostly used for treatment of urinary tract infections, represent a major therapeutic option in case of infection with ESBL-producing bacteria.
This study shows that wastewaters from healthcare facilities represent a reservoir of multidrug-resistant bacteria in Burkina Faso. Wastewaters collected from the healthcare centers representing tertiary and secondary level of the healthcare system were the most contaminated. The ESBL-producing E. coli and K. pneumoniae isolates were resistant to all commonly used antibiotics in Burkina Faso, such as β-lactams, β-lactams combined with ESBL-inhibitors (amoxicillin + clavulanic acid and piperacillin + tazobactam), quinolones, fluoroquinolones, aminoglycosides, sulfonamides, cyclins, and macrolides. Only amikacin and fosfomycin showed good activity against these bacteria. Some of the isolates also produced AmpC-β-lactamases and carbapenemases, limiting the treatment options even further. Untreated healthcare wastewaters entering the environment expose people and animals to the risk of infection by these multi-resistant bacteria. Therefore, it is important to include healthcare wastewater monitoring in the future national AMR monitoring program.
Material and methods
Study sites and sampling
A prospective study was carried out in 5 healthcare centers in Burkina Faso representing the different levels of the healthcare systemin Burkina Faso. The samples were collected from Yalgado Ouédraogo teaching hospital in Ouagadougou (university hospital, tertiary level care), Koudougou regional hospital center in Koudougou and El Fateh Suka clinic in Ouagadougou (secondary level care), Source de Vie medical center in Ouagadougou and Saint Camille medical center in Nanoro rural area (primary level).
Three healthcare centers had a sewer system, Yalgado Ouédraogo teaching hospital, Koudougou regional hospital center and Saint Camille medical center. Yalgado Ouédraogo teaching hospital sewers are connected to the city sewage system leading to the city’s wastewater treatment plant. Wastewater from the hospital is discharged into the general sewage without any prior treatment. Koudougou regional hospital center has a chemical treatment device. The treated wastewater is discharged into the municipality channel, which is connected to a backwater in the town. Source de Vie medical center and El Fateh Suka clinic do not have a sewer system and their wastewater is collected in septic tanks. The management of wastewater in these two healthcare centers and in Saint Camille medical center in Nanoro are not clearly documented. As a rule, there is no wastewater treatment plants in rural areas in Burkina Faso, instead, the wastewaters are directly discharged into the environment without any treatment.
We collected wastewater samples from several sites along the sewers from the healthcare centers with a sewer system and from septic tanks from the healthcare centers without a sewer system. Two rounds of sampling were done, 1) from october to december 2019 and 2) from october 2020 to march 2021. A total of 84 wastewater samples were collected (Table 1). In each case, one liter of wastewater was collected in a sterile glass bottle. The samples were immediately placed in a cooler containing ice blocks and transported within 12 h to the microbiology laboratory of the Clinical Research Unit of Nanoro (CRUN) for analysis.
Bacterial count, isolation, and identification
Two dilutions were prepared for each sample (1/10 and 1/100) using sterile 0.9% physiological saline water. Following the WHO Tricycle instructions , 100 µL of each dilution was inoculated on ESBL-selective agar plates (ChromAgar™ ESBL, Paris, France), which were incubated at 35 ± 2 °C for 24 h. A positive control was carried out for all samples by inoculating a non-selective Cystine Lactose Electrolyte Deficient (CLED) agar plate with 100µL of the sample. After incubation, all visible bacterial colonies on the plates were counted, and the results were expressed into colony-forming units per milliliter of wastewater (CFU/mL). Only a plate of one dilution (1/10 or 1/100) from each sample was chosen for the bacterial count, depending on the abundance of bacteria on the plates.
The agar plates were also inspected for different morphotypes of bacteria, according to the manufacturer’s instructions (ChromAgar™ ESBL, Paris, France). Red or pink colonies were assumed to be E. coli, and blue, green, or blue-green the KESC group (Klebsiella, Enterobacter, Serratia and Citrobacter). Five colonies of the same morphotype of E. coli or the KESC group were picked for purification on eosin methylene blue agar (EMB). The purified isolates were identified using the API20E system (Biomérieux, Marcy-l’Etoile, France).
Antimicrobial susceptibility testing
Antimicrobial susceptibility testing of 170 presumptive ESBL-producing bacterial isolates (109 E. coli and 61 K. pneumoniae isolates) was performed using the disk diffusion method on Muller Hinton (MH) agar. Thirty-one antibiotic discs (Condalab, Madrid, Spain) were tested (Table 4) and the results were interpreted according to the American Clinical and Laboratory Standards Institute (CLSI) 2021 guidelines .
Extended spectrum β-lactamase (ESBL) confirmation
ESBL confirmation was carried out on Mueller Hinton (MH) agar using the double disc synergy test (DDST) between a 3rd generation cephalosporin (ceftriaxone or ceftazidime, C3G), a 4th generation cephalosporin (cefepime, C4G) and amoxicillin + clavulanic acid (AMC), following the CLSI 2021 guidelines. The result was interpreted as positive when there was a visible synergy inhibition zone between C3G-AMC-C4G (Fig. 1).
Phenotypic AmpC-β-lactamase testing
The 51 isolates (37 E. coli and 14 K. pneumoniae) with cefoxitin inhibition zone diameter less than 18 mm (≥ 18 mm) were tested for the AmpC-β-lactamase production. A bacterial suspension prepared with fresh colonies (McFarland 0.5) was inoculated onto entire surface of the MH agar supplemented with cloxacillin at 4 µg/l and a disk of cefoxitin was placed on the plate. The test was positive if the inhibition zone diameter around cefoxitin disc was ≥ 18 mm.
The isolates that were resistant to meropenem were tested for carbapenemase-production using the immunochromatographic test O.K.N.V.I. RESIST-5 (CORIS BioConcept, Belgium) according to the manufacturer’s instructions. A total of 21 isolates were tested for the five main carbapenemases (OXA-48-like, KPC, NDM, VIM, IMP) within 15 min.
Availability of data and materials
All data generated or analyzed during this study are included in this published article.
Amoxicillin + clavulanic acid
Colony forming unit
Cystine Lactose Electrolyte Deficient
Clinical and Laboratory Standards Institute
Clinical research unit of Nanoro
Third generation cephalosporin
Fourth generation cephalosporine
Double disc synergy test
Eosin methylene blue
Klebsiella, Enterobacter, Serratia And Citrobacter
Institute of Tropical Medicine
Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399(10325):629–55. https://doi.org/10.1016/S0140-6736(21)02724-0. Erratum.In:Lancet.2022;400(10358):1102.
Sugden R, Kelly R, Davies S. Combatting antimicrobial resistance globally. Nat Microbiol. 2016:16187. https://doi.org/10.1038/nmicrobiol.2016.187.
O’Neill J. Tackling drug-resistant infections globally: final report and recommendations. In: Review on antimicrobial resistance. London: Wellcome Trust and UK Government; 2016. p. 84.
World Bank. Drug-resistant infections: a threat to our economic future. Washington, DC: World Bank; 2017. Licence: Creative Commons Attribution CC BY 3.0 IGO.
Michael CA, Dominey-Howes D, Labbate M. The antimicrobial resistance crisis: causes, consequences, and management. Front Public Heal. 2014;2:145. https://doi.org/10.3389/fpubh.2014.00145.
Ouedraogo AS, Jean-Pierre H, Banuls AL, Ouedraogo R, Godreuil S. Émergence et diffusion de la résistance aux antibiotiques en Afrique de l’Ouest : facteurs favorisants et évaluation de la menace. Med Sante Trop. 2017;27(2):147–54.
Hedgespeth ML, Sapozhnikova Y, Pennington P, Clum A, Fairey A, Wirth E. Pharmaceuticals and personal care products (PPCPs) in treated wastewater discharges into Charleston Harbor. South Carolina Sci Total Environ. 2012;437:1–9. https://doi.org/10.1016/j.scitotenv.2012.07.076.
Al Aukidy M, Verlicchi P, Voulvoulis N. A framework for the assessment of the environmental risk posed by pharmaceuticals originating from hospital effluents. Sci Total Environ. 2014;493:54–64. https://doi.org/10.1016/j.scitotenv.2014.05.128.
Dadgostar P. Antimicrobial resistance: implications and costs. Infect Drug Resist. 2019;12:3903–10. https://doi.org/10.2147/IDR.S234610.
Chokshi A, Sifri Z, Cennimo D, Horng H. Global contributors to antibiotic resistance. J Glob Infect Dis. 2019;11(3):131. https://doi.org/10.4103/jgid.jgid.
Chang X, Meyer MT, Liu X, Zhao Q, Chen H, Chen JA, et al. Determination of antibiotics in sewage from hospitals, nursery and slaughter house, wastewater treatment plant and source water in Chongqing region of Three Gorge Reservoir in China. Environ Pollut. 2010;158(5):1444–50. https://doi.org/10.1016/j.envpol.2009.12.034.
Khan MT, Shah IA, Ihsanullah I, Naushad M, Ali S, AliShah SH, Mohammad A. Hospital wastewater as a source of environmental contamination: an overview of management practices, environmental risks, and treatment processes. J Water Process Eng. 2021;41:101990. https://doi.org/10.1016/j.jwpe.2021.101990.
Ekwanzala MD, Lehutso RF, Kasonga TK, Dewar JBMM. Environmental dissemination of selected antibiotics from hospital wastewater to the aquatic environment. Antibiotics. 2020;9(7):431. https://doi.org/10.3390/antibiotics9070431.
Chunhui Z, Liangliang W, Xiangyu G, Xudan H. Antibiotics in WWTP discharge into the Chaobai River, Beijing. Arch Environ Prot. 2016;42(4):48–57. https://doi.org/10.1515/aep-2016-0036.
Aydin S, Aydin ME, Ulvi A, Kilic H. Antibiotics in hospital effluents: occurrence, contribution to urban wastewater, removal in a wastewater treatment plant, and environmental risk assessment. Env Sci Pollut Res Int. 2019;26(1):544–58. https://doi.org/10.1007/s11356-018-3563-0.
Rozman U, Duh D, Cimerman M, Turk SŠ. Hospital wastewater effluent: hot spot for antibiotic resistant bacteria. J Water Sanit Hyg Dev. 2020;10(2):171–8. https://doi.org/10.2166/washdev.2020.086.
Paulus GK, Hornstra LM, Alygizakis N, Slobodnik J, Thomaidis N, Medema G. The impact of on-site hospital wastewater treatment on the downstream communal wastewater system in terms of antibiotics and antibiotic resistance genes. Int J Hyg Environ Health. 2019;222(4):635–44. https://doi.org/10.1016/j.ijheh.2019.01.004.
Zurfluh K, Bagutti C, Brodmann P, Alt M, Schulze J, Fanning S, et al. Wastewater is a reservoir for clinically relevant carbapenemase- and 16s rRNA methylase-producing Enterobacteriaceae. Int J Antimicrob Agents. 2017;50(3):436–40. https://doi.org/10.1016/j.ijantimicag.2017.04.017.
Tesfaye H, Alemayehu H, Desta AF, Eguale T. Antimicrobial susceptibility profile of selected Enterobacteriaceae in wastewater samples from health facilities, abattoir, downstream rivers and a WWTP in Addis Ababa, Ethiopia. Antimicrob Resist Infect Control. 2019;8(1):1–11. https://doi.org/10.1186/s13756-019-0588-1.
Rodríguez EA, Garzón LM, Gómez ID, Jiménez JN. Multidrug resistance and diversity of resistance profiles in carbapenem-resistant Gram-negative bacilli throughout a wastewater treatment plant in Colombia. J Glob Antimicrob Resist. 2020;22:358–66. https://doi.org/10.1016/j.jgar.2020.02.033.
Al Aukidy M, Al Chalabi S, Verlicchi P. Hospital wastewater treatments adopted in Asia, Africa, and Australia. Hospital wastewaters: characteristics, management, treatment and environmental risks. 2018:171–88.
Mubedi JI, Devarajan N, Faucheur S, Mputu JK, Atibu EK, Sivalingam P, et al. Effects of untreated hospital effluents on the accumulation of toxic metals in sediments of receiving system under tropical conditions: Case of south India and Democratic Republic of Congo. Chemosphere. 2013;93(6):1070–6. https://doi.org/10.1016/j.chemosphere.2013.05.080.
Hocquet D, Muller A, Bertrand X. What happens in hospitals does not stay in hospitals: antibiotic-resistant bacteria in hospital wastewater systems. J Hosp Infect. 2016;93(4):395–402. https://doi.org/10.1016/j.jhin.2016.01.010.
Bougnom BP, Zongo C, McNally A, Ricci V, Etoa FX, Thiele-Bruhn S, et al. Wastewater used for urban agriculture in West Africa as a reservoir for antibacterial resistance dissemination. Environ Res. 2019;168:14–24. https://doi.org/10.1016/j.envres.2018.09.022.
Bougnom BP, Thiele-Bruhn S, Ricci V, Zongo C, Piddock LJV. Raw wastewater irrigation for urban agriculture in three African cities increases the abundance of transferable antibiotic resistance genes in soil, including those encoding extended spectrum β-lactamases (ESBLs). Sci Total Environ. 2020;698:134201. https://doi.org/10.1016/j.scitotenv.2019.134201.
Abasse O, Boukaré K, Sampo E, Bouda R, Cissé H, Stéphane K, et al. Spread and antibiotic resistance profile of pathogens isolated from human and hospital wastewater in Ouagadougou. Microbes Infect Dis. 2021;3(2):318–31. https://doi.org/10.21608/mid.2021.72261.1143.
Markkanen MA, Haukka K, Pärnänen KMM, Dougnon VT, Bonkoungou IJO, Garba Z, et al. Metagenomic analysis of the abundance and composition of antibiotic resistance genes in hospital wastewater in Benin, Burkina Faso, and Finland. MSphere. 2023;8(1). https://doi.org/10.1128/msphere.00538-22.
Rouamba T, Barry H, Ouédraogo E, Tahita MC, Yaméogo NV, Poda A, et al. Safety of chloroquine or hydroxychloroquine plus azithromycin for the treatment of COVID-19 patients in Burkina Faso: an observational prospective cohort study. Ther Clin Risk Manag. 2021;17:1187–98. https://doi.org/10.2147/TCRM.S330813.
Adama B, Armel P, Kadari C, Apoline KS, Boukary O, AbdoulRisgou O, et al. Effect of hydroxychloroquine or chloroquine and azithromycin on COVID-19 patients’ recovery and mortality: evidence from a hospital based retrospective cohort study conducted in Burkina Faso. J Infect Dis Epidemiol. 2021;7(2):1–9. https://doi.org/10.23937/2474-3658/1510192.
Le TH, Ng C, Chen H, Yi XZ, Koh TH, Barkham TMS, et al. Occurrences and characterization of antibiotic-resistant bacteria and genetic determinants of hospital wastewater in a tropical country. Antimicrob Agents Chemother. 2016;60(12):7449–56. https://doi.org/10.1128/AAC.01556-16.
Galvin S, Boyle F, Hickey P, Vellinga A, Morris D, Cormican M. Enumeration and characterization of antimicrobial-resistant Escherichia coli bacteria in effluent from municipal, hospital, and secondary treatment facility sources. Appl Environ Microbiol. 2010;76(14):4772–9. https://doi.org/10.1128/AEM.02898-09.
Drieux L, Haenn S, Moulin L, Jarlier V. Quantitative evaluation of extendedspectrum β-lactamase-producing Escherichia coli strains in the wastewater of a French teaching hospital and relation to patient strain. Antimicrob Resist Infect Control. 2016;5:9. https://doi.org/10.1186/s13756-016-0108-5.
Atta HI, Idris SM, Gulumbe BH, Awoniyi OJ. Detection of extended spectrum beta-lactamase genes in strains of Escherichia coli and Klebsiella pneumoniae isolated from recreational water and tertiary hospital waste water in Zaria. Nigeria Int J Environ Health Res. 2022;32(9):2074–82. https://doi.org/10.1080/09603123.2021.1940884.
Addae-Nuku DS, Kotey FCN, Dayie NTKD, Osei MM, Tette EMA, Debrah P, et al. Multidrug-resistant bacteria in hospital wastewater of the Korle Bu teaching hospital in Accra. Ghana Environ Health Insights. 2022;16:1–9. https://doi.org/10.1177/11786302221130613.
Soré S, Sawadogo Y, Bonkoungou JI, Kaboré SP, Béogo S, Sawadogo C, et al. Detection, identification and characterization of extended-spectrum beta-lactamases producing Enterobacteriaceae in wastewater and salads marketed in Ouagadougou, Burkina Faso. Int J Biol Chem Sci. 2020;14(8):2746–57. https://doi.org/10.4314/ijbcs.v14i8.8.
French GL. Clinical impact and relevance of antibiotic resistance. Adv Drug Deliv Rev. 2005;57(10):1514–27. https://doi.org/10.1016/j.addr.2005.04.005.
Guessennd N, Ouattara M, Ouattara N, Nevry R, Gbanon V, Tiekoura K, et al. Étude des bactéries multirésistantes des effluents hospitaliers d’un centre hospitalier et universitaire (CHU) de la ville d’Abidjan (Côte d’Ivoire). J Appl Biosci. 2013;69:5456–64. https://doi.org/10.4314/jab.v69i0.95071.
Adekanmbi AO, Akinpelu MO, Olaposi AV, Oyelade AA. Diversity of extended spectrum beta-lactamase (ESBL) genes in Escherichia coli isolated from wastewater generated by a sick bay located in a university health care facility. Gene Reports. 2020;20:100738. https://doi.org/10.1016/j.genrep.2020.100738.
Ye Q, Wu Q, Zhang S, Zhang J, Yang G, Wang H, et al. Antibiotic-resistant extended spectrum β-lactamase- and plasmid-mediated AmpC-producing enterobacteriaceae isolated from retail food products and the pearl river in Guangzhou, China. Front Microbiol. 2017;8:1–12. https://doi.org/10.3389/fmicb.2017.00096.
Sangadah K, Kartawidjaja J. Hospital wastewater treatment scenario around the globe. Orphanet J Rare Dis. 2020;21(1):1–9. https://doi.org/10.1016/B978-0-12-819722-6.00015-8.
Egbule OS. Detection and transfer of extended spectrum beta lactamase enzymes from untreated hospital waste water. Adv Microbiol. 2016;06(07):512–20. https://doi.org/10.4236/aim.2016.67051.
Czatzkowska M, Wolak I, Harnisz M, Korzeniewska E. Impact of anthropogenic activities on the dissemination of ARGs in the environment—A review. Int J Environ Res Public Health. 2022;19(19):12853. https://doi.org/10.3390/ijerph191912853.
Galarde-López M, Velazquez-Meza ME, Bobadilla-Del-valle M, Carrillo-Quiroz BA, Cornejo-Juárez P, Ponce-De-león A, et al. Surveillance of antimicrobial resistance in hospital wastewater: identification of carbapenemase-producing Klebsiella spp. Antibiotics. 2022;11(3):288. https://doi.org/10.3390/antibiotics11030288.
World Health Organization. WHO integrated global surveillance on ESBL-producing E. coli using a “One Health” approach: implementation and opportunities. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO.
Clinical an Laboratory Standards Institute. Clinical an Laboratory Standards Institute. Available at: https://www.treata.academy/wp-content/uploads/2021/03/CLSI-31-2021.pdf. Accessed 20 Dec 2021.
We sincerely thank the staff of the hygiene services of the participating hospitals for their assistance in sampling the wastewaters. We also thank the staff of the clinical biology laboratory of the Clinical Research Unit of Nanoro who helped us enormously with sample analysis.
The study was supported by the Belgium Directorate General for Development Cooperation (DGD) through the collaborative framework agreement 4 (FA4–DGD program) between Clinical Research Unit of Nanoro (CRUN), Burkina Faso and Institute of Tropical Medicine of Antwerp (ITM), Belgium and the Academy of Finland through the AMRIWA project.
Ethics approval and consent to participate
This study received approval from the health research committee of Burkina Faso (N°153–12-2018/ CE-RS). Authorizations were obtained from all the hospitals.
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The authors declare no competing interests.
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Garba, Z., Bonkoungou, I.O.J., Millogo, N.O. et al. Wastewater from healthcare centers in Burkina Faso is a source of ESBL, AmpC-β-lactamase and carbapenemase-producing Escherichia coli and Klebsiella pneumoniae. BMC Microbiol 23, 351 (2023). https://doi.org/10.1186/s12866-023-03108-0