|Year : 2021 | Volume
| Issue : 1 | Page : 52-56
Effect of water reservoirs types on the prevalence and antibiotic resistance profiles of Pseudomonas aeruginosa isolated from bathroom water in hospitals
Sri Agung Fitri Kusuma1, Tina Rostinawati1, Rini Hendriani2, Muhammad Faisal Budiman3, Ida Parwati4
1 Department of Biology Pharmacy, Faculty of Pharmacy, Padjadjaran University, Sumedang, West Java, Indonesia
2 Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Padjadjaran University, Sumedang, West Java, Indonesia
3 PT Kimia Farma Tbk, Bandung, Indonesia
4 Clinical Pathology Department, Faculty of Medical, Padjadjaran University, Bandung, Indonesia
|Date of Submission||27-Jul-2020|
|Date of Decision||03-Sep-2020|
|Date of Acceptance||25-Sep-2020|
|Date of Web Publication||09-Jan-2021|
Dr. Sri Agung Fitri Kusuma
Komplek Permata Biru, Cinunuk, Cileunyi, West Java
Source of Support: None, Conflict of Interest: None
This study was aimed to isolate and characterize Pseudomonas aeruginosa antibiotic resistance profiles that isolated from bathroom water of five hospitals in Bandung, Indonesia, with different types of water reservoirs. Total of 25 water samples from bathrooms of five hospitals were collected and analyzed for the existence of P. aeruginosa colonies on the surface of MacConkey agar media using a streak plate method and identified using phenotypic identification and a series of biochemical tests. All P. aeruginosa isolates were tested against ceftazidime, piperacillin/tazobactam, ciprofloxacin, meropenem, and gentamicin containing in paper disc, using the agar diffusion method. Of all samples, the total number of P. aeruginosa isolates was less than that of non-P. aeruginosa. In hospitals that use permanent bathtubs, a greater total bacterial count was obtained than those using pails. From 110 isolates, 14.54% were multidrug resistance antibiotics. The majority of the resistant isolates were from hospital B with permanent bathtubs. Of 25 isolates from that hospital, P. aeruginosa isolates were resistant to ceftazidime (20%), piperacillin/tazobactam (4%), ciprofloxacin (20%), and gentamicin (20%). The multiple antibiotic resistance index value of P. aeruginosa isolates was 0.4–0.6. Thus, it can be concluded that the bathroom wáter in the hospital with permanent bathtubs were potential reservoirs of antibiotic-resistant P. aeruginosa.
Keywords: Antibiotic, bathroom, hospital, Pseudomonas aeruginosa, resistance, water
|How to cite this article:|
Kusuma SA, Rostinawati T, Hendriani R, Budiman MF, Parwati I. Effect of water reservoirs types on the prevalence and antibiotic resistance profiles of Pseudomonas aeruginosa isolated from bathroom water in hospitals. J Adv Pharm Technol Res 2021;12:52-6
|How to cite this URL:|
Kusuma SA, Rostinawati T, Hendriani R, Budiman MF, Parwati I. Effect of water reservoirs types on the prevalence and antibiotic resistance profiles of Pseudomonas aeruginosa isolated from bathroom water in hospitals. J Adv Pharm Technol Res [serial online] 2021 [cited 2021 Jan 15];12:52-6. Available from: https://www.japtr.org/text.asp?2021/12/1/52/306552
| Introduction|| |
The hospital is a place for patients to treat the disease, both inpatient and outpatient. However, this goal does not always have a positive impact on patients, especially in patients who are known to have weak immune systems so that they are easily infected with other microorganisms. As a result, it worsens the patient's condition and increases the cost of treatment. Infections that occur in hospitalized patients are called nosocomial infections. This infection can attack the urinary tract (34%), patients after surgery (17%), lower respiratory tract (13%), blood vessels (14%), etc., (21%). Among the reported causal bacteria of the nosocomial infection, Pseudomonas aeruginosa was found as the most common of nosocomial infections causative agent.,
P. aeruginosa infection causes disease in various tissues, including the circulatory system (bacteremia and septicemia), respiratory tract, central nervous system, heart (endocarditis), ears (including external otitis), eyes, bones, urinary tract, gastrointestinal tract, and leather.,, It was reported that the septicemia caused by P. aeruginosa reached an 80% mortality rate. Several antibiotics such as: antibiotics penicillin group (aminopenicillin, carboxypenicillin, piperacillin), cephalosporin (ceftazidime, cefoperazone, cefepime) groups, imipenem, aztreonam, chloramphenicol, aminoglycocamin, gentinamycinamycin, gentinycinamycin, cannocinamycin, and the fluoroquinolone group (ciprofloxacin, ofloxacin, levofloxacin) were administered as the treatments for P. aeruginosa infections. However lately, some studies reported the multidrug antibiotic resistance of P. aeruginosa clinical isolates. The increasing rates of resistant P. aeruginosa in hospitalized patients have a significant impact to the increasing of mortality rate and hospital length of stay. The discovery of these several resistance cases, encouraging the spread of P. aeruginosa with focusing on their habitat sources, not only in human individual factors, but also the hospital environment deserves serious attention. Although the consensus of the role of contaminated water in P. aeruginosa infection transmission is still debated, several studies have demonstrated that water is a major contributor to the spread of P. aeruginosa in hospital environments.,, Water systems can be a source of P. aeruginosa infection.,,, Hand washing with contaminated tap water were detected as the contamination source in hospital. The spread of P. aeruginosa might occur from patient to the water system, or vice versa. Thus, the resistance characteristic of P. aeruginosa isolates that found from water system in hospital may come from the patients or vice versa. However, the environmental reservoirs of antibiotic resistance factors in the hospital are still unclear. The improvement of hygiene and water management in the hospital environment, especially water in the bathroom, is an important thing that must be considered. It is recognized that P. aeruginosa is a bacterium that can increase its virulence factor when forming biofilm layers. Thus, the ease of cleaning water reservoirs in hospital bathrooms, is thought to affect the level of virulence of P. aeruginosa.
| Materials and Methods|| |
This study used antibiotics as follows: gentamicin 10 μg CT0774B (Oxoid), 10 μg meropenem CT0774B (Oxoid), 110 μg piperacillin/tazobactam 100/10 CT0725B (Oxoid), ceftazidime 30 ceftazidime CT0412B (Oxoid), and 5 μg ciprofloxacin CT0425B (Oxoid).
Water samples used in this study were collected from bathroom of five different hospitals in Bandung regency, West Java, Indonesia. The samples from each hospital consisted of different class level (one bathroom of first class, two bathrooms of second class, and two bathrooms of the third class). In addition, each of the hospitals used different water reservoirs in their bathroom, i.e., permanent bathtubs and pails. A volume of 15 ml water sample was taken aseptically using a sterile pipette and stored in a sterile test tube.
Enumeration, isolation, and identification of Pseudomonas aeruginosa
The samples were analyzed using a dilution method to achieve bacterial suspension concentration of 10−1–10−3, then 1 ml of each concentration was inoculated in the Petri dish More Details containing 19 ml agar MacConkey and aerobically incubated at 37°C for 24 h. The colony number of P. aeruginosa were counted using a colony counter tool and then subcultured to fresh MacConkey agar plates, incubated at 37°C and further identified after 18–24 h. The colonies were verified using phenotypic identification and biochemical tests, i.e., oxidase test, triple sugar iron test, Indole test, motile test, carbohydrate fermentation (a serial fermentation test of glucose, lactose, sucrose, maltose, and mannitol), citrate test, Methyl Red, and Voges–Proskauer test. The identification results were then compared to the P. aeruginosa ATCC 27853 as bacterial standard.
All antibiotics resistance characteristics of P. aeruginosa isolates were tested against antibiotics containing in paper disc. The bacteria colonies were transferred from a slant agar to a sterile 0.95% NaCL solution and the turbidity was set to achieve turbidity standard, equal to 0.5 McFarland. The suspension in volume of 20 μl then swabbed onto the surface of Mueller Hinton Agar (MHA) using a cotton bud sterile and impregnated with available antibiotics disc. The dishes, then incubated for 37°C for 24 h. Quality control was conducted using P. aeruginosa ATCC 27853 and the inhibition zones were compared with the standard inhibitory diameter of each antibiotics, presented in the Clinical and Laboratory Standards Institute library.
| Results and Discussion|| |
Total colony count
The colony number of P. aeruginosa in different isolation sources, i.e., permanent bathtubs and pails was compared. As well as on distribution systems of drinking water, the entire surface of the water reservoirs that in contact with water, can be a place for the colonization of microorganisms and potential to develop biofilm layers.,, Moreover, the flow-through of cold tap water over a period of 43 days was potent to developed biofilm. In the present study, out of 25 water samples examined, all samples showed contain of fluorescent colony. The result showed that the total colonies on hospital with permanent bathtubs were found higher than that of from pails [Table 1].
P. aeruginosa having rounded and a greenish yellow colony and grape like-odor on the agar MacConkey. In addition, on the MacConkey agar, P. aeruginosa was observed as bacteria strain that produced fluorescence when viewed under ultraviolet light. These fluorescing colonies were sampling to be further tested and the result revealed that the suspected fluorescent colonies that isolated were confirmed as P. aeruginosa, as it performed the same identification result as P. aeruginosa ATCC 27853.
Antibiotic resistance in aquatic environment is an important case which must be considered because antibiotic resistance genes can be transferred easily from aquaculture to human. P. aeruginosa is commonly found in aquatic habitats, but their habitat with different ecosystems and sanitation levels, can produce P. aeruginosa with different characteristic profiles. Therefore, the profile of P. aeruginosa in water samples in each hospital must be evaluated to determine the profile characteristics of bacteria, especially their resistance to the commonly used antibiotics. In this present study, the resistance profiles of the 110 P. aeruginosa isolates from bathroom water of total five hospitals were phenotypically characterized against ceftazidime, piperacillin/tazobactam, ciprofloxacin, meropenem, and gentamicin. These antibiotics compile with the standard determination of resistance tests for P. aeruginosa. The resistance pattern of the P. aeruginosa isolates revealed that 5/110 (4.54%) were resistant to ceftazidime, 5/110 (4.54%) were resistant to ciprofloxacin, 1/110 (0.91%) were resistant to piperacillin/tazobactam, and 5/110 (4.54%) were resistant to gentamycin, as shown in [Table 2]. The environmental isolates were tended to be more sensitive than clinical isolates, this may due to the clinical isolates had been exposed to antibiotics. The details of resistance data of all isolates from each hospital are shown in [Table 3]. Based on data on [Table 3], total of 25 P. aeruginosa isolates from a hospital with permanent bathtubs demonstrated (Hospital B) their resistance against ceftazidime (20%), piperacillin/tazobactam (4%), ciprofloxacin (20%), and gentamicin (20%). In addition, their intermediate resistance characteristics were also shown on piperacillin/tazobactam (16%) and meropenem (4%).
|Table 2: Interpretative of antibiotics resistance profile (Clinical Laboratory Standards Institute, 2013)|
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|Table 3: Details of interpretive resistance profile of Pseudomonas aeruginosa from five hospitals|
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All the resistant isolates were sourced from hospital B which using permanent bathtubs. A profile of multiple antibiotic resistance (MAR) of hospital B isolates is shown in [Table 4]. The MAR index was 0.4–0.6 and the similar study of P. aeruginosa isolates from effluent water gave the same range. The position of a bathtub drain which higher than the minimum the surface of the water, tend to form a biofilm which functioned as pathogens reservoir and a source of water contamination. P. aeruginosa cells may persist for several weeks in the form of biofilms. The biofilm forms might improve their potential to produce virulence factors, including the antibiotic resistance mechanism. Although the level of P. aeruginosa resistance was not as high as reported in other studies, but it must be considered that the resistance genes of the bacteria can be transmitted to other P. aeruginosa cells. This fact can endanger the individual which frequently contacted with the contaminated water in the hospital bathroom. The acquired antibiotic resistance can be transmitted through mobile genetic element. Each individual infected with resistant P. aeruginosa, resulting in the difficulty of infection treatment and must invent the antibacterial agents for alternative therapy. Therefore, hospital management must have focused in the monitoring and evaluating the bacterial parameters in the aquatic environment to improve the water hygiene. The frequency and precision in the process of cleaning the bathroom are very important to do. This study recommended the use of the pails compared to the permanent bathtub in the bathroom of the hospital. Because the pails are more easily to be cleaned, therefore, the cleaning frequency may often do, compared to the permanent bathtub. In addition to the cleaning process, the use of antiseptics can decrease the level of contamination.
|Table 4: Multiple antibiotic resistance index of Pseudomonas aeruginosa isolated from the water reservoir in bathroom of hospital B|
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| Conclusion|| |
The confirmed existence of multidrug-resistant P. aeruginosa found in the bathroom water of hospitals generates a high probability risk both directly on the individual health associated with the water source and indirectly impact on the health of the wide community.
Authors would like to acknowledge to Padjadjaran University, Indonesia, for the research support and funding and also thankful to the hospitals for the water sampling.
Financial support and sponsorship
This study was supported by Padjadjaran University.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Weinstein RA. Nosocomial infection update. Emerg Infect Dis 1998;4:416-20.
Esen S, Leblebicioglu H. Prevalence of nosocomial infections at intensive care units in Turkey: A multicentre 1-day point prevalence study. Scand J Infect Dis 2004;36:144-8.
Malacarne P, Stella A, Giudici D, Bertolini G. Infection surveillance in intensive care units. Preliminary results of a multicenter GiViTI study in 71 Italian ICUs. Minerva Anestesiol 2004;70:321-8.
Ketchum PA. Microbiology Concept and Applications. USA: John Wiley and Son, Inc; 1988.
Ryan KJ, Falcow S. Medical Microbiology. In: 3rd
ed. Amerika: Appleton and Lang; 1994.
Todar K. Textbook of Bacteriology: Pseudomonas Aeruginosa. Madison: University of Wisconsin; 2004.
Karsinah K, Lucky HM, Suharto S, Mardiastuti HW. Medical Microbiology. Jakarta: Binarupa Aksara; 1993.
Katzung BG. Pharmacology: Basic and clinical. 8th ed. Jakarta: Salemba Medika; 2004.
Tsakris A, Pournaras S, Woodford N, Palepou MF, Babini GS, Douboyas J, et al
. Outbreak of infections caused by Pseudomonas aeruginosa
producing VIM-1 carbapenemase in greece. J Clin Microbiol 2000;38:1290-2.
Exner M, Kramer A, Lajoie L, Gebel J, Engelhart S, Hartemann P. Prevention and control of health care-associated waterborne infections in health care facilities. Am J Infect Control 2005;33:S26-40.
Trautmann M, Lepper PM, Haller M. Ecology of Pseudomonas aeruginosa
in the intensive care unit and the evolving role of water outlets as a reservoir of the organism. Am J Infect Control 2005;33:S41-9.
Williams MM, Armbruster CR, Arduino MJ. Plumbing of hospital premises is a reservoir for opportunistically pathogenic microorganisms: A review. Biofouling 2013;29:147-62.
Petignat C, Francioli P, Nahimana I, Wenger A, Bille J, Schaller MD, et al
. Exogenous sources of Pseudomonas aeruginosa
in intensive care unit patients: Implementation of infection control measures and follow-up with molecular typing. Infect Control Hosp Epidemiol 2006;27:953-7.
Oguntibeju OO, Nwobu RAU. Occurrence of Pseudomonas aeruginosa
in post operate wound infection. Pak J Med Sci 2004;20:187-191.
Rogues AM, Boulestreau H, Lashéras A, Boyer A, Gruson D, Merle C, et al
. Contribution of tap water to patient colonisation with Pseudomonas aeruginosa
in a medical intensive care unit. J Hosp Infect 2007;67:72-8.
Romano S, Bourdier A, Parer S, Masnou A, Burgel L, Raczka F, et al
. Peripheral venous catheter and bloodstream infection caused by Pseudomonas aeruginosa
after a contaminated preoperative shower. Infect Control Hosp Epidemiol 2013;34:544-6.
Bert F, Maubec E, Bruneau B, Berry P, Lambert-Zechovsky N. Multi-resistant Pseudomonas aeruginosa
outbreak associated with contaminated tap water in a neurosurgery intensive care unit. J Hosp Infect 1998;39:53-62.
Bédard E, Prévost M, Déziel E. Pseudomonas aeruginosa
in premise plumbing of large buildings. Microbiol Open 2016;5:937-56.
Clinical and Laboratory Standards Institute Performance standards for antimicrobial susceptibility testing; twenty-fourth international supplements. Wayne: Clinical and Laboratory Standards Institute; 2014.
Kilb B, Lange B, Schaule G, Flemming HC, Wingender J. Contamination of drinking water by coliforms from biofilms grown on rubber-coated valves. Int J Hyg Environ Health 2003;206:563-73.
Servais P, Laurent P, Randon G. Comparison of the bacterial dynamics in various French distribution systems. J Water Supply Res T 1995;44:10-17.
Wingender J, Flemming HC. Contamination potential of drinking water distribution network biofilms. Water Sci Technol 2004;49:277-86.
Moritz MM, Flemming HC, Wingender J. Integration of Pseudomonas aeruginosa
and Legionella pneumophila in drinking water biofilms grown on domestic plumbing materials. Int J Hyg Environ Health 2010;213:190-7.
Brodsky MH, Nixon MC. Rapid method for detection of Pseudomonas aeruginosa
on MacConkey agar under ultraviolet light. Appl Microbiol 1973;26:219-20.
Chuah LO, Effarizah ME, Goni AM, Rusul G. Antibiotic application and emergence of multiple antibiotic resistance (MAR) in global catfish aquaculture. Curr Environ Health Rep 2016;3:118-27.
Ruiz L, Domínguez MA, Ruiz N, Viñas M. Relationship between clinical and environmental isolates of Pseudomonas aeruginosa
in a hospital setting. Arch Med Res 2004;35:251-7.
Odjadjare EE, Igbinosa EO, Mordi R, Igere B, Igeleke CL, Okoh AI. Prevalence of multiple antibiotics resistant (MAR) Pseudomonas species in the final effluents of three municipal wastewater treatment facilities in South Africa. Int J Environ Res Public Health 2012;9:2092-107.
Igbinosa EO, Obuekwe IS. Evaluation of antibiotic resistant gene in abattoir environment. J Appl Sci Environ Manage 2014;18:165-70.
Igbinosa IH, Igbinosa EO, Okoh AI. Molecular detection of metallo β-lactamase and putative virulence genes in environmental isolates of pseudomonas species. Pol J Environ Stud 2014;23:2327-31.
[Table 1], [Table 2], [Table 3], [Table 4]