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A. Elmanama et al., J. Al-Aqsa Unv., 10 (S.E.) 2006 Contribution of Hospital Wastewater to the Spread of
Antibiotic Resistance in Comparison to Non-Health
Institution
Dr. Abdelraouf A. Elmanama *
Dr. Abboud Y. ElKichaoui **
Miss. Mai Mohsin ∗∗*
ﺭﻴﻭـﻁﺘ ﻩﺎـﺠﺘﺍ ﻲﻓ ﺭﺍﺩﺤﻨﻼﻟ ﺔﻓﺎﻀ ﻹﺎﺒ ﺔﻴﻭﻴﺤﻟﺍ ﺕﺍﺩﺎﻀﻤﻠﻟ ﺔﻤﻭﺎﻘﻤﻟﺍ ﺔﻠﻜﺸﻤﻟ ﺔﻴﻤﺎﻌﻟﺍ ﺓﺩﺎﻴﺯﻟﺍ ﺎﻴﺭﻴﺘﻜﺒﻟﺍ ﺔﻤﻭﺎﻘﻤ ﺭﻭﺼ ﺔﺴﺍﺭﺩﻟ ﺙﺤﺒﻟﺍ ﺍﺫﻫ ﻡﻤﺼ .
ﺩﻘﻟ ﺓﺭﻴﻁﺨ ﺕﺎﻔﻋﺎﻀﻤ ﻪﻟ ﺓﺩﻴﺩﺠ ﺔﻴﻭﻴﺤ ﺕﺍﺩﺎﻀﻤ ﺔﻴﺤﺼ ﺔﺴﺴﺅﻤﻜ ﺓﺯﻏ ﻉﺎﻁﻗ ﻲﻓ ﺀﺎﻔﺸﻟﺍ ﻰﻔﺸﺘﺴﻤ ﻥﻤ ﺎﻴﺭﻴﺘﻜﺒﻟﺍ ﻩﺫﻫ لﺯﻋ ﻡﺘ ﺩﻘﻟﻭ ﺔﻴﻭﻴﺤﻟﺍ ﺕﺍﺩﺎﻀﻤﻠﻟ ﺕﻌﻤﺠ ﺔﺴﺍﺭﺩﻟﺍ ﻩﺫﻫ ﻲﻓ . ﺔﻴﺤﺼ ﺭﻴﻏ ﺕﺎﺴﺴﺅﻤ ﻥﻤ ﺕﻟﺯﻋ ﺎﻴﺭﻴﺘﻜﺒ ﻊﻤ ﻩﺫﻫ ﺔﻤﻭﺎﻘﻤﻟﺍ ﺭﻭﺼ ﺔﻨﺭﺎﻘﻤﻭ ﺔﻌﻤﺎﺠﻟﺍ ﻥﻤ ﺔﻔﻠﺘﺨﻤ ﻥﻜﺎﻤﺃ ﺙﻼﺜﻭ ﺀﺎﻔﺸﻟﺍ ﻰﻔﺸﺘﺴﻤ ﻥﻤ ﺔﻔﻠﺘﺨﻤ ﻥﻜﺎﻤﺃ ﺙﻼﺜ ﻥﻤ ﺔﻤﺩﺎﻌﻟﺍ ﻩﺎﻴﻤﻟﺍ ﺕﺎﻨﻴﻋ ﻩﺎـﻴﻤ ﻥﻤ ﺔﻨﻴﻋﻭ ﺔﻤﺩﺎﻌﻟﺍ ﻩﺎﻴﻤﻟﺍ ﺔﺠﻟﺎﻌﻤﻟ ﺓﺯﻏ ﺔﻁﺤﻤ ﺝﺭﺨﻤﻭ لﺨﺩﻤ ﻥﻤﻭ ﺓﺯﻏ ﻉﺎﻁﻗ ﻲﻓ ﺔﻴﻤﻼﺴﻹﺍ ﻥﺎـﻜ ﺎـﻬﻌﻤﺠ ﻡﺘ ﻲﺘﻟﺍ ﺕﺎﻨﻴﻌﻟﺍ ﻉﻭﻤﺠﻤ . ﺭﺤﺒﻟﺍ ﻲﻓ ﺠﻟﺎﻌﻤﻟﺍ ﺔﻁﺤﻤ ﺏﺼﻤ ﻥﻤ ﺏ ﺭﻘﻟﺎﺒ ﺭﺤﺒﻟﺍ ﺔﻟﻭﺯﻌﻤﻟﺍ ﺎﻴﺭﻴﺘﻜﺒﻟﺍ ﻥﻤ لﻜ ﺏﺴﻨ ﺕ .
ﻨﺎﻜﻭ ﺕﺎﻨﻴﻌﻟﺍ ﻩﺫﻫ ﻥﻤ ﺔﻔﻠﺘﺨﻤ ﺎﻴﺭﻴﺘﻜﺒ لﺯﻋ ﻡﺘ ﺩﻗﻭ ﺔﻨﻴﻋ :ﻲﻟﺎﺘﻟﺎﻜ 30.5% E. coli, 33.1% Pseudomonas spp., 10.4% Klebsiella spp., 4.5% Proteus spp. and 21.4% Enterococcus spp. ﺔﺒﻟﺎﺴﻟﺍ ﺎﻴﺭﻴﺘﻜﺒﻟﺍ ﺔﻤﻭﺎﻘﻤ ﺔﺒﺴﻨ ﺕﻨﺎﻜﻭ ﺔﻴﻭﻴﺤﻟﺍ ﺕﺍﺩﺎﻀﻤﻠﻟ ﺔﻴﺴﺎ ﺴﺤﻟﺍ ﺭﺎﺒﺘﺨﺍ ﺎﻬﻟ ﻱﺭﺠﺍ ﺎﻴﺭﻴﺘﻜﺒﻟﺍ ﻩﺫﻫ :ﻲﻟﺎﺘﻟﺍ ﻭﺤﻨﻟﺍ ﻰﻠﻋ ﺎﻴﻭﻴﺤ ﺍﺩﺎﻀﻤ ﺭﺸﻋ ﺔﺴﻤﺨﻟ Cephalexin (52.1%), Co-Trimoxazole (41.3%), Tetracycline (41.3%), Chloramphenicol (39.7%), Nalidixic Acid (36.4%), Piperacillin (28.9%), Amoxycillin (35.5%), Ceftizoxime (14.0%), Azreonam (13.2%), Ciprofloxacin (12.4%), Tobramycin (11.6%), Gentamicin (10.7%), Ceftazidime and Amikacin (8.3%) and Imipenem (0.0%). :ﻲﻟﺎﺘﻟﺍ ﻭﺤﻨﻟﺍ ﻰﻠﻋ ﺔﻴﻭﻴﺤ ﺕﺍﺩﺎﻀﻤ ﺱﻤﺨﻟ ﺔﺒﺠﻭﻤﻟﺍ ﺎﻴﺭﻴﺘﻜﺒﻟﺍ ﺔﻤﻭﺎﻘﻤ ﺔﺒﺴﻨﻭ * Medical Technology Department, Faculty of Science, Islamic University of Gaza, Palestine, [email protected] ** Biology Department, Faculty of Science, Islamic University of Gaza, Palestine ∗ * Medical Technology Department, Faculty of Science, Islamic University-Gaza. Palestine. Contribution of Hospital Wastewater… Streptomycin (91.0%), Vancomycin (75.8%), Erythromycin (60.6%), Teicoplanin (9.1%) and Ampicillin (6.1%). ﺀﺎﻔﺸـﻟﺍ ﻰﻔﺸـﺘﺴﻤ ﻥﻤ ﺔﺠﺭﺎﺨﻟﺍ ﺔﻤﺩﺎﻌﻟﺍ ﻩﺎﻴﻤﻟﺍ ﺕﺎﻨﻴﻋ ﻥﻤ ﺔﻟﻭﺯﻌﻤﻟﺍ ﺎﻴﺭﻴﺘﻜﺒﻟﺍ ﻥﺃ ﺩﺠﻭ ﺩﻘﻟﻭ ﺔـﻤﻭﺎﻘﻤﻟﺍ ﺎـﻴﺭﻴﺘﻜﺒﻟﺍ ﻥـﻤ ﺭـﺒﻜﺍ ﺩﺩﻋ ﻰﻠﻋ ﻱﻭﺘﺤﺘ ﺔﻴﻤﻼﺴﻹﺍ ﺔﻌﻤﺎﺠﻟﺍ ﻲﻓ ﺕﺍﺭﺒﺘﺨﻤﻟﺍ ﻰﻨﺒﻤ ﻥﻤﻭ .ﻯﺭﺨﻷﺍ ﻥﻜﺎﻤﻷﺍ ﻊﻤ ABSTRACT
A potential post-antibiotic era is threatening present and future medical advances. The current worldwide increase in resistant bacteria and, simultaneously, the downward trend in the development of new antibiotics have serious implications. This research conducted to study the resistance profile of bacterial isolates from Al-Shifa hospital in Gaza as a health institution and comparing their profile to a non-health institution. In this study, wastewater sample were collected from three different sewers receiving wastewater in Al-Shifa hospital, from three sewers receiving wastewater in Islamic University of Gaza (IUG), from inlet and outlet of Gaza wastewater treatment plant (WWTP) and from sea water. A total of 45 samples were collected and 154 different bacteria were isolated from these samples. From the isolated bacteria 30.5% were E. coli, 33.1% Pseudomonas sp., 10.4% Klebsiella sp., 4.5% Proteus sp. and 21.4% Enterococcus sp. Isolates were subjected to antimicrobial susceptibility testing. the percent of resistance for Gram-negative bacteria to 15 antibiotics were as the following Cephalexin (52.1%), Co-Trimoxazole (41.3%), Tetracycline (41.3%), Chloramphenicol (39.7%), Nalidixic Acid (36.4%), Piperacillin (28.9%), Amoxycillin (35.5%), Ceftizoxime (14.0%), Azreonam (13.2%), Ciprofloxacin (12.4%), Tobramycin (11.6%), Gentamicin (10.7%), Ceftazidime and Amikacin (8.3%) and Imipenem (0.0%). The percent of resistance for Gram-positive bacteria (Enterococcus) to 5 antibiotics were as the following: Streptomycin (91.0%), Vancomycin (75.8%), Erythromycin (60.6%), Teicoplanin (9.1%) and Ampicillin (6.1%)

Keywords: Antimicrobial resistance, hospitals wastewater, Gaza.

A. Elmanama et al., J. Al-Aqsa Unv., 10 (S.E.) 2006 Antibiotic resistance has become a major clinical and public health problem within the lifetime of most people living today (Stuart, 2002).
Confronted by increasing amounts of antibiotics over the past 60 years,
bacteria have responded to the deluge with the propagation of progeny no
longer susceptible to them. While it is clear that antibiotics are pivotal in the
selection of bacterial resistance, the spread of resistance genes and of
resistant bacteria also contributes to the problem (Stuart, 2002).
Antibiotic resistance is not only found in pathogenic bacteria but also in environmental organisms inhabiting terrestrial and aquatic habitats.
However, higher numbers of resistant bacteria occur in polluted habitats
compared with unpolluted habitats, indicating that humans have contributed
substantially to the increased proportion of resistant bacteria occurring in
the environment (Baya et al., 1986 and Pathak, 1993).
The emergence and spread of antimicrobial resistance are complex problems driven by numerous interconnected factors (WHO, 2002). The
widespread and often inappropriate administration of antibiotics in
livestock, pets, and humans has been shown to result in the development of
antibiotic-resistant bacteria and is generally accepted to be the primary
pathway for proliferation of antibiotic-resistant bacteria in the environment
(Wegener et al., 1999).
Possible mechanisms by which humans enhance the spread of antibiotic resistance among environmental bacteria include the deliberate or accidental
introduction of antibiotics, resistant bacteria and resistance genes into the
environment. Antibiotics exert a selection in favor of resistant bacteria by
killing or inhibiting growth of susceptible bacteria; resistant bacteria can
adapt to environmental conditions and serve as vectors for the spread of
antibiotic resistance (Wegener et al., 1999 and Kruse, 1999).
The main risk for public health is that resistance genes are transferred from environmental bacteria to human pathogen (Wegener et al., 1999 and
Kruse, 1999).

There are several routes of entry of antimicrobial agents into the environment. Studies have shown that introduction by these routes has
changed the antibiotic susceptibility of the microbes in those environments
(Chitnis et al., 2000).
One of these routes is the sewage, the antibiotics that we take in are not all processed by our bodies. Some of them are expelled as waste and wind up in our wastewater treatment plants. Of bacteria isolated from sludge remaining Contribution of Hospital Wastewater… after wastewater treatment at one plant, 46.4% were resistant to multiple
antibiotics. Sewage from hospitals and pharmaceutical plants has been
shown to contribute to antibiotic resistance in treatment plants (Chitnis et
al., 2000).

The volume of antibiotics used in hospitals and private households and released into effluent and municipal sewage indicates a selection pressure
on bacteria (Kümmerer and Henninger, 2003). Waste effluent from
hospitals contains high numbers of resistant bacteria and antibiotic residues
at concentrations able to inhibit the growth of susceptible bacteria (Grabow
& Prozesky, 1973, Linton, 1974, Fontaine and Hoadley, 1976).

Accordingly, hospital waste effluent could increase the numbers of resistant
bacteria in the recipient sewers by both mechanisms of introduction and
selection for resistant bacteria (Al-Ahmed et al., 1999).
Due to heavy antibiotic use, hospital wastewater contains larger numbers of resistant organisms than domestic wastewater. In Florida, vancomycin
resistant E. faecium were isolated, without enrichment, from hospital
wastewater (Harwood et al., 2002). VRE were found in 35% of the hospital
sewage samples in two Swedish studies (Blanch, 2003 and Iversen et al.,
2002)
. Twenty-five percent of enterococci were vancomycin resistant in a
German study of biofilms from hospital wastewater, and of these, many
were multiply resistant (Schwart et al., 2003). Reinthaler et al. (2003)
showed significantly higher percentages of E. coli in the inlet water of a
treatment plant receiving hospital waste than two other treatment plants. A
study of Acinetobacter showed that an increase in the prevalence of
oxytetracycline resistance was correlated with hospital wastewater
(Guardabassi et al., 1998).
Although sewage treatment processes reduce the numbers of bacteria in wastewater, the effluent will still generally contain large numbers of both
resistant and susceptible bacteria. Schwartz et al. (2003) showed a decrease
in VRE from 16% in untreated wastewater to 12.5% at the outlet. High
numbers of resistant coliforms have also been found in treatment plant
effluents (Reinthaler et al., 2003) and rivers receiving effluent from
treatment plants have higher numbers of resistant organisms.
In Gaza there are no studies or data concerning resistance profiles of microorganisms isolated from hospital or community sewage. This study was an attempt to generate original local data and examine the possibility of hospital effluents contributing to the resistance problem . A. Elmanama et al., J. Al-Aqsa Unv., 10 (S.E.) 2006 MATERIALS AND METHODS:
Sample Site Selection
As part of the study samples of sewage were collected from sewers and sewage treatment plants. Four different sites were selected for the study and from each site samples were collected from different locations. Table (1) illustrates the sampling sites and locations. Table 1. Sampling sites and locations
Location of sample collection at each sites
Intensive care unit sewer, Burn unit sewer and Al-Shifa Hospital Laboratories sewer
L building sewer, M building sewer and Laboratories building sewer From inlet and outlet About 20 meters from the point of sewage Seawater
discharge in seawater Sample Collection:
Wastewater and seawater samples were collected at approximately 2- weeks intervals over a period of 3 months from each of 9 locations. From each site the samples were collected five times. From each location, at each sampling visit, one wastewater sample was taken. Samples were transported in ice box to the laboratory and processed within 2 hours of collection. Sample Processing:
Each sample was inoculated on blood agar, MacConkey agar, M- Enterococcus Agar, Pseudomonas Agar, HiCrome UTI Agar plates and
Brain heart infusion broth tubes using bacteriological loop and incubated
aerobically at 37°C for 24–48 hours. Growing colonies were identified
biochemically in a systematic way according to standard methods
(Vandepitte et al., 1996).
All Gram-negative rods were identified by using API 20E strips. The initial characterization of enterococci was based on catalase reaction, hemolysis, and colony morphology. Further identification of enterococci was accomplished by the use of bile esculin test. Contribution of Hospital Wastewater… Antimicrobial Susceptibility Testing:
Bacterial susceptibility testing was done by the disk diffusion method according to Kirby-Bauer method (Bauer et al., 1966) following the NCCLS
assessment criteria (NCCLS, 2001). Bacterial inocula were prepared by
suspending the freshly grown bacteria in 4-5 ml sterile BHIB and the
turbidity was adjusted to that of a 0.5 McFarland standard. The inoculum
suspension was spread in three directions on a Mueller Hinton agar plate
surface with a sterile swab Filter paper disks containing designated amounts
of the antimicrobial drugs obtained from commercial supply firms
(HiMedia)
The antimicrobial disks tested for all isolates were: Amikacin 30µg, Amoxycillin 30µg, Aztreonam 30µg, Ceftazidime 30µg, Ceftizoxime 30µg, Cephoxitin 30µg, Chloramphenicol 30µg, Ciprofloxacin 30µg, Co-Trimoxazole 23.75µg, Gentamicin 10µg, Imipenem 10µg, Nalidixic Acid 30µg, Piperacillin 100µg, Tetracycline 30µg, Tobramycin 10µg, were tested against Gram negative bacteria. On the other hands, Streptomycin 10µg, Tetracycline 30µg, Teicoplanin 30µg, Vancomycin 30µg, Ampicillin 10µg, Erythromycin 15µg were tested against Gram positive bacteria. The plates were incubated aerobically at 37°C for 18-24 hours. Zone of inhibition around antibiotic disks were recorded and using the chart provided by the antimicrobials manufacturer, results were interpreted as sensitive, intermediate or resistant. RESULTS:
This study was conducted during the period of June, 2005 to September, 2005, and attempted to isolate E. coli, Pseudomonas sp., Proteus sp., Klebsiella sp., and Enteroccocus sp. from wastewater sample for the purpose of studying the possible contribution of Al-Shifa hospital to the increasing problem of antibiotic resistance. Standard antimicrobial susceptibility test was performed for all isolates. A total of 45 wastewater samples were collected from 9 different sampling points. Each point was sampled 5 times with 2 weeks intervals. Three sampling points at Al-Shifa hospital (burn unit sewer, ICU unit sewer and laboratory sewer), another three from Islamic University-Gaza (L building sewer, M building sewer and laboratory building sewer), two from the Gaza Wastewater Treatment Plant (Inlet and outlet of the plant) and one from the seawater near the GWWTP discharge point. From the 45 wastewater A. Elmanama et al., J. Al-Aqsa Unv., 10 (S.E.) 2006 samples, 154 bacterial strains were isolated. The highest number of bacteria isolated from Al-Shifa hospital and accounted for 32.5% (50 isolates) of the isolated bacteria followed by sites from the Islamic University-Gaza, 29.9% (46), GWWTP, 26.6% (41) and seawater 11.0% (17), as illustrated in details in Table (2) . Table 2. Number of bacteria isolated from each sampling point
Bacteria
Pseudomonas
Klebsiella
The most frequently identified bacterium was Pseudomonas sp. (33.1%) followed by E. coli (30.5%), Enterococcus sp. (21.4%), Klebsiella sp. (10.4%) and Proteus sp. (4.5%). The Gram-negative isolates showed wide variation in their response to the tested antimicrobial drugs as shown in Table (3). High resistance rate to amoxicillin (43.1%), ceftizoxime (33.3%), nalidixic acid (72.5%), cephalexin (90.2%), aztreonam (19.6%), and ceftazidime (13.7%) was observed among Pseudomonas sp. The highest resistance rate for tetracycline (100%), amikacin (100%), chloramphenicol and co-Trimoxazole (71.4%) was exhibited by Proteus sp. For imipenem antibiotic, there was no resistance at all. Table 3. Resistance rates (%) of Gram-negative to antibiotics
Pseudomonas
Klebsiella
12.8 11.8 12.5 0 31.9 90.2 12.5 0 Contribution of Hospital Wastewater… 14.9 13.7 0 14.3 In Vitro activities of 15 different antibiotics against the Gram-negative bacterial isolates are illustrated in Table (4). A high resistance rate among Gram-negative was observed against cephalexin (52.1%) followed by Co-Trimoxazole and tetracycline (41.3%), chloramphenicol (39.7%), nalidixic acid (36.4%) and amoxicillin (35.5%). The lowest resistance was to amikacin and ceftazidime (8.3% ) Table 4. Antibiogram of 15 different antibiotics against the Gram-negative
isolates
Susceptibility Percentage
Antibiotics
Resistance
Sensitive
Co-Trimoxazole 41.3 Chloramphenicol 39.7 Ciprofloxacin 12.4 11.6 76.0 Ceftazidime 8.3 8.3 83.5 Ceftizoxime 14.0 16.5 69.4 Gentamicin 10.7 8.3 81.0 Imipenem 0.0 Tetracycline 41.3 26.4 32.2 Tobramycin 11.6 7.4 81.0 The resistance pattern for each bacterium varied according to the site from which the bacteria were isolated. For E. coli the highest resistance rate to tetracycline, amoxicillin, ciprofloxacin and chloramphenicol was for those isolated from the inlet of the GWWTP and were (66.7%), (66.7%), (66.7%) and (33.3%) respectively. For tobramycin, nalidixic acid, cephalexin, Co-Trimoxazole, piperacillin, gentamicin and Ceftazidime the highest rate of resistance for E. coli which was isolated from the laboratory building of A. Elmanama et al., J. Al-Aqsa Unv., 10 (S.E.) 2006 IUG and account for (40.0%), (40.0%), (80.0%), (80.0%), (80.0%), (40.0%) and (40.0%) respectively. The only Gram-positive isolate was Enteroccocus sp. and showed the highest rate of resistance to streptomycin (91.0%). Also it was, 75.8%, 60.6%, 39.3%, 9.1% and 6.1%, for vancomycin, terythromycin, tetracycline, teicoplanin and ampicillin, respectively. This high resistance rate observed for all Enterococcus spp., regardless of the isolation site is shown in Table(5) Table 5. Percentage resistance of Enterococcus sp. isolated from different
site to antibiotics
isolates
A: Ampicillin, Te: Tecoplanin , S: Streptomycin, E: Erythromycin, Va: Vancomycin and T: Tetracycline A high proportion of the isolated strains showed resistance to more than two drugs. The multiple drug resistance of the isolates is illustrated in Table (6) Table 6. Multiple resistance patterns of the isolated strains.
E. coli
Resistance
To two antibiotics To three antibiotics antibiotics 6 12.8 8 15.7 8 24.2 Contribution of Hospital Wastewater… DISCUSSION:
This study was conducted to study the contribution of wastewater effluent from different parts of Al-Shifa hospital on the prevalence of resistant bacteria in the recipient sewers in comparative with the contribution of wastewater effluent from non-health institution (Islamic university of Gaza and Gaza wastewater treatment Plant) on the prevalence of resistant bacteria, and to see the impact of wastewater effluent from GWWTP in the seawater. In this study, different aspects concerning the occurrence and fate of antibiotic resistant bacteria in sewage was investigated: • The effects of waste effluent from a hospital on the prevalence of resistant bacteria in the recipient sewers. • The susceptibility pattern of bacteria isolated from wastewater effluent from IUG and GWWTP. • The impact of wastewater effluent from GWWTP in the prevalence of resistant bacteria in the recipient seawater. From the total of 45 wastewater and seawater samples that were collected from 9 different sampling points, 154 bacterial strains were isolated. The most frequently identified bacterium was Pseudomonas sp. (33.1%) followed by E. coli (30.5%), Enterococcus sp. (21.4%), Klebsiella sp. (10.4%) and Proteus sp. (4.5%). Our results indicate that high incidence of antibiotic resistance among both gram-negative and gram-positive isolates. For gram-negative bacteria, high resistance rate to amoxicillin (43.1%), ceftizoxime (33.3%), nalidixic acid (72.5%), cephalexin (90.2%), aztreonam (19.6%), and ceftazidime (13.7%) was observed among Pseudomonas sp. The highest resistance rate for tetracycline (100%), amikacin (100%), chloramphenicol and co-Trimoxazole (71.4%) was exhibited by Proteus sp. For imipenem antibiotic, there was no resistance at all. For gram-positive isolate (Enterococcus sp.) ,The highest resistance rate was to streptomycin (91.0%). Also it was, 75.8%, 60.6%, 39.3%, 9.1% and 6.1%, to vancomycin, terythromycin, tetracycline, teicoplanin and ampicillin, respectively. The lowest resistance was to ampicillin (6.1%). In comparison with the levels of antibiotic resistance reported in the literature for clinical isolates (Astal et al., 2002), Pseudomonas spp. isolates
from sewage were generally more susceptible to antimicrobial agents .
The resistance pattern for each bacterium varied according to the site from which the bacteria were isolated. For E. coli the highest resistance rate to A. Elmanama et al., J. Al-Aqsa Unv., 10 (S.E.) 2006 tetracycline, amoxicillin, ciprofloxacin and chloramphenicol was for those
isolated from the inlet of the GWWTP, the same result was reported in
previous study and indicated that the highest resistance rates were found in
E. coli strains of a sewage treatment plant which treats not only municipal
sewage but also sewage from a hospitals (Reinthaler et al., 2003). For
tobramycin, nalidixic acid, cephalexin, Co-Trimoxazole, piperacillin,
gentamicin and Ceftazidime the highest rate of resistance for E. coli which
was isolated from the laboratory building of IUG .
With regard to Pseudomonas sp., the resistance rate is shown to be high for most antibiotics and reached 100% in some sites for nalidixic acid, cephalexin, Co-Trimoxazole and chloramphenicol. The Pseudomonas sp. strains isolated from Al-Shifa hospital and sea were more resistant to antibiotics than Pseudomonas sp. isolated from other sites. The most resistance Klebsiella sp. isolate was that isolated from the laboratory building of the IUG. The highest resistance rate of Klebsiella was
observed against piperacillin (100%). One explanation to this high
resistance rate for the bacteria that isolated from the laboratory of the IUG
may be due to heavy metals, biocides and various chemicals that discharged
in sewage of this building and these substances have the potential to select
for antibiotic resistance (Foster, 1983).
Enteroccocus sp. showed highest rate of resistance to streptomycin followed by vancomycin and erythromycin. This high resistance rate
observed for all Enterococcus sp. regardless of the isolation site, results
from other study indicate that the majority of the vancomycin resistance
enterococci were resistant to at least two of the tested antimicrobial agents
besides vancomycin (Iversen et al., 2002).
From this study it can be demonstrated that bacteria that has been isolated from wastewater samples from Al-Shifa hospital and Laboratory building of
IUG contain higher number of antibiotic resistant bacteria than bacteria that
isolated from other sites in this study. Accordingly, previous studies have
shown than waste effluent from hospitals contain higher levels of antibiotic-
resistant enteric bacteria than waste effluent from other sources, hospital
waste effluent could increase the numbers of resistant bacteria in the
recipient sewer by both mechanisms of introduction and selection for
resistant bacteria. (Grabow & Prozesky 1973, Linton et al., 1974,
Walterand & Vennes, 1985, Fontaine & Chopade, 1994)

It is demonstrated that the resistance rate for some bacteria that isolated from the seawater sample is generally high particularly for Pseudomonas sp. Isolates, one study reported that river which is contaminated by treated Contribution of Hospital Wastewater… wastewater with many kinds of pollutants, is also contaminated with
antibiotic resistant bacteria (Iwane et al., 2003).
CONCLUSION AND RECOMMENDATION:
From the present investigation we can conclude that the release of wastewater from the hospital under study was associated with an increase in the prevalence of antibiotic resistance. It is generally agreed that the selection and dissemination of resistant bacteria in nature should be avoided in order to ensure effective treatment against infectious disease in humans and maintain an ecological balance that favors the predominance of a susceptible bacterial flora in nature. According to the results of this study, factors other than the indiscriminate use of antibiotics in human medicine, animal husbandry, and agriculture may disrupt the microbial balance in favor of resistant bacteria . REFERENCES:
1. Al-Ahmad, A.; Daschner, F. D. and Kümmerer, K. (1999): Biodegradability of cefotiam, ciprofloxacin, meropenem, penicillin G, and sulfamethoxazole and inhibition of wastewater bacteria. Arch. Environ. Contam. Toxicol. 37, pp:158-163 (1999) 2. Astal, Z; El-Manama, A. and Sharif, F.A., (2002): Antibiotic resistance of bacteria associated with community-acquired urinary tract infections in the southern area of the Gaza Strip. Journal of Chemotherapy, Vol. 14, No. 3, pp: 259-264. 3. Bauer AM, Kirby WMM, Sherris JC and Turck M. (1966): Antibiotic susceptibility testing by a standard simple disk method. Am J Clin Pathol; 45, pp:493-6. 4. Blanch, A. R., J. L. Caplin, A. Iversen, I. Kühn, A. Manero, H. D. Taylor, and X. Vilanova. (2003): Comparison of Enterococcal populations related to urban and hospital wastewater in various climatic and geographic European regions. J. Appl. Microbiol. 94, pp:994-1002. 5. Baya, A. M. et al. (1986): Coincident plasmids and antimicrobial resistance in marine bacteria isolated from polluted and unpolluted atlantic ocean samples. Appl. Environ. Microbiol. 51, pp:1285-1292 6. Chitnis V, Chitnis D, Patil S, and Kant R., (2000): Hospital effluent: A source of multiple drug-resistant bacteria. Current Science, Vol. 79, pp:989-991. A. Elmanama et al., J. Al-Aqsa Unv., 10 (S.E.) 2006 7. Fontaine T., III and Hoadley, A. (1976): Transferable drug resistance associated with coliforms isolated from hospital and domestic sewage. Health Lab. Sci. 13, pp: 238-245 . 8. Fontaine, T and Chopade A. (1994): High levels of multiple metal resistance and its correlation to antibiotic resistance in environmental isolates of Acinatobacter. Biometals 7, pp:67-74. 9. Foster, T. J. (1983): Plasmid-determined resistance to antimicrobial drugs and toxic metal ions in bacteria. Microbiol. Rev. 47, pp: 361-409. 10. Grabow, W and Prozesky, O. (1973): Drug resistance of coliform bacteria in hospital and city sewage. Antimicrob. Agents Chemother. 3, pp:175-180 . 11. Guardabassi, L., A. Petersen, J. E. Olsen, and A. Dalsgaard. (1998): Antibiotic resistance in Acinetobacter spp. isolated from sewers receiving waste effluent from a hospital and a pharmaceutical plant. Appl. Environ. Microbiol. 64, pp:3499-3502 12. Harwood, V. J., M. Brownell, W. Perusek, and J. E. Whitlock. (2001): Vancomycin-resistant Enterococcus spp. isolated from wastewater and chicken feces in the United States. Appl. Environ. Microbiol. 67, pp:4930-4933. 13. Iversen A, Franklin A and Kuhn I., (2002): High prevalence of vancomycin-resistant enterococci in Swedish sewage. Journal of Applied and Environmental Microbiology, 6, pp: 2838-2842. 14. Iwane T, Urase T and Yamamoto K. (2001): Possible impact of treated wastewater discharge on incidence of antibiotic resistant bacteria in river water. Water Sci Technol. 2, pp: 91-99 . 15. Kruse, H.(1999): Indirect transfer of antibiotic resistance genes to man. Acta Vet. Scand.92 (suppl.), pp:59-65 . 16. Kümmerer. K and Henninger. A., (2003): Promoting resistance by the emission of antibiotics from hospitals and household into effluent. Clinical Microbiology and Infection, 12, pp: 1203. 17. Linton, K. B., Richmond, M. H., Bevan, R. and Gillespie, W. A. (1974): Antibiotic resistance and R factors in coliform bacilli isolated from hospital and domestic sewage. J. Med. Microbiol. 7, pp:91-103 .
18. National Committee for Clinical Laboratory Standards. (2001): Performance standards for antimicrobial susceptibility testing. Eleventh Informational Supplement. Document M100-S11. (2001) 21, No. 1. NCCLS, Wayne, Pennsylvania, USA. 19. Pathak, S. P., Gaur, A. and Bhattacherjee, J. W. (1993): Distribution and antibiotic resistance among aerobic heterotrophic bacteria from rivers in relation to pollution. J. Environ. Sci. Health A28, pp:73-87 . Contribution of Hospital Wastewater… 20. Reinthaler, F.F., Posch, G. Feierl, G. Wust, D. Haas, G. Ruckenbaur, F. Mascher, and E. Marth. (2003): Antibiotic resistance of E.coli in sewage and sludge. Water Res. 37, pp:1685-1690. 21. Stuart. B., (2002): Factors impacting on the problem of antibiotic resistance. Journal of Antimicrobial Chemotherapy,1, pp:25-30. 22. Schwartz T, Kohnen W, Jansen B , and Obst U., (2003): Detection of antibiotic-resistant bacteria and their resistance genes in wastewater, surface water, and drinking water biofilms. FEMS Microbiol. Ecol . 23. ،43pp:325-335. 24. Vandepitte, A; El-Nageh, M.M.; Stelling, J.M.; Tikhomirov, E. and Estrela, A. 1996): WHO Regional Publications, Eastern Mediterranean Series. vol 15. Alexandria, Egypt: WHO Regional Office for the Eastern Mediterranean; 1996. Guidelines for Antimicrobial Resistance Surveillance. 25. Walter, M. V., and J. W. Vennes. (1985): Occurrence of multiple- antibiotic-resistant enteric bacteria in domestic sewage and oxidation lagoons. Appl. Environ. Microbiol. 50, pp:930-933. 26. Wegener, H., Aarestrup, F., Gerner-Smidt, P. and Bager, F. (1999): Transfer of resistant bacteria from animals to man. Acta Vet. Scand. 92 (suppl.), pp:51-58 . 27. World Health Organization (2002): Antibiotic resistance. WHO Media center WHO/Geneva. http://www.who.int/mediacentre/factsheets/fs194/en.

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Comunidad Internacional de Mujeres viviendo con VIH/SIDA Manual para la atención de la Salud Sexual y Reproductiva de mujeres que viven con VIH y VIH avanzado (sida) Manual práctico para proveedores de servicios de salud por niveles de atención del Ministerio De Salud Pública y Asistencia Social de Guatemala Dr. Jorge Alejandro Villavicencio Álvarez

Re-thinking the benefits of genetic engineering compared to its drawbacks

Perceived Risks Incurred Along With Genetic Engineering's Alluring Benefits New approaches to the practice of medicine and to food production have arrived on the technolo-gical scene as a consequence of the knowledge gained through modern genome sequencing. Now Scientists and genetic engineers can modify and manipulate the fundamental genetic code of cer-tain crops and animals to benefit mankind. Although the stated goals of genetic engineering and genetic modification are noble, these activities are not without associated risks and drawbacks, which apparently have received much less attention. The discussion below is an attempt to reme-dy that oversight by discussing both aspects in one gulp in a form that is easy to understand, without hype, with the venom removed and the invective wording toned down (from how it was originally stated elsewhere in many cases). We eschew being extreme in portraying either view; otherwise, adversaries would dismiss it out-of-hand as not being worthy to even consider further. In compiling the list of risks (and benefits) here below, we rely only on information and facts provided by internationally recognized scientific journals, nationally recognized newspapers, and three of the Public Broadcasting System's (PBS) NOVA series [1]-[3]. Each of these particular sources is well known for thoroughly crosschecking its supporting facts and, moreover, is avail-able from most U.S. public libraries for further confirmation. We specifically avoided visiting or viewing Web sites, pro or con (such as those of the USDA, FDA, EPA, The Foundation for Eco-nomic Trends, Friends of the Earth, International Green Peace, or the Earth Liberation Front) because information posted on the Web, in general, is notorious for being self-serving (by dis-seminating biases interspersed with truth), ephemeral (since it can vanish), and time-varying. Our aim here is not to convert or dissuade any existing views away from the current U.S. policy of encouraging progress in genetic engineering/genetic modification because the apparent con-sensus is that it is important for the long-term welfare of the U.S. and the world, both scientific-cally and economically, to continue on this course. The objective here is merely to delineate the benefits (as perceived by its advocates) and the drawbacks (as perceived by its opponents) of Genetically Modified Organisms (GMO), all in one place. The worries of the GMO critics appear to all pertain, at a high level, to one or more of the following four questions: