title: Antibiotics and antibiotic-resistant bacteria in waters associated with a hospital in Ujjain, India.
abstract: BACKGROUND
  Concerns have been raised about the public health implications of the presence of antibiotic residues in the aquatic environment and their effect on the development of bacterial resistance. While there is information on antibiotic residue levels in hospital effluent from some other countries, information on antibiotic residue levels in effluent from Indian hospitals is not available. Also, concurrent studies on antibiotic prescription quantity in a hospital and antibiotic residue levels and resistant bacteria in the effluent of the same hospital are few. Therefore, we quantified antibiotic residues in waters associated with a hospital in India and assessed their association, if any, with quantities of antibiotic prescribed in the hospital and the susceptibility of Escherichia coli found in the hospital effluent.
  
  
  METHODS
  This cross-sectional study was conducted in a teaching hospital outside the city of Ujjain in India. Seven antibiotics--amoxicillin, ceftriaxone, amikacin, ofloxacin, ciprofloxacin, norfloxacin and levofloxacin--were selected. Prescribed quantities were obtained from hospital records. The samples of the hospital associated water were analysed for the above mentioned antibiotics using well developed and validated liquid chromatography/tandem mass spectrometry technique after selectively isolating the analytes from the matrix using solid phase extraction. Escherichia coli isolates from these waters were tested for antibiotic susceptibility, by standard Kirby Bauer disc diffusion method using Clinical and Laboratory Standard Institute breakpoints.
  
  
  RESULTS
  Ciprofloxacin was the highest prescribed antibiotic in the hospital and its residue levels in the hospital wastewater were also the highest. In samples of the municipal water supply and the groundwater, no antibiotics were detected. There was a positive correlation between the quantity of antibiotics prescribed in the hospital and antibiotic residue levels in the hospital wastewater. Wastewater samples collected in the afternoon contained both a higher number and higher levels of antibiotics compared to samples collected in the morning hours. No amikacin was found in the wastewater, but E.coli isolates from all wastewater samples were resistant to amikacin. Although ciprofloxacin was the most prevalent antibiotic detected in the wastewater, E.coli was not resistant to it.
  
  
  CONCLUSIONS
  Antibiotics are entering the aquatic environment of countries like India through hospital effluent. In-depth studies are needed to establish the correlation, if any, between the quantities of antibiotics prescribed in hospitals and the levels of antibiotic residues found in hospital effluent. Further, the effect of this on the development of bacterial resistance in the environment and its subsequent public health impact need thorough assessment.
authors.affiliation: Division of Global Health, Department of Public Health Sciences, Karolinska Institutet, Nobels väg 9, SE 17177 Stockholm, Sweden. vishaldiwan@hotmail.com
authors.forename: Vishal
authors.initials: V
authors.lastname: Diwan
authors.forename: Ashok J
authors.initials: AJ
authors.lastname: Tamhankar
authors.forename: Rakesh K
authors.initials: RK
authors.lastname: Khandal
authors.forename: Shanta
authors.initials: S
authors.lastname: Sen
authors.forename: Manjeet
authors.initials: M
authors.lastname: Aggarwal
authors.forename: Yogyata
authors.initials: Y
authors.lastname: Marothi
authors.forename: Rama V
authors.initials: RV
authors.lastname: Iyer
authors.forename: Karin
authors.initials: K
authors.lastname: Sundblad-Tonderski
authors.forename: Cecilia
authors.initials: C
authors.lastname: Stålsby-Lundborg
mesh_terms: D002939:Ciprofloxacin / Q000302:isolation & purification; D003430:Cross-Sectional Studies; D024881:Drug Resistance, Bacterial; D004363:Drug Utilization; D004926:Escherichia coli / Q000187:drug effects* / Q000302:isolation & purification; D006784:Hospitals, Teaching; D006801:Humans; D007194:India; D062065:Wastewater / Q000737:chemistry* / Q000382:microbiology; D014867:Water / Q000737:chemistry*
chemical_list: D002939:Ciprofloxacin; D062065:Wastewater; D014867:Water