title: Human recreational exposure to antibiotic resistant bacteria in coastal bathing waters.
abstract: Infections caused by antibiotic resistant bacteria (ARB) are associated with poor health outcomes and are recognised globally as a serious health problem. Much research has been conducted on the transmission of ARB to humans. Yet the role the natural environment plays in the spread of ARB and antibiotic resistance genes is not well understood. Antibiotic resistant bacteria have been detected in natural aquatic environments, and ingestion of seawater during water sports is one route by which many people could be directly exposed. The aim was to estimate the prevalence of resistance to one clinically important class of antibiotics (third-generation cephalosporins (3GCs)) amongst Escherichia coli in coastal surface waters in England and Wales. Prevalence data was used to quantify ingestion of 3GC-resistant E. coli (3GCREC) by people participating in water sports in designated coastal bathing waters. A further aim was to use this value to derive a population-level estimate of exposure to these bacteria during recreational use of coastal waters in 2012. The prevalence of 3GC-resistance amongst E. coli isolated from coastal surface waters was estimated using culture-based methods. This was combined with the density of E. coli reported in designated coastal bathing waters along with estimations of the volumes of water ingested during various water sports reported in the literature to calculate the mean number of 3GCREC ingested during different water sports. 0.12% of E. coli isolated from surface waters were resistant to 3GCs. This value was used to estimate that in England and Wales over 6.3 million water sport sessions occurred in 2012 that resulted in the ingestion of at least one 3GCREC. Despite the low prevalence of resistance to 3GCs amongst E. coli in surface waters, there is an identifiable human exposure risk for water users, which varies with the type of water sport undertaken. The relative importance of this exposure is likely to be greater in areas where a large proportion of the population enjoys water sports. Millions of water sport sessions occurred in 2012 that were likely to have resulted in people ingesting E. coli resistant to a single class of antibiotics (3GCs). However, this is expected to be a significant underestimate of recreational exposure to all ARB in seawater. This is the first study to use volumes of water ingested during different water sports to estimate human exposure to ARB. Further work needs to be done to elucidate the health implications and clinical relevance of exposure to ARB in both marine and fresh waters in order to fully understand the risk to public health.
authors.affiliation: European Centre for Environment and Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall TR1 3HD, UK. Electronic address: afcl202@exeter.ac.uk.
authors.forename: Anne F C
authors.initials: AF
authors.lastname: Leonard
authors.affiliation: European Centre for Environment and Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall TR1 3HD, UK. Electronic address: L.zhang@exeter.ac.uk.
authors.forename: Lihong
authors.initials: L
authors.lastname: Zhang
authors.affiliation: European Centre for Environment and Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall TR1 3HD, UK.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Balfour
authors.affiliation: European Centre for Environment and Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall TR1 3HD, UK. Electronic address: R.garside@exeter.ac.uk.
authors.forename: Ruth
authors.initials: R
authors.lastname: Garside
authors.affiliation: European Centre for Environment and Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall TR1 3HD, UK. Electronic address: W.h.gaze@exeter.ac.uk.
authors.forename: William H
authors.initials: WH
authors.lastname: Gaze
mesh_terms: D000900:Anti-Bacterial Agents / Q000494:pharmacology; D004352:Drug Resistance, Microbial; D004739:England; D004926:Escherichia coli / Q000187:drug effects; D005618:Fresh Water; D006801:Humans; D011998:Recreation; D012623:Seawater; D013550:Swimming; D014852:Wales
chemical_list: D000900:Anti-Bacterial Agents
keywords: Antibiotic resistant bacteria; Coastal waters; Escherichia coli; Third-generation cephalosporin; Water sports