|Gabriel Andari Kristanto||Department of Civil, Faculty of Engineering, Universitas Indonesia, Kampus UI Depok, Depok 16424, Indonesia|
|William Koven||Department of Civil, Faculty of Engineering, Universitas Indonesia, Kampus UI Depok, Depok 16424, Indonesia|
The widespread uses of antibiotics have encouraged antibiotic resistant bacteria to develop and wastewater treatment plants (WWTPs) are believed to be hotspots for the dissemination of such bacteria. This research was conducted to ascertain the effect of WWTPs at a Jakarta public hospital on the prevalance of antibiotic resistant E. coli in three antibiotics, namely Meropenem, Ciprofloxacin and Cefixime, using the Kirby Bauer method. WWTPs apply activated sludge, polystyrene filtration, and chlorination to treat hospital wastewater. Raw wastewater was found to contain 4.6×104 CFU E. coli with the percentage of antibiotic-resistant E. coli in Meropenem of 3.8%, in Ciprofloxacin of 53.8%, and in Cefixime of 56.3%, while treated wastewater contained antibiotic resistant E. coli in Meropenem at the level of 20%, in Ciprofloxacin of 60%, and in Cefixime of 80% for 1.3×103 CFU E. coli. Hospital WWTPs increased the percentage of antibiotic-resistant E. coli. The E. coli becoming resistant to Meropenem, the Carbapenem class antibiotic known for its effectiveness in dealing with antibiotic-resistant bacteria.
Antibiotics; Escherichia coli; Kirby Bauer; Resistant bacteria; Wastewater
As more and more people move to the city, one inevitable consequence that needs to be faced is crowded living conditions with inadequate facilities and job opportunities, forcing people to live in poverty. Poverty brings problems with sanitation, malnutrition and infectious diseases, amongst others. According to the World Health Organization (WHO) and the United Nation Children’s Fund (UNICEF), 700 million people have no access to drinking water (the majority in Africa), 200 million people face sanitation problems, and 1 billion people defecate in the open (WHO & UNICEF, 2014).
In 2017, the Indonesian population has reached more than 260 million people, many of whom are concentrated in the capital Jakarta (World Population Review, 2018), which had a population of 10 million people and a density of approximately 15,000 people per km2. This dense population means the city faces problems similar ones faced by other populous cities, especially poverty, sanitation, access to drinking water, and infectious diseases (DKI Jakarta Bureau of Statistics, 2014).
Antibiotics are the key to treat diseases caused by bacteria in most countries, including Indonesia. A survey conducted by the Parent Care Foundation (Yayasan Orang Tua Peduli) revealed that in Indonesia 86.4% of cases of dengue fever and 74.1% of diarrhea were treated with antibiotics, even though such diseases can sometimes be treated just by resting or consuming vitamin C (Yayasan Lembaga Konsumen Indonesia, 2014). Antibiotics are used not only in medical treatment, but also in agriculture to protect high value crops from bacteria, in livestock to prevent diseases and to stimulate their growth, and in fisheries to prevent bacterial contamination (Kümmerer, 2009). From 2000 to 2010, global antibiotic consumption increased by 36%, from 54 billion to 73 billion pills (Van Boeckel et al., 2014)
These numbers show that the widespread use of antibiotics has reached a critical point. It is the major cause of the emergence of antibiotic resistant bacteria (ARB). The former health minister of Indonesia stated that at least 12,209 cases of ARB have been found, which is estimated to increase to at least 6,935 new cases annually in the country (Suara Pembaharuan, 2011).
Antibiotic resistance is defined as the ability of bacteria to grow in certain concentrations of antibiotics which are designated to inhibit such growth. The minimum concentration of antibiotic to inhibit bacterial growth is defined as Minimum Inhibitory Concentration (MIC), which is determined by scientists by various experiments. Bacteria are considered to be resistant when the antibiotic concentration needed to inhibit their growth exceeds the MIC (Drlica & Perlin, 2011).
Scientists are concerned that the growth of ARB will return us to the age before antibiotics had been discovered, when thousands of people died just because of small infections. Hence, it is very important to study the hotspots where ARB emerge, so that effective action can be taken to tackle the problem. One of these hotspots is wastewater treatment plants (WWTPs) (Rizzo et al., 2013).
A large amount of antibiotic residual is excreted from the human body. It is estimated that at least 70% of total antibiotics consumed are excreted without undergoing any changes (Kümmerer, 2009). The excreted antibiotics, having been reduced by the human metabolism, have a no-kill concentration, known as sub-inhibitor concentration. These antibiotics are mixed intensely with pathogenic bacteria in wastewater. The long journey begins from the wastewater collection system to the WWTPs. In WWTPs, more intense contact takes place: in no-kill concentration, bacteria absorb the antibiotics and begin to adapt to them, ultimately developing antibiotic resistant (Rizzo et al., 2013). At the final stage of the process, most WWTPs apply chlorination to ensure that all the microorganisms and viruses are destroyed. Seen as the key process in preventing the dissemination of ARB, many researchers have, however, found this process to have low affectivity in dealing with the problem (Everage et al., 2014).
Eventually, the treated wastewater, which still contains partially changed antibiotics, ARB and Antibiotic Resistant Gen (ARG) from destroyed ARB, is discharged into a receiving water body. The partially-changed antibiotic will induce mutation, and ARG will make genetic transformation, making the antibiotic susceptible to indigenous bacteria in the receiving water and becoming ARB (Everage et al., 2014).
In Europe and the United States, research in antibiotic resistant dissemination has been developing. The research objects have ranged from antibiotic concentration to bacteria gen in urban wastewater (Birošová et al., 2014; Everage et al., 2014; Paulus et al., 2019). In Indonesia, there is a lack of research concerning WWTPs as hotspots for ARB dissemination, although there have been many recorded cases of ARB (MIMS Today, 2017). Some of the reasons why some countries have fallen behind others in research include lack of human resources, unavailable measuring instruments, and dilution of wastewater due to high water consumption per capita per day (Al-Maadheed et al., 2019). Research should therefore start with WWTPs, where tons of microorganisms have close contact with large amounts of antibiotics, confirming the presence of ARB dissemination in WWTPs.
Hospitals commonly use antibiotics to treat patients for various diseases. They experience a 25% higher antibiotic concentration than domestic WWTPs (Paulus et al., 2019). As a result, the contact between antibiotics and bacteria is more likely to happen at WWTPs owned by hospitals. This research aims to conduct a preliminary study of antibiotic resistant Escherichia coli in each unit of the waste water treatment plant at one of Jakarta's public hospitals. The hospital will hereinafter be referred to as RSX for confidentiality purposes.
The effect of hospital wastewater treatment plants on antibiotic resistant E. coli depends on the unit's process. Activated sludge increased by 4.17% the average of antibiotic-resistant E. coli due to its rich environment, which contains a wide variety of bacteria and nutrient. The filtration effect on antibiotic resistant E. coli depends on the filtration medium and the type of antibiotic. In the filtration process of this research, the average antibiotic resistant E. coli increase is 4.17%, while on average chlorination increased antibiotic resistant E. coli by 7.03%. Antibiotic resistant bacteria have a more perfect structure body, making them able to withstand disinfectants better than susceptible bacteria. Overall, the process in the hospital WWTP increased antibiotic- resistant E. coli by around 20%.
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