Comparison of antibiotic-resistant bacteria and antibiotic resistance genes abundance in hospital and community wastewater: A systematic review

Nasreen Hassoun-Kheir*, Yoav Stabholz, Jan Ulrich Kreft, Roberto de la Cruz, Jesús L. Romalde, Joseph Nesme, Søren J. Sørensen, Barth F. Smets, David Graham, Mical Paul

*Corresponding author for this work

Research output: Contribution to journalReviewResearchpeer-review


Antibiotic-resistant bacteria (ARB) and antibiotic-resistance genes (ARGs) are constantly shed into the aquatic environment, with hospital wastewater potentially acting as an important source for resistance spread into the environment. A systematic review was conducted aiming to investigate the role of hospital wastewater on dissemination of antimicrobial resistance in the aquatic environment. Studies included in the review compared the prevalence of ARB and/or ARGs in hospital versus community wastewater. Data were extracted on ARB and/or ARG prevalence. Data on sampling techniques, microbiological methodology and risk of bias of included studies were recorded. Thirty-seven studies were included. Higher frequencies of antibiotic resistance determinants were found in hospital wastewater compared to community sources in 30/37 (81%) of included studies. However, trends for specific multi-drug-resistant bacteria differed. Antibiotic-resistant Gram-negative were more prevalent in hospital compared to community wastewaters, with higher concentrations of extended-spectrum-beta-lactamase-producing pathogens and carbapenemase-producing Enterobacteriaceae in hospital sources in 9/9 studies and 6/7 studies, respectively. Hospitals did not contribute consistently to the abundance of vancomycin-resistant Enterococci (VRE); 5/10 studies found higher abundance of VRE in hospital compared to community wastewaters. Reporting on sampling methods, wastewater treatment processes and statistical analysis were at high risk of bias. Extreme heterogeneity in study methods and outcome reporting precluded meta-analysis. Current evidence concurs that hospital wastewater is an important source for antibiotic resistance in aquatic environments, mainly multidrug-resistant Gram-negative bacteria. Future research is needed to assess the effect of wastewater treatment processes on overall antibiotic resistance in the aquatic environment.

Original languageEnglish
Article number140804
JournalScience of the Total Environment
Number of pages11
Publication statusPublished - 2020


  • Antibiotic resistance genes
  • Antibiotic resistant bacteria
  • Antimicrobial resistance
  • Community
  • Hospital
  • Wastewater

Cite this

Hassoun-Kheir, N., Stabholz, Y., Kreft, J. U., de la Cruz, R., Romalde, J. L., Nesme, J., Sørensen, S. J., Smets, B. F., Graham, D., & Paul, M. (2020). Comparison of antibiotic-resistant bacteria and antibiotic resistance genes abundance in hospital and community wastewater: A systematic review. Science of the Total Environment, 743, [140804].