Quinolone Resistant Enterobacteriaceae and Pseudomonas in Environmental Water in Dhaka , Bangladesh

Pathogens that carry antibacterial resistant genes represent a threat for failure of antibiotic therapy and are associated with high mortality, morbidity and expenses. In Bangladesh, although quinolone resistance in clinical infections has been reported, environmental influence to this resistance is poorly known. Thus, to examine the existence of quinolone resistant bacterial strains in surface water in Dhaka, the study was conducted during June 2012 to January 2014. Surface water samples from Dhaka city were screened and isolated quinolone resistant Pseudomonas putida, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Molecular and genetic analysis identified the resistant determinants in these isolates. The study suggests that potential role of water for the dissemination and transmission of resistant genes among microorganisms causing human and animal infections in Bangladesh.


Introduction
Quinolone is one of the most commonly prescribed broad spectrum antimicrobial in the world at present era.This class of drug is currently used to treat a number of diseases including pyelonephritis, sexually transmitted diseases, prostatitis, chronic bronchitis, community-acquired and nosocomial pneumonia, intra-abdominal, pelvic, skin and tissue infections. 1 But the increasing occurrence of microbial resistance to this drug is threatening confident use of quinolone in clinical infections.
The mechanism of action of quinolone is to inhibit bacterial de-oxyribo neucleic acid (DNA) replication and resistance to quinolones has been classified in three broad categories: (i) targetmediated (ii) plasmid mediated and (iii) chromosome mediated.[10][11][12][13][14][15][16] PMQR mechanisms include target protection proteins of the qnr gene family: qnrA, qnrB, qnrC, qnrD and qnrS 9,[17][18][19][20] and per C, enzymatic modification gene aac-(6′)-Ib-cr and the efflux pump genes like oqxA, oqxB and qepA.In Bangladesh, quinolone is one of the most frequently prescribed drugs, and organisms resistant to this drug is increasingly high. 21But precise information about the spreading of these resistant organisms influenced by water systems is poorly known.The objective of the study was to examine the existence of quinolone resistant bacterial strains in surface water in Dhaka.The study also determined the molecular characteristics of these isolates.

Materials and Methods
Water from the longest lake (about 4.5 km) passing through the middle of Dhaka city, which receives waste water from the surrounding residents, commercial buildings and clinics, was chosen for sampling (figure 1).The study was conducted during June 2012 to January 2014.A total of four water samples were collected from opening of a pipe-line carrying waste water to Banani lake; edge of lake adjacent to the pipeline opening; middle of lake (approx.50 m away from lake edge) and from the edge of the lake around one km away from the second sampling point adjacent to a slum and market places, where direct contact of human and animal to the lake water was evident, were screened.In all cases, 50 milliliter of water was filtered through 0.45-μm-pore-sized membranes.Membranes were suspended in 3 ml distilled water inside sterile tubes.From each tube, 100 l suspensions were cultured on Mueller-Hinton agar.Growing colonies were counted, identified and tested for antimicrobial susceptibility by the BD Phoenix-100 system (Nippon Becton Dickinson Co. Ltd., Tokyo).Minimum Inhibitory Concentrations (MICs) for ciprofloxacin (CIP) of each isolate were observed and the isolates those displayed MIC >4  g/ml were considered CIP-resistant according to Clinical and Laboratory Standard Institute (CLSI) guideline and selected for further evaluation.
Genomic DNA was extracted from selected isolates using Wizard genomic DNA purification kit (Promega Corporation, USA) and the harvested DNAs were amplified by Polymerized Chain Reaction (PCR) in presence of specific primers.

Discussion
In this study, the isolation of quinolone resistant bacteria from two out of four environmental water samples collected from a lake in Dhaka.
Ten quinolone resistant gene encoding strains were isolated, where one strain was not identified by BD Phoenix-100 system and others included three P. putida, two E. coli, two K. pneumoniae, two P. aeruginosa.The current study is the first evidence for the existence of quinolone resistant P. putida, K. pneumoniae and P. aeruginosa in environmental water in Bangladesh.A previous study reported CIP-resistant E. coli in hospital waste water in Bangladesh 26 , and also did not find qnr gene in their E. coli isolates, similar to the current study result.But they showed co-existence of both gyrA and gyrB in isolates and we found only gyrA resistant gene in our E. coli isolates.However, taking together it could be concluded that in disseminating E. coli in Bangladesh water quinolone resistance is mainly determined by mutation of DNA gyrase that exhibit high-level of resistance to quinolone group of drugs.Another recent study showed increased rate of CIP resistance in common clinical isolates like E. coli, P. aeruginosa, K. pneumonia, etc. in Bangladesh. 27In this study, it was to be found that high-level of resistance determining gene gyrA in those clinically relevant bacteria in environment indicating important influence of environmental bacteria in harvesting and spreading of resistant genes among clinical isolates.
It is a long running debate in epidemiology field whether environmental organisms significantly influence clinical infection or not.However, with the current expanded understanding it is now clear that dissemination of resistant organisms and/or their resistant determinants from humans to animals and vice versa, often involve environmental pathways including foodstuffs, animal wastes and water sources.Thus, the environment plays an important role in both the emergence and spread of microbial resistance. 28Zurfluh K et al showed drug resistant isolates from river water in Switzerland were comparable with those isolates from clinics, healthy human carriers and food-producing animals. 29It could be applicable in other parts of the world, including Bangladesh.We observed DNA gyrase targeted resistance in 50% of isolates, warned a careful observation of this mutation in clinical isolates.Plasmidmediated quinolone resistance (PMQR) was observed in eight environmental isolates in Bangladesh.Although PMQR mechanisms confer low level resistance to quinolones, 2, 8-16 but they are thought to enable the occurrence of chromosomal mutation in bacteria which then lead to increased resistance levels, as high as upto 250-fold. 2,12,14 Ulike target-mediated resistance, which is transmitted vertically from generation to generation, PMQR can be transmitted horizontally (through bacterial conjugation) as well as vertically.Moreover, plasmids that confer quinolone resistance typically carry additional genes that cause resistance to other antimicrobials. 9,11,12,14 Qunolone resistant E.coli (TUM 12598 and TUM 12599) and K. pneumonia (TUM 13741) are also included as ESBLproducing bacteria according to our previous study. 30

Conclusion
This study provides evidence for the importance of the water-related environment as a reservoir of emerging threat of quinolone resistance and raises worrisome of increasing prevalence of quinolone resistant organisms in clinics in Bangladesh.More attention and investigations in environmental and clinical settings are required to challenge the threat by quinolone resistant bacteria.

Figure 1 :
Figure 1: Location of water sampling

Table I :
Target genes, used primers and PCR reaction conditions qnrC, qnrD, qnrS, aac(6`)-lb-cr, oqxA, oqxB and qepA in the isolates.In case of gyrA, gyrB and parC the resulting amplicons were further purified by QIA quick PCR purification kit (QI-

Table II :
Quinolone-resistant bacteria in water samples (1/10, 10%) and aac(6')lb-cr (1/10, 10%).gyrB, parC, qnrB, qnrC, qnrD and qepA were not observed in any isolates in environmental water 32r finding is comparable with the study ofZurfluh et al.where they showed that ESBL producing E. coli in their collected environmental water samples were carrying resistant determinants against quinolones.Concomitant quinolone and other class of drugs resistant bacteria are not uncommon in clinical setting in Bangladesh, as Rahman M et al. reported 46.3% MDR-Salmonella typhi were less susceptible to CIP.32