Wastewater Surveillance for Carbapenem-Resistant Organism Outbreak Prediction in a Chinese Tertiary Hospital

NCT07804433 | Not Yet Recruiting DMC

• 2 other identifiers: PUMCH-WW-ARG-202601050010
• Study Type: observational
• Target: 720
• Locations: 1 country
• Sites: 1

Brief Summary

Carbapenem-resistant organisms (CRO) pose a critical threat to global public health, and hospitals serve as major epicenters for their emergence and spread. Traditional clinical infection surveillance often detects CRO outbreaks only after infections have already occurred, missing the window for early intervention. Wastewater-based epidemiology has demonstrated its early warning potential during the COVID-19 pandemic and is increasingly recognized as a promising tool for antimicrobial resistance surveillance. Our preliminary 22-day pilot study at Peking Union Medical College Hospital revealed two distinct antimicrobial resistance gene (ARG) dynamics patterns across different hospital areas: the Internal Medicine Ward exhibited a "chronic resistance background" with persistently high abundance of carbapenemase genes (IMP/GES types \>5,000 ppm), while the Emergency/Fever Clinic showed "acute pulse outbreaks" characterized by transient 50- to 200-fold surges of mcr-3 and QnrVC genes. These findings suggest that hospital functional areas have fundamentally different ARG profiles with unique temporal signatures. This prospective observational cohort study aims to establish a wastewater-based early warning system for hospital-acquired CRO outbreaks by conducting longitudinal monitoring across four key functional areas: Outpatient Building, Internal Medicine Ward, Surgical Ward, and Emergency/Fever Clinic at Peking Union Medical College Hospital over a 6- to 9-month period. Twenty-four-hour flow-proportional composite wastewater samples will be collected daily using automatic samplers. Laboratory analyses include ARG large-panel testing (300+ subtypes, daily), metagenomic sequencing (weekly, plus pulse-triggered intensified sampling), and viable bacterial culture with whole-genome sequencing of key isolates. Concurrently, we will collect de-identified clinical CRO isolates and antibiotic consumption data (Defined Daily Doses) from the corresponding hospital buildings. Multidimensional association analyses will be performed using cross-correlation function analysis, Granger causality tests, and cgMLST-based genomic comparisons to determine the lead time of wastewater ARG signals ahead of clinical CRO diagnoses and to provide direct evidence of clonal homology between wastewater and clinical isolates. An early warning model will be constructed using dynamic thresholds (moving average + 2SD/3SD) and machine learning algorithms. This study integrates environmental, clinical, and pharmaceutical data following the One Health framework. By establishing a replicable building-level wastewater resistome surveillance protocol, this research is expected to provide hospitals with a proactive tool for early CRO outbreak detection, enabling timely infection prevention and control measures. All clinical data will be de-identified, and the study has been designed to pose no greater than minimal risk to patients, with a waiver of informed consent sought in accordance with relevant ethical regulations.

Conditions

Drug Resistance, Bacterial; Carbapenems; Wastewater

Outcome Measures

Primary Outcomes (2)

• Wastewater Antimicrobial Resistance Gene (ARG) Abundance

  Abundance of 300+ ARG subtypes (including carbapenemase genes blaIMP, blaGES, blaKPC, blaNDM, blaOXA; colistin resistance gene mcr-3; quinolone resistance gene QnrVC) measured in copies per million 16S rRNA reads (ppm) from 24-hour composite wastewater samples collected at 4 hospital sites

  Daily for 6-9 months

• Whole-Genome Sequences of Clinical CRO Isolates

  Clinical CRO isolates (50-80 selected strains) from each building during the study period are subjected to whole-genome sequencing (≥50× coverage). cgMLST typing, ARG annotation (AMRFinderPlus), and phylogenetic analysis are performed for clonal homology comparison with wastewater isolates.

  Clinical CRO isolates (50-80 selected strains) from each building during the study period

Study Arms (4)

Outpatient Building

Community reference, non-hospitalized medical area

Internal Medicine Ward

Chronic high-resistance background area

Surgical Ward

Surgical prophylactic antibiotic use area

Emergency

Acute pulse outbreak sentinel area

Eligibility Criteria

• Sex: all
• Healthy Volunteers: No
• Age Groups: Child (0-17), Adult (18-64), Older Adult (65+)
• Sampling Method: Non-Probability Sample

Study Population

Environmental samples: 24-hour composite wastewater samples from 4 designated sewer manholes (Outpatient Building, Internal Medicine Ward, Surgical Ward, Emergency/Fever Clinic) at Peking Union Medical College Hospital. Clinical data: De-identified CRO-positive culture results from patients treated in the above 4 hospital buildings during the study period.

You may qualify if:

• Wastewater samples collected from the four designated sampling sites (Outpatient Building, Internal Medicine Ward, Surgical Ward, and Emergency/Fever Clinic).
• hour composite samples collected using automatic samplers following the flow-proportional mixing protocol.
• Clinical data: Patients with laboratory-confirmed CRO infection (carbapenem-resistant Enterobacterales, Pseudomonas aeruginosa, Acinetobacter baumannii, etc.) from the above 4 hospital buildings during the study period.
• Clinical data de-identified at the time of extraction.

You may not qualify if:

• Wastewater samples from sites other than the four designated locations.
• Samples contaminated or degraded during collection, transport, or storage.
• Clinical data: CRO-positive results indicating colonization rather than infection.
• Clinical data with incomplete key information (species, specimen source, date of detection, or department/location).

Sponsors & Collaborators

• Peking Union Medical College Hospital: lead

Study Sites (1)

Peking Union Medical College Hospital

Beijing, Beijing Municipality, 100730, China

Location

Related Publications (2)

• Liu X, Wong MKL, Zhang D, Chan DCL, Chan OSK, Chan GPL, Shum MH, Peng Y, Lai CKC, Cowling BJ, Zhang T, Fukuda K, Lam TT, Tun HM. Longitudinal monitoring reveals the emergence and spread of blaGES-5-harboring carbapenem-resistant Klebsiella quasipneumoniae in a Hong Kong hospital wastewater discharge line. Sci Total Environ. 2023 Dec 10;903:166255. doi: 10.1016/j.scitotenv.2023.166255. Epub 2023 Aug 11.

  PMID: 37574056 BACKGROUND

• Hendriksen RS, Munk P, Njage P, van Bunnik B, McNally L, Lukjancenko O, Roder T, Nieuwenhuijse D, Pedersen SK, Kjeldgaard J, Kaas RS, Clausen PTLC, Vogt JK, Leekitcharoenphon P, van de Schans MGM, Zuidema T, de Roda Husman AM, Rasmussen S, Petersen B; Global Sewage Surveillance project consortium; Amid C, Cochrane G, Sicheritz-Ponten T, Schmitt H, Alvarez JRM, Aidara-Kane A, Pamp SJ, Lund O, Hald T, Woolhouse M, Koopmans MP, Vigre H, Petersen TN, Aarestrup FM. Global monitoring of antimicrobial resistance based on metagenomics analyses of urban sewage. Nat Commun. 2019 Mar 8;10(1):1124. doi: 10.1038/s41467-019-08853-3.

  PMID: 30850636 BACKGROUND

Biospecimen

Retention: SAMPLES WITH DNA

720 wastewater samples

Study Officials

• bin du, Dr

  Peking Union Medical College Hospital

  PRINCIPAL INVESTIGATOR

Central Study Contacts

yuda fei, Dr

CONTACT

+86 18501360830; fei_yuda@!63.com

Study Design

• Study Type: observational
• Observational Model: COHORT
• Time Perspective: PROSPECTIVE
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: September 1, 2026
• First Posted: September 4, 2026
• Study Start: September 1, 2026
• Primary Completion (Estimated): September 1, 2028
• Study Completion (Estimated): September 1, 2028
• Last Updated: September 4, 2026

Record last verified: 2026-09

Data Sharing

• IPD Sharing: Will share
• Shared Documents: STUDY PROTOCOL, SAP, CSR
• Time Frame: upon study completion

Locations

CN (1)