Associations between socio-spatially different urban areas and knowledge, attitudes, practices and antibiotic use: A cross-sectional study in the Ruhr Metropolis, Germany.

Inappropriate and excessive antibiotic use fuels the development of antibiotic resistance. Determinants of antibiotic use, including knowledge and attitudes, are manifold and vary on different spatial scales. The objective of this study was to examine the associations between socio-spatially diverse urban areas and knowledge, attitudes, practices and antibiotic use within a metropolitan city. A cross-sectional survey was conducted in the general population in socio-spatially different areas in Dortmund, Germany, in February and March 2020. Three urban areas were chosen to represent diverse socio-spatial contexts (socio-spatially disadvantaged: A, intermediate: B, socio-spatially disadvantaged: C). Participants were selected via simple random sampling. The questionnaire comprised knowledge and attitude statements and questions around antibiotic use and handling practices. Differences between the areas were examined by estimating odds ratios (OR) and corresponding 95% confidence intervals by multiple logistic regression. Overall, 158 participants were included. Participants of Area C showed the lowest proportions of correct knowledge statements, indicated more often attitudes contrary to common recommendations, lower risk awareness and reported more often antibiotic use (C: 40.8%; A: 32.7%; B: 26.5%) and potential mishandling practices (C: 30.4%; A: 9.6%; B: 17.3%). The multiple logistic regression confirmed these differences. Around 42.3% (C), 33.3% (A) and 20.0% (B) of the diseases mentioned for which an antibiotic was used are mainly caused by viral pathogens. A common misconception across all areas was the perception of antibiotic resistance as an individual rather than a universal issue. This study reveals distinct differences between socio-spatially diverse urban areas within a metropolitan city, regarding knowledge, attitudes and practices around antibiotics and ABR. Our findings confirm that enhanced efforts are required to better inform the population about the adequate use and handling of antibiotics. This study emphasizes the need for future interventions to be tailored to the specific local socio-economic context.

Prevalence of multidrug-resistant and extended-spectrum beta-lactamase-producing Escherichia coli in urban community wastewater.

Antibiotic resistance (ABR) and the spread of multidrug-resistant and extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli via wastewater to environmental compartments are of rapidly growing global health concern. Health care facilities, industries and slaughterhouses discharge high loads of ABR bacteria with their wastewater. However, the general community is often the biggest indirect discharger. Yet, research focusing explicitly on this important diffuse source is rather scarce raising questions about variations in the occurrence of ESBL-producing E. coli in wastewater from different communities and over time. Between April 2019 and March 2020, wastewater from three socio-spatially different districts in the Ruhr Metropolis, Germany, and the receiving wastewater treatment plant was sampled monthly and analysed for the occurrence of ESBL-producing E. coli via culture-based methods. Isolates were validated with matrix assisted laser desorption ionization time of flight mass spectrometry and antibiotic resistance profiles were analysed via microdilution. Results were interpreted using the European Committee on Antimicrobial Susceptibility Testing criteria. The German Commission for Hospital Hygiene and Infection Prevention criteria were used for multidrug-resistance categorization. Phenotypic ESBL-producing E. coli could be isolated from every wastewater sample demonstrating that the general community is an important indirect discharger. The socio-spatially disadvantaged area displayed higher absolute loads of ESBL-producing E. coli compared to the other two areas, as well as higher adjusted loads for domestic discharge and inhabitants, particularly during winter, indicating a higher ABR burden. Thirty-two isolates (28.6%) were characterized as multidrug-resistant Gram-negative bacteria (3MRGN). Resistance profiles varied only for those antibiotics, which can be administered in outpatient care. Resistance levels tended to be around 10% lower in the socio-spatially advantaged area. This study shows that spatial and seasonal influences regarding the occurrence of ESBL-producing E. coli in wastewater from socio-spatially different communities are identifiable.

Comparing the German enabling environment for nationwide Water Safety Plan implementation with international experiences: Are we still thinking big or already scaling up?

Ensuring safe drinking-water is the target of the Water Safety Plan (WSP) approach, which has been successfully applied to a large number of water supply systems around the world. Effective country-wide scaling up of WSP implementation requires an enabling environment at the policy level. By utilizing a multi-step mixed methods approach, this study summarizes international experience with WSP implementation and scaling-up efforts following the 8 steps of the WSP road map published by WHO and IWA for an enabling environment, shows what steps Germany has in place, and compares this with published international experience to inspire further policy action. Contrasting the international experience to the German situation revealed several overlaps but also profound differences, which, in turn, offer opportunities for mutual learning. Most experience in Germany and internationally is documented for the earlier steps of the WSP road map. Information particularly on developing a national strategy, securing financial instruments, activities to support continual implementation of WSPs and on review of the overall WSP experiences and sharing lessons learned appears to be scarce, while the importance of training, collaboration and alliances, and the value of a regulatory push are often stressed. In Germany, stakeholder engagement, guidance documents and workshop materials have been of vital importance. Information that could particularly inform further action in Germany mostly relate to considering a national WSP strategy, and how to shape an approach for external quality assurance of WSPs.

What drives antibiotic use in the community? A systematic review of determinants in the human outpatient sector.

Inadequate and excessive use of antibiotics in humans, animals, and plants has been identified among the key drivers of antibiotic resistance (ABR). In human medicine, the great majority of antibiotics are prescribed in the outpatient sector with profound differences in antibiotic consumption across various geographical scales and between health care sectors; raising questions around the underlying drivers. Moving beyond individual patient-related determinants, determinants of antibiotic use in the outpatient sector were categorized as compositional, contextual and collective, enabling an analysis of potential area effects on antibiotic use. 592 variables identified in 73 studies were sorted into 46 determinant groups. Compositional determinants provided the strongest evidence with age, education, employment, income, and morbidity exhibiting a clear influence on antibiotic use. Regarding contextual and collective determinants, deprivation, variables around health care services, Hofstede's dimensions of national culture and regulation affect antibiotic use. The results are biased towards high-income and western countries, often relying on secondary data. However, the findings can be used as signposts for associations of certain variables with antibiotic use, thereby enabling further research and guiding interventions.

Coping with uncertainty in water management: Qualitative system analysis as a vehicle to visualize the plurality of practitioners' uncertainty handling routines.

Accelerated environmental and societal change and its dynamic present a challenge for water management, making it increasingly relevant to integrate uncertainties into the decision-making process. The challenge to science informing practice is how to provide scientific uncertainty information in a way that this information becomes usable for practitioners. We know that practitioners have developed routines in order to cope with uncertainties, but in order to facilitate the transfer of uncertainty information, this study analyses by whom, when and where in the decision-making process uncertainty routines are used. This research contributes to the plurality of practitioners' perspectives on decision-making under uncertainty in water management. Based on expert elicitation we show that, depending on the business unit and on the time horizon of the management object, practitioners are using different uncertainty routines and hence are in need of more tailor-made uncertainty information to inform their decision-making. Our qualitative systems modeling approach highlighting a reservoir management example serves as a boundary object visualizing the intersection of uncertainty routines and fostering cross-communication and acknowledgement of different perspectives among practitioners. It thus provides a platform for learning. Moreover, it provides a clear understanding of the uncertainty information needs which scientists may cover and increases the usability of their research findings, closing the science-practice gap in adaptive management and transformation processes.

Integrated hydrologic modeling as a key for sustainable urban water resources planning.

In this study, a coupling of surface water (SWAT), groundwater (MODFLOW) and solute transport (MT3DMS) models was performed to quantify surface-groundwater and quantity-quality interactions under urban area expansion. The responses of groundwater level, nitrate concentrations (related to human activities) and chloride concentrations (related to seawater intrusion) to urban area expansion and corresponding changes in the urban water budget were examined on a macro-scale level. The potentials of non-conventional water resources scenarios, namely desalination, stormwater harvesting and treated wastewater (TWW) reuse were investigated. In a novel analysis, groundwater improvement and deterioration under each scenario were defined in spatial-temporal approach. The quality deterioration cycle index was estimated as the ratio between the amounts of low and high quality recharge components within the Gaza Strip boundary predicted for year 2030. The improvement index for groundwater level (IIL) and the improvement index for groundwater quality (IIQ) were developed for the scenarios as measures of the effectiveness toward sustainable groundwater planning. Even though the desalination and TWW reuse scenarios reflect a noticeable improvement in the groundwater level, the desalination scenario shows a stronger tendency toward sustainable groundwater quality. The stormwater harvesting scenario shows a slight improvement in both groundwater quality and quantity. This study provides a 'corridor of options', which could facilitate future studies focusing on developing a micro-level assessment of the above scenarios.