Wastewater Surveillance for Carbapenem-Resistant Organism Outbreak Prediction in a Chinese Tertiary Hospital (WW-CRO-PREDICT)

September 1, 2026 updated by: Peking Union Medical College Hospital

Longitudinal Wastewater Monitoring of Antimicrobial Resistance Genes Across Functional Hospital Areas and Its Association With Clinical Carbapenem-Resistant Organism Infections: A Prospective Observational Cohort Study

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.

Study Overview

Status

Not yet recruiting

Conditions

Study Type

Observational

Enrollment (Estimated)

720

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Locations

  • China
    • Beijing Municipality
      • Beijing, Beijing Municipality, China, 100730
        • Peking Union Medical College Hospital
        • Contact:

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Child
  • Adult
  • Older Adult

Accepts Healthy Volunteers

No

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.

Description

Inclusion Criteria:

  • Wastewater samples collected from the four designated sampling sites (Outpatient Building, Internal Medicine Ward, Surgical Ward, and Emergency/Fever Clinic).
  • 24-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.

Exclusion Criteria:

  • 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).

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

Cohorts and Interventions

Group / Cohort
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

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Wastewater Antimicrobial Resistance Gene (ARG) Abundance
Time Frame: Daily for 6-9 months
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
Time Frame: Clinical CRO isolates (50-80 selected strains) from each building during the study period
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

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Peking Union Medical College Hospital

Investigators

  • Principal Investigator: bin du, Dr, Peking Union Medical College Hospital

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Estimated)

September 1, 2026

Primary Completion (Estimated)

September 1, 2028

Study Completion (Estimated)

September 1, 2028

Study Registration Dates

First Submitted

September 1, 2026

First Submitted That Met QC Criteria

September 1, 2026

First Posted (Actual)

September 4, 2026

Study Record Updates

Last Update Posted (Actual)

September 4, 2026

Last Update Submitted That Met QC Criteria

September 1, 2026

Last Verified

September 1, 2026

More Information

Terms related to this study

Other Study ID Numbers

  • PUMCH-WW-ARG-2026
  • 01050010 (Other Grant/Funding Number: Peking Union Medical Foundation)

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

YES

IPD Plan Description

De-identified metagenomic and whole-genome sequencing data will be submitted to NCBI Sequence Read Archive upon study completion, in accordance with journal requirements and data sharing policies

IPD Sharing Time Frame

upon study completion

IPD Sharing Supporting Information Type

  • STUDY_PROTOCOL
  • SAP
  • CSR

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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