Antimicrobial resistance (AMR) in hospital wastewater is a recognized public health concern, yet the dynamics of its emergence remain poorly understood. This study aimed to characterize the quantitative and qualitative changes in the microbial community of a newly built internal medicine intensive care hospital wing following the start of patient treatment. Wastewater samples were collected regularly from eight relevant sites, including seven patient-associated locations within the intensive care ward and the central sanitary sewer where all effluent converged. Culture-based analyses targeted the "ESCAPE-SO" bacterial and fungal groups ("Enterococci", "Staphylococci", "Candida", "Acinetobacter", "Pseudomonas", "Enterobacteriaceae", "Stenotrophomonas", "Others"). Comparisons were made between a 12-month pre-operation period (only flushing every 72 h to prevent contamination of the drinking water system) and the first 12 months of patient treatment. The results showed a significant increase in mean bacterial concentrations from 53 [0-349] CFU/mL before patient treatment to 8423 [3054-79,490] CFU/mL during patient treatment (p = 0.0224) with a particular focus on Pseudomonas spp. as the dominant genus. Resistance against all four main antibiotic classes of the WHO AWaRe essential "watch" list (carbapenems, third-generation cephalosporins, broad-spectrum penicillin and ciprofloxacin) emerged within the first twelve months and depended on the amount of prescribed antibiotics and the number of patients treated. These findings indicate that hospital activity drives rapid development of antimicrobial resistance in wastewater microbial communities, highlighting the critical role of clinical antibiotic use in shaping environmental resistomes. This study provides quantitative evidence that resistance can emerge within months of hospital operation, emphasizing the need for early monitoring and targeted interventions to mitigate the spread of AMR from hospital effluents into broader environmental systems.
Keywords: ESKAPE pathogens; Pseudomonas spp.; antibiotic resistance emergence; antimicrobial resistance; clinical antibiotic use; environmental resistome; hospital wastewater; intensive care unit; wastewater microbiome; wastewater surveillance.