Soiled Toilet Paper for Community-based Surveillance of Antibiotic Resistance and Enteric Pathogens: A Pilot Study

In many countries, soiled toilet paper is placed in trash bins rather than flushed down the toilet. We investigated the use of soiled toilet paper in Guatemalan markets to surveil for pathogenic sequence types (STs) of E. coli and third generation cephalosporin-resistant E. coli (3GCR-EC). We collected used toilet paper from trash bins in the restrooms of three Guatemalan public markets. We screened samples for E. coli and 3GCR-EC. Whole genome sequencing was used to characterize the isolates. E. coli was successfully cultured from all 30 toilet paper samples. Soiled toilet paper was an effective matrix for surveilling multidrug-resistant E. coli and could be an efficient method in certain contexts.