Appraisal of potential environmental risks associated with human antibiotic consumption in Turkey

Seasonal analysis of commonly prescribed antibiotics in Istanbul city

Antibiotics are among the most common medicine groups since they are used to treat infectious diseases, as nutritional supplements in livestock breeding, and for preservation in the food industry. Turkey is among the highest antibiotic consumers in the world. In the present study, the most popular 14 antibiotics available in Turkey were monitored in one hospital sewage and two urban wastewater treatment plant influents and effluents seasonally in Istanbul province, the largest metropolitan center in Turkey. The present research aimed to develop a robust analytical method to determine 14 antibiotics, including six chemical groups, in environmental matrices which are considered significant antibiotic pollution sources, namely hospital sewage and urban wastewater. Solid-phase extraction (SPE) and UPLC-MS/MS analysis parameters included optimized column temperature, eluent, mobile phase, and flow rate. Three SPE cartridges were employed in recovery studies. The antibiotic recovery rates varied between 40 and 100%, and all analytes were identified within 3 min with UPLC-MS/MS under optimal conditions. It was determined that method detection limits (MDLs) varied between 0.07 and 2.72 µg/L for the antibiotics. In all seasons, the highest beta-lactam group antibiotic concentrations were identified in hospital sewage. The season with the greatest variety of antibiotics in urban wastewater was spring. Clarithromycin and ciprofloxacin were the antibiotics determined at the highest concentration in the influent and effluent of the wastewater treatment plant in all seasons. This study showed that the most widely used beta-lactam group antibiotics were found in high amounts in hospital sewage wastewater but in low concentrations in the treatment plants, and hence, it is seen that the degradability of beta-lactam group antibiotics was high. The presence of clarithromycin, ciprofloxacin, lincomycin, levofloxacin, and trimethoprim antibiotics in hospital sewage in higher amounts and also in inlet and outlet of wastewater treatment plants proves that those are resistant antibiotics.

The remediation of sulfonamides from the environment by Pleurotus eryngii mycelium. Efficiency, products and mechanisms of mycodegradation

The objective of the study was to assess the applicability of the mycelium obtained from the in vitro cultures of nontoxic bracket fungus, Pleurotus eryngii, to sulfonamides mycodegradation. Samples containing one of the six selected sulfonamides, sulfanilamide derivatives, were incubated with the mycelium of P. eryngii for 7 and 14 days in vitro. Subsequently, change in the sulfonamide concentration was assessed in the samples using the UPLC-QTof. The transformation products were identified based on monoisotopic molecular mass and fragmentation spectra. The studied sulfonamides did not inhibit the growth of P. eryngii mycelium in the in vitro cultures. In addition, a considerable reduction of sulfonamide concentration was observed in all the incubated samples (from 73.7 ± 8.3% to 99.8 ± 0.3%). In the case of three sulfonamides, the reduction in concentration >90% occurred after 7 days of incubation. However, the transformation of sulfonamides was partially caused by their degradation to simpler organic compounds. After incubation, the products of condensation of sulfonamides with formyl, acyl, and sugar groups, and amino acid-derived compounds were identified in the samples. This indicated the partially reversible nature of the mycodegradation process.

What antibiotics for what pathogens? The sensitivity spectrum of isolated strains in an intensive care unit

Antibiotic sensitivity spectrum of isolated strains differs according to hospital departments, the hospitals themselves, and countries. Discrepancies also exist in terms of antibiotic use and dosage. The aim of the present study is to compare the antibacterial agents, the types of infections, the number and type of pathogens, and the sensitivity to antibiotics used in the Intensive Care Unit (ICU) of the Emergency Clinical County Hospital of Oradea, Romania. Over a one-year period, data were gathered from the pharmacy computer system and medical records of inpatients. WHO Anatomical Therapeutic Chemical (ATC)/defined daily doses (DDD) methodology was used to assess drug administration data, and antibiotic use was expressed as DDD/1000 PD (patient days). The antibiotic susceptibility of isolated strains was expressed through the cumulative antibiogram. The overall consumption of antimicrobial agents was 1247.47 DDD/1000 PD. The most common drugs used were cephalosporins and fluoroquinolones (52.97% of the total). Ceftriaxone was the most commonly used, followed by levofloxacin. Infections of the respiratory and urinary tract were the most frequently diagnosed infections. The most commonly isolated bacteria type was Acinetobacter baumannii (22.12% overall), isolated especially from the respiratory tract and resistant to all the β-lactam antibiotics including carbapenems. Antimicrobials intake at the ICU is much higher compared to medical and surgical wards. After we tested the existence of a possible connection between antibiotic consumption and antibiotic resistance of bacteria, it was revealed that on our sample exists a poor positive association.

Bacteriological quality, heavy metal and antibiotic resistance in Sapanca Lake, Turkey

Sapanca Lake is important as a source of drinking water. In this study, we aimed to detect the bacterial quality, the frequency of bacterial antibiotic and heavy metal resistance, and bioindicator bacteria in the water samples taken from Sapanca Lake in the period between 2008 and 2010. The resistance of bacterial isolates to certain antibiotics and heavy metal salts was investigated using disc diffusion and minimum inhibitory concentration techniques. Bacterial metabolic reactions were tested using the VITEK 2 Compact 30 micro identification system for identification of cultivable bacteria. Twenty-seven bacteria species belonging to three classes-Gammaproteobacteria, Bacilli, Flavobacteria-were recorded for the first time in Sapanca Lake. The highest indicator bacteria were recorded as 71 ± 3.1 × 10⁴ CFU/100 ml in the summer season. The highest bacterial resistance was recorded as 90.47% against vancomycin in a total of 84 strains. Ampicillin (88.10%) and amoxicillin-clavulanate (64.29%) followed them. The resistance varied between 10.71 and 59.52% against cefuroxime, kanamycin, aztreonam, ceftazidime, cefotaxime, and oxacillin. The highest frequency against heavy metal salts was recorded as 74.19% against NiCl₂. The heavy metal resistance against Cu, Zn, Hg, and Cd detected as 52.38%, 46.42%, 33.33%, and 26.19%, respectively. The results showed that the occurrence of heavy metals and antibiotic sources in Sapanca Lake induced a tolerance in bacteria for the metal salts and antibiotic derivatives tested. The fluctuations in the indicator bacteria and the occurrence of pathogenic bacteria also showed the possibility that the coastal areas of Sapanca Lake had been exposed to contamination due to inadequate sewage treatment.

An overview of cephalosporin antibiotics as emerging contaminants: a serious environmental concern

Antibiotics have been categorized as emerging pollutants due to their indiscriminate usage, continuous input and persistence in various environmental matrices even at lower concentrations. Cephalosporins are the broad-spectrum antibiotics of β-lactam family. Owing to its enormous production and consumption, it is reported as the second most prescribed antibiotic classes in Europe. The cephalosporin wastewater contains toxic organic compounds, inorganic salts, and active pharmaceutical ingredients (API) which pose a potential threat to the organisms in the environment. Therefore, removal of cephalosporin antibiotics from the environment has become mandatory as it contributes to increase in the level of chemical oxygen demand (COD), causing toxicity of the effluent and production of cephalosporin-resistant microbes. So far, several processes have been reported for degradation/removal of cephalosporins from the environment. A number of individual studies have been published within the last decade covering the various aspects of antibiotics. However, a detailed compilation on cephalosporin antibiotics as an emerging environmental contaminant is still lacking. Hence, the present review intends to highlight the current ecological scenario with respect to distribution, toxicity, degradation, various remediation technologies, and the regulatory aspects concerning cephalosporins. The latest successful technologies for cephalosporin degradation/removal discussed in this review will help researchers for a better understanding of the nature and persistence of cephalosporins in the environment along with the risks associated with their existence. The research thrust discussed in this review will also evoke new technologies to be attempted by the future researchers to develop sustainable options to remediate cephalosporin-contaminated environments.

Bacteria That Make a Meal of Sulfonamide Antibiotics: Blind Spots and Emerging Opportunities

The release of sulfonamide antibiotics into the environment is alarming because the existence of these antibiotics in the environment may promote resistance in clinically relevant microorganisms, which is a potential threat to the effectiveness of antibiotic therapies. Controllable biodegradation processes are of particular significance for the inexpensive yet effective restoration of sulfonamide-contaminated environments. Cultivation-based techniques have already made great strides in successfully isolating bacteria with promising sulfonamide degradation abilities, but the implementation of these isolates in bioremediation has been limited by unknown microbial diversity, vast population responsiveness, and the impact of perturbations from open and complex environments. Advances in DNA sequencing technologies and metagenomic analyses are being used to complement the information derived from cultivation-based procedures. In this Review, we provide an overview of the growing understanding of isolated sulfonamide degraders and identify shortcomings of the prevalent literature in this field. In addition, we propose a technical paradigm that integrates experimental testing with metagenomic analysis to pave the way for improved understanding and exploitation of these ecologically important isolates. Overall, this Review aims to outline how metagenomic studies of isolated sulfonamide degraders are being applied for the advancement of bioremediation strategies for sulfonamide contamination.

Abundance of antibiotics, antibiotic resistance genes and bacterial community composition in wastewater effluents from different Romanian hospitals

Antimicrobial resistance represents a growing and significant public health threat, which requires a global response to develop effective strategies and mitigate the emergence and spread of this phenomenon in clinical and environmental settings. We investigated, therefore, the occurrence and abundance of several antibiotics and antibiotic resistance genes (ARGs), as well as bacterial community composition in wastewater effluents from different hospitals located in the Cluj County, Romania. Antibiotic concentrations ranged between 3.67 and 53.05 μg L^-1, and the most abundant antibiotic classes were β-lactams, glycopeptides, and trimethoprim. Among the ARGs detected, 14 genes confer resistance to β-lactams, aminoglycosides, chloramphenicol, macrolide-lincosamide-streptogramin B (MLSB) antibiotics, sulfonamides, and tetracyclines. Genes encoding quaternary ammonium resistance and a transposon-related element were also detected. The sulI and qacEΔ1 genes, which confer resistance to sulfonamides and quaternary ammonium, had the highest relative abundance with values ranging from 5.33 × 10^-2 to 1.94 × 10^-1 and 1.94 × 10^-2 to 4.89 × 10^-2 copies/16 rRNA gene copies, respectively. The dominant phyla detected in the hospital wastewater samples were Proteobacteria, Bacteroidetes, Firmicutes, and Actinobacteria. Among selected hospitals, one of them applied an activated sludge and chlorine disinfection process before releasing the effluent to the municipal collector. This conventional wastewater treatment showed moderate removal efficiency of the studied pollutants, with a 55-81% decrease in antibiotic concentrations, 1-3 order of magnitude lower relative abundance of ARGs, but with a slight increase of some potentially pathogenic bacteria. Given this, hospital wastewaters (raw or treated) may contribute to the spread of these emerging pollutants in the receiving environments. To the best of our knowledge, this study quantified for the first time the abundance of antibiotics and ARGs in wastewater effluents from different Romanian hospitals.

Assessment of the biodegradability of selected sulfa drugs in two polluted rivers in Poland: Effects of seasonal variations, accidental contamination, turbidity and salinity

The aim of our study was to assess the aerobic biodegradation of four selected sulfonamides (sulfanilamide, sulfamethoxazole, sulfadiazine and sulfathiazole) using water samples drawn from highly polluted rivers. Additionally, we aimed to identify the factors that have a significant effect on the process efficiency. The 19 water samples were collected from Brynica and Czarna Przemsza rivers (in Poland) at the same location at approximately monthly intervals. A characteristic feature of the results is the presence of significant differences between the rates of sulfonamides biodegradation in particular samples. The sulfonamide most resistant to biodegradation was sulfamethoxazole, whereas sulfathiazole was most biodegradable. Seasonal variations and related microbial population changes had the most significant effects on sulfonamides biodegradation, e.g., the studied process was highly inhibited during wintertime. A decrease in the biodegradation rate in the river water could be caused by an accidental water pollution by industrial wastewater with heavy metals, an increase in salinity and a decrease in pH, and turbidity.

Environmental Risk Assessment (ERA) of diclofenac and ibuprofen: a public health perspective

Non-steroidal anti-inflammatory drugs (NSAIDs) have been widely used in human and veterinary medicine, representing potential aquatic environmental contamination. This study aimed to perform an Environmental Risk Assessment (ERA) of NSAIDs diclofenac (Dic) and ibuprofen (Ibu) in cities of the state of Paraná, Brazil, over the course of three years, by using available data from the Brazilian Public Health System. The environmental risk (ER) was assessed by employing the European Medicines Agency (EMeA) approach, and predicted environmental concentrations (PECs) were calculated. The refined PECs considered the drug metabolism and the excretion data, and also the sewage treatment plant removal rates of biological filters and activated sludge processes to define environmental scenarios. References to the predicted no effect concentration (PNEC) for these pharmaceuticals were considered, and the PEC/PNEC ratio was calculated; ratio values ⩾ 1 suggested an ER. Environmental risk was conducted on several cities, and the lack of an adequate sanitation system in the majority of Paraná cities forecasts a significant concern with the exposure to possible environmental damages in those cities. The high PEC/PNEC ratios in several cities showed that current usage patterns of these drugs constitute an environmental issue in need of resolution by health and environmental authorities.

Consumption-based approach for predicting environmental risk in Greece due to the presence of antimicrobials in domestic wastewater

The main objective of the current study was to estimate the potential environmental risks associated with human consumption of antimicrobials in Greece. Consumption data was collected for the 24 most often used antimicrobials for the years 2008-2010, and their predicted environmental concentrations (PECs) in raw and treated wastewater were calculated using mass balances and literature data on human excretion and elimination efficiency during wastewater treatment. The ecotoxicological risk was estimated by calculating the ratio of PEC to predicted no-effect concentration (PNEC) for three categories of aquatic organisms (algae, daphnids, and fish). PNEC values were calculated based on experimental ecotoxicity data and data originated from the Ecological Structure Activity Relationship (ECOSAR). PEC values in raw sewage ranged between 0.02 μg L(-1) (erythromycin) and 27 μg L(-1) (amoxicillin), while in treated wastewater, the highest concentration was predicted for cefuroxime axetil (6.6 μg L(-1)). Based on acute toxicity data for algae, risk quotient (RQ) values higher than 1 were obtained for 7 out of the 24 target antimicrobials in raw and treated wastewater, while no significant risk was estimated for daphnids and fish. Regarding the possible risk due to the chronic toxicity of antimicrobials, RQ values higher than 80 were obtained for amoxicillin and clarithromycin in algae. The use of baseline toxicity data from ECOSAR showed that the environmental risk from exposure to mixtures of antimicrobials was low for all three aquatic species. However, further studies on toxicity of mixtures should be performed as calculation of toxicity ratio (TR) values showed that 90 % of the target antimicrobials seem to exhibit a specific mode of toxic action when present in mixtures rather than baseline toxicity. As a result, an underestimation of toxicity based on the ECOSAR model is possible for the mixture of target antimicrobials. For Greek rivers where low (dilution factor, D<10) and medium (D=10-100) dilution of wastewater occurs, moderate to high risk is expected due to the existence of individual antimicrobials such as amoxicillin, clarithromycin, ciprofloxacin, azithromycin, erythromycin, and levofloxacin in discharged treated wastewater.

Development of sensitive and reliable LC-MS/MS methods for the determination of three fluoroquinolones in water and fish tissue samples and preliminary environmental risk assessment of their presence in two rivers in northern Poland

Antibiotic consumption (e.g. fluoroquinolones (FQs)) and, as a consequence, their presence in the environment, have received a lot of attention in the last several years due to increasing numbers of diseases and infections that are becoming resistant to traditional treatments for both humans and animals. In addition, even though antibiotics are safe for human and veterinary usage, ecosystems may be exposed to these substances. In this study, analytical methods for determining enrofloxacin (ENR), norfloxacin (NOR) and ciprofloxacin (CIP) in water samples and fish tissue based on the LC-MS/MS technique were developed and validated. As there is no data available concerning the risks posed by antibiotics in Poland, the proposed methods were applied for monitoring drug presence in environmental samples collected from two rivers in northern Poland. Evaluations of the ecotoxicity of ENR, NOR and CIP towards four different species of aquatic organisms: marine bacteria (Vibrio fischeri), green algae (Scenedesmus vacuolatus), duckweed (Lemna minor) and crustacean (Daphnia magna), were also carried out. All the investigated compounds were detected at least once in the survey. NOR was found to be the most ubiquitous drug with concentrations of up to 442.8 ng L(-1). Moreover, it was established that L. minor is the most sensitive species to the investigated drugs (EC50NOR = 0.13 mg L(-1), EC50ENR = 0.22 mg L(-1) and EC50CIP = 0.34 mg L(-1)). The calculated risk quotient (RQ) values confirmed that the concentrations of the investigated FQs in the environmental samples were at a level of moderate environmental risk (1<RO ≤ 10), however, for CIP they were found to be closer to a level of high environmental risk (RQCIP = 8.1).

Prevalence of sulfonamide-resistant bacteria, resistance genes and integron-associated horizontal gene transfer in natural water bodies and soils adjacent to a swine feedlot in northern Taiwan

Antibiotics are commonly used in swine feed to treat and prevent disease, as well as to promote growth. Antibiotics released into the environment via wastewater could accelerate the emergence of antibiotic-resistant bacteria and resistance genes in the surrounding environment. In this study, we quantified the occurrence of sulfonamides, sulfonamide-resistant microorganisms and resistance genes in the wastewater from a swine farm in northern Taiwan and its surrounding natural water bodies and soils. Sulfonamide levels were similar in the receiving downstream and upstream river water. However, the prevalence of sulfonamide-resistant bacteria and resistance genes, as analyzed by cultivation-dependent and -independent molecular approaches, was significantly greater in the downstream compared to the upstream river water samples. Barcoded-pyrosequencing revealed a highly diverse bacterial community structure in each sample. However, the sequence identity of the sulfonamide resistance gene sul1 in the wastewater and downstream environment samples was nearly identical (99-100%). The sul1 gene, which is genetically linked to class 1 integrons, was dominant in the downstream water bodies and soils. In conclusion, the increased prevalence of sulfonamide resistance genes in the wastewater from a swine farm, independent of the persistent presence of sulfonamides, could be a potential source of resistant gene pools in the surrounding environment.

Environmental risk assessment of selected pharmaceuticals in Turkey

In this study, environmental risks of selected pharmaceuticals were investigated to assess potential hazards. Ciprofloxacin, Clarithromycin, Cefuroxime axetil, antibiotics, Benzalkoniuman antiseptic, Paracetamol, an analgesic, and Naproxen, an anti-inflammatory, were selected due to their high rate of usage in Turkey. Ciprofloxacin was found to have the highest risk due to its high PEC/PNEC ratio (28.636). Benzalkonium, Paracetamol and Clarithromycin have a potential to cause environmental hazards. The biodegradation and biological concentration factors (BCF) of the drugs were also determined using EPA/STWIN and EPA/BCFWIN programs. The results illustrated that these pharmaceuticals are nonbiodegradable in wastewater treatment plants. The BCFs of Benzalkonium and Clarithromycin were found to be very high, 70.790 L/kg and 56.490 L/kg, respectively. It was suggested that alternative treatment methods other than biological ones should be investigated for these pharmaceuticals because of their low biodegradability. Also, unnecessary use of antibiotics is supposed to be discouraged to reduce environmental hazards.

Degradation of sulfamethazine by gamma irradiation in the presence of hydrogen peroxide

The gamma irradiation-induced degradation of sulfamethazine (SMT) in aqueous solution in the presence of hydrogen peroxide (H2O2) was investigated. The initial SMT concentration was 20mg/L and it was irradiated in the presence of extra H2O2 with initial concentration of 0, 10 and 30 mg/L. The results showed that gamma irradiation was effective for removing SMT in aqueous solution and its degradation conformed to the pseudo first-order kinetics under the applied conditions. When initial H2O2 concentration was in the range of 0-30 mg/L, higher concentration of H2O2 was more effective for the decomposition and mineralization of SMT. However, the removal of total organic carbon (TOC) was not as effective as that of SMT. Total nitrogen (TN) was not removed even at absorbed dose of 5 kGy, which was highest dose applied in this study. Major decomposition products of SMT, including degradation intermediates, organic acids and some inorganic ions were detected by high performance liquid chromatography (HPLC) and ion chromatography (IC). Sulfate (SO4(2-)), formic acid (HCOOH), acetic acid (CH3COOH), 4-aminophenol, 4-nitrophenol were identified in the irradiated solutions. Possible pathways for SMT decomposition by gamma irradiation in aqueous solution were proposed.

Application of electrolysis to inactivation of antibacterials in clinical use

Contamination of surface water by antibacterial pharmaceuticals (antibacterials) from clinical settings may affect aquatic organisms, plants growth, and environmental floral bacteria. One of the methods to decrease the contamination is inactivation of antibacterials before being discharged to the sewage system. Recently, we reported the novel method based on electrolysis for detoxifying wastewater containing antineoplastics. In the present study, to clarify whether the electrolysis method is applicable to the inactivation of antibacterials, we electrolyzed solutions of 10 groups of individual antibacterials including amikacin sulfate (AMK) and a mixture (MIX) of some commercial antibacterials commonly prescribed at hospitals, and measured their antibacterial activities. AMK was inactivated in its antibacterial activities and its concentration decreased by electrolysis in a time-dependent manner. Eighty to ninety-nine percent of almost all antibacterials and MIX were inactivated within 6h of electrolysis. Additionally, cytotoxicity was not detected in any of the electrolyzed solutions of antibacterials and MIX by the Molt-4-based cytotoxicity test.

Effects of the presence of sulfonamides in the environment and their influence on human health

World production and consumption of pharmaceuticals has been steadily increasing. Anti-infectives have been particularly important in modern therapy of microbial infection. Sulfonamides have been widely used for a long time as anti-infectives and are still widely prescribed today. This review presents the most common types of sulfonamides used in healthcare and veterinary medicine and discusses the problems connected with their presence in the biosphere. Based on the analysis of over 160 papers, it was found that small amounts of sulfonamides present in the environment were mainly derived from agricultural activities. These drugs have caused changes in the population of microbes that could be potentially hazardous to human health. This human health hazard could have a global range, and administrative activities have been ineffective in risk reduction.

Biotic and abiotic degradation of four cephalosporin antibiotics in a lake surface water and sediment

Cephalosporins are widely used veterinary and human antibiotics, but their environmental fate and impacts are still unclear. We studied degradation of four cephalosporins (cefradine, cefuroxime, ceftriaxone, and cefepime) from each generation in the surface water and sediment of Lake Xuanwu, China. The four cephalosporins degraded abiotically in the surface water in the dark with half-lives of 2.7-18.7d, which were almost the same as that in sterilized surface water. Under exposure to simulated sunlight, the half-lives of the cephalosporins decreased significantly to 2.2-5.0d, with the maximal decrease for ceftriaxone from 18.7d in the dark to 4.1d under the light exposure. Effects of dissolved organic matter (DOM) and nitrate on photodegradation of the cephalosporins were compound-specific. While DOM (5 mg L(-1)) stimulated the photodegradation of only cefradine (by 9%) and cefepime (by 34%), nitrate (10 microM) had effects only on cefepime (stimulation by 13%). Elimination rates of the cephalosporins in oxic sediment (half-lives of 0.8-3.1d) were higher than in anoxic sediment (half-lives of 1.1-4.1d), mainly attributed to biodegradation. The data indicate that abiotic hydrolysis (for cefradine, cefuroxime, and cefepime) and direct photolysis (for ceftriaxone) were the primary processes for elimination of the cephalosporins in the surface water of the lake, whereas biodegradation was responsible for the elimination of the cephalosporins in the sediment. Further studies are needed on chemical structure, toxicity, and persistence of transformation products of the cephalosporins in the environment.