Using a targeted ecopharmacovigilance intervention to control antibiotic pollution in a rural aquatic environment

Broadening the Perspective on Reducing Pharmaceutical Residues in the Environment

The present study reviews options for reducing harm from pharmaceuticals that are known to cause adverse impacts by their presence in the environment. It reviews recent global and European Union policy development, which could go further in recognizing and addressing the issue in a global context. It considers green chemistry, which can help clean up production processes but holds only long-term promise for creating "green" alternatives. It explores the potential of health promotion and disease prevention, which can contribute significantly to a reduction of the disease burden and thus the need for medicines, both for infectious and for noncommunicable disease. Eco-directed sustainable prescribing practices are reviewed, which have been adopted successfully to reduce the use of harmful pharmaceuticals. We note recent developments in medicines optimization and precision medicine, which hold promise for improving patient outcomes, saving costs, and reducing pharmaceutical use, through individually tailored prescribing whereby the patient codecides their therapy. Waste prevention through reuse or redistribution is beginning to find public support and "take-back" waste disposal schemes set up via extended producer responsibility systems have achieved high returns. Finally, the paper summarizes preferred advanced wastewater technologies, including innovative low-cost, low-energy options. In summary, although end-of-pipe options have a role to play, particularly for highly concentrated wastewaters, solutions further up the medicinal chain and disease prevention interventions, informed by a broad view of health and health care, are needed to pursue a much greater potential reduction of pharmaceuticals in the environment than can be achieved by end-of-pipe solutions alone. Environ Toxicol Chem 2024;43:653-663. © 2023 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Risks of benzalkonium chlorides as emerging contaminants in the environment and possible control strategies from the perspective of ecopharmacovigilance

An unprecedented increase in the use of disinfection products triggered by the coronavirus disease 2019 (COVID-19) pandemic is resulting in aggravating environmental loads of disinfectants as emerging contaminants, which has been considered a cause for worldwide secondary disasters. This review analyzed the literature published in the last decade about occurrence, bioaccumulation, and possible environmental risks of benzalkonium chlorides (BKCs) as emerging contaminants. Results indicated that BKCs globally occurred in municipal wastewater, surface water, groundwater, reclaimed water, sludge, sediment, soil, roof runoff, and residential dust samples across 13 countries. The maximum residual levels of 30 mg/L and 421 μg/g were reported in water and solid environmental samples, respectively. Emerging evidences suggested possible bioaccumulation of BKCs in plants, even perhaps humans. Environmentally relevant concentrations of BKCs exert potential adverse impacts on aquatic and terrestrial species, including genotoxicity, respiratory toxicity, behavioural effects and neurotoxicity, endocrine disruption and reproductive impairment, phytotoxicity, etc. Given the intrinsic biocidal and preservative properties of disinfectants, the inductive effects of residual BKCs in environment in terms of resistance and imbalance of microorganisms have been paid special attention. Considering the similarities of disinfectants to pharmaceuticals, from the perspective of ecopharmacovigilance (EPV), a well-established strategy for pharmaceutical emerging contaminants, we use the control of BKC pollution as a case, and provide some recommendations for employing the EPV measures to manage environmental risks posed by disinfectant emerging contaminants.

Organophosphate esters in rural wastewater along the Yangtze river Basin: Occurrence, removal efficiency and environmental implications

Organophosphate esters (OPEs) discharged from rural domestic wastewater were one of the important sources of OPEs in receiving water bodies, which has posed a potential threat to the ecological environment. However, very little information on the characteristics of OPEs in the rural domestic wastewater is available. Herein, the occurrence, removal efficiency and environmental implication of OPEs in rural domestic wastewater treatment facilities (RD-WWTFs) along the Yangtze River Basin were investigated. Results indicated that the median concentrations of ΣAlkyl-OPEs, ΣHalogenated-OPEs, ΣAryl-OPEs and the total OPE (ΣOPEs) in influents were 28.28, 99.25, 10.22 and 136.84 ng/L, while the median concentrations of them in effluents were 25.80, 141.86, 7.98 and 173.31 ng/L, respectively. Undoubtedly, halogenated OPEs were the most abundant in both influent and effluent, followed by alkyl and aryl OPEs, and they accounted for average proportions of 69.50%, 19.96%and 10.54% for influents, and 78.16%, 16.14%and 5.71% for effluents, respectively. Specifically, tris(2-chloroisopropyl) phosphate (TCPP, median: 55.17 ng/L in influents and 85.75 ng/L in effluents) was the dominant contributor to the ΣOPEs concentrations with average proportions of 37.75% and 47.33% for influents and effluents, respectively. Moreover, the concentration ranks for most OPEs except for aryl OPEs from high to low were upper reaches > lower reaches > middle reaches. However, negative values of tris(2-chloroethyl)phosphate (TCEP, -32.4%), TCPP (-55.4%) and tris(1,3-dichloroisopropyl) phosphate (TDCPP, -26.3%) were observed. The removal rates of alkyl OPEs (10-20%) and aryl OPEs (20-30%) were also not sufficient. Ecological risk values of ΣOPEs showed that there were 2.44% of high risk, 31.7% of moderate risk and 41.5% of low risk for effluents; while 0.00%, 48.8% and 46.3% were exhibited in high, moderate and low risk for influents, indicating that very slight reduction in risk was achieved by the RD-WWTFs.

Nitrogen-doped graphene for tetracycline removal via enhancing adsorption and non-radical persulfate activation

Nitrogen-doped graphene (NG) was synthesized via direct thermal annealing treatment. The obtained NG showed outstanding removal ability for tetracycline (TC) ascribed to enhanced adsorption and persulfate activation. The maximum TC adsorption capacity calculated from the Langmuir model of NG was 227.3 mg/g, which was 1.66 times larger than nitrogen-free graphene. The coexistence of NG and persulfate (PS) exhibited complete degradation of TC within 120 min attributed to the successful modification of nitrogen. Further analysis demonstrated that non-radical electron transfer was the dominant degradation pathway, which was different from the widely acknowledgeable radical mechanism. An electron donor-mediator-acceptor system was introduced, in which TC, NG, and PS performed as electron donor, mediator, and acceptor, respectively. The potential intermediates in the TC degradation process were detected and toxicity assessment was also performed. In addition, more than 75.8% of total organic carbon was removed, and excellent reusability was manifested in multiple adsorption and degradation experiments.

Characteristic analysis of bio-oil from penicillin fermentation residue by catalytic pyrolysis

The hazardous waste penicillin fermentation residue (PR) is a huge hazard to the environment. The bio-oil produced by the pyrolysis of the penicillin fermentation residue has the potential to become a biofuel in the future. This paper studied the pyrolysis characteristics of PR at 400°C ∼700°C. According to the weight loss and weight loss rate of PR, the whole process of pyrolysis can be divided into three stages for analysis: dehydration and volatilization, initial pyrolysis, and pyrolytic char formation. The experimental results showed that the yield of the liquid phase is the highest (33.11%) at 600°C. GC-MS analysis results showed that high temperature is beneficial to reduce the generation of oxygenated hydrocarbons (73%∼31%) and the yield of nitrogenous compounds gradually increased (19%∼43%); the yield of hydrocarbons was low in 400°C∼600°C pyrolysis (2%∼5%) but significantly increased around 700°C (22%). In the temperature range of 400°C to 700°C, the proportion of C5-C13 in bio-oil gradually increased (26%-64%), and the proportion of C14-C22 gradually decreased (47%-16%). The catalyst can increase the proportion of hydrocarbons in the bio-oil component. And the Fe₂O₃/HZSM-5 mixed catalyst has a significant reduction effect on oxygen-containing hydrocarbons and nitrogen-containing compounds.

Attitudes and opinions about ecopharmacovigilance from multi-disciplinary perspectives: a cross-sectional survey among academic researchers in China

As a promising upstream strategy to reduce the environmental loads of pharmaceutical emerging contaminants (PECs) through source control, ecopharmacovigilance (EPV) is concerned with the set of activities to identify, evaluate, understand, and prevent against diverse PEC-related problems, and has been accepted as a multi-disciplinary and multi-stakeholder system. This cross-sectional observational survey aimed to assess the attitudes and opinions about EPV from multi-disciplinary perspectives among Chinese academic professors from four main EPV-related disciplines including pharmacy, management, clinical medicine, and environmental and ecological science based on a self-developed questionnaire. Forty-two usable survey instruments were acquired. Results showed that the responding Chinese academic researchers from different disciplines expressed consistently positive attitudes and strong intentions for EPV, in spite of several disparities existing among disciplinary groups showing that pharmacy and medical researchers felt more certain of the environmental adverse effects of PECs, and researchers in pharmacy and environmental and ecological science were more interested in EPV. A multi-disciplinary consensus was achieved in regard to the types of key stakeholders in EPV practices including the pharmaceutical manufacturers, the public, the drug safety authority, hospitals, and the environmental protection agency. The main roles and responsibilities of each stakeholder identity in EPV practices were summarized based on the expert opinions.

Effects of environmental factors on the fleroxacin photodegradation with the identification of reaction pathways

The abuse of fluoroquinolones (FQs) antibiotics leads to bacterial resistance and environmental pollution, so it is of great significance to verify the decomposition mechanism for eliminating antibiotic efficiently and conveniently. The effects of various environmental factors and the fleroxacin (FLE) photodegradation mechanisms were investigated by high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS), UV-Vis absorption spectroscopy, fluorescence spectroscopy and quantum chemical calculation. Six possible photodegradation reaction paths on T₁ (excited triplet state) were proposed and simulated. The departure of the piperazine ring and the substitution of F atom at C-6 position by OH group were determined as the main reactions based on the reaction rates and energy barriers of each path. The multi-pathway reactions resulted in the fastest photodegradation rates of FLE at pH 6-7 than other pH conditions. NaN₃ would promote FLE photodegradation by inhibiting the reverse reaction of the separation process of F atom at C-8 and the generation of biphenyl molecules, which was a novel and distinctive phenomenon in this report. ·OH would rapidly combine with the free radicals generated in photolysis processes and made a great contribution to FLE photodegradation. Ca²⁺, Mg²⁺ and Ba²⁺ could stabilize the carboxyl group to impede the photo-competitive process of the decarboxylation reaction, while NO₃^- could generate reactive oxygen species to promote photodegradation.

Insights into the occurrence, elimination efficiency and ecological risk of antibiotics in rural domestic wastewater treatment facilities along the Yangtze River Basin, China

China is embarking on the treatment of rural domestic wastewater, but little information on the characteristics of antibiotics in the rural domestic wastewater is available. As one of the most important new-emerging pollutants, antibiotic has been explicitly proposed to be controlled and treated since the fifth plenary session of the 19th Central Committee of the Communist Party of China. Thus, the occurrence, elimination efficiency and ecological risk of antibiotics, as well as conventional wastewater quality parameters were investigated in influents and effluents from 41 rural domestic wastewater treatment facilities (RD-WWTFs) along the Yangtze River Basin. Results showed that elimination efficiencies of routinely monitored conventional pollutants in 33 RD-WWTFs (accounting for 80.5%) were effective based on conventional wastewater quality parameters. Of 39 target antibiotics selected, 26 ones were detected in the influents and effluents with a detection frequency (DF) between 2.4% and 100%. No significant decrease of antibiotics was observed in the effluents compared with that in the influents except chlortetracyclin (CTE) and tetracycline (TCs). The composition characteristics of antibiotics showed regional differences. Among the investigated antibiotics, ofloxacin (OFX), doxycycline (DOX), roxithromycin (ROX) and lincomycin (LIN) were the predominant, totally accounted for a median percentage of more than 60% of ΣAB concentrations in both influents and effluents. Ecological risk values of ΣABs showed that 11 effluents presented high risks (26.8%), 18 ones had moderate risks (43.9%), and the rest 12 ones showed low risks (29.3%). Moreover, oxytetracycline (OXY), norfloxacin (NOR), LIN and ROX was the dominant contributors to the ecological risk values. Overall, the elimination effect of antibiotics was limited in RD-WWTFs along the Yangtze River Basin, which was likely to pose potential adverse impacts on aquatic ecosystems.

Spatiotemporal variations and ecological risks of typical antibiotics in rivers inflowing into Taihu Lake, China

Antibiotics have become a global public concern due to the widespread presence of antibiotic-resistant bacteria and genes. This study investigated the spatial and seasonal variation of conventional water quality parameters and 10 selected antibiotics in rivers inflowing into Taihu Lake. The results showed that total nitrogen, as a pollution driver factor, varied with the seasons, and higher concentrations of pollutants were generally found in the dry season compared with the wet season. For antibiotics, seven of them were detected in surface waters (n = 66) with detection frequencies (DFs) of 1.52-100% and eight antibiotics with DFs of 2.56-100% in sediments (n = 39). Sulfamethoxazole (SMZ, median: 1.47 ng/L), trimethoprim (TMP, median: 0.35 ng/L), and roxithromycin (ROX, median: 0.47 ng/L) with 100% DFs followed by erythromycin (ERY, median: 0.56 ng/L) with a DF of 90.91% accounted for a median percentage of 44.54%, 9.08%, 20.42%, and 13.16% of the ΣABs concentrations in surface waters. In contrast, enrofloxacin (ENR, median: 0.54 ng/g) and ROX (median: 0.29 ng/g) with 100% DFs accounted for a median percentage of 58.21% and 31.71% of the ΣABs concentrations in sediments. Antibiotics in surface waters were mainly related to T, DO, TN and NH₃-N, but were mainly related to T, pH and TN for antibiotics in sediments. Furthermore, most of the detected antibiotics showed higher concentrations and more species of antibiotics in winter than in summer or autumn. Similarly, the ecological risk values of antibiotics showed higher in winter than in the other two seasons, whereas the overall risk levels were considered acceptable.

Impact of the COVID-19 pandemic on household disinfectant consumption behaviors and related environmental concerns: A questionnaire-based survey in China

Considering the potential hazardous effects of disinfectant residues on environment, organisms and biodiversity, the sharp rise in use of disinfectants during COVID-19 pandemic has been considered highly likely to cause worldwide secondary disasters in ecosystems and human health. This questionnaire-based survey investigated the impact of COVID-19 outbreak on household disinfectant product consumption levels and behavior of 3667 Chinese residents. In particular, in the context that no strategy is currently available to minimize the disinfectant pollution, based on the similarities between disinfectants and pharmaceuticals, we proposed a perspective of ecopharmacovigilance (EPV), which is an effective measure to minimize the environmental risks posed by pharmaceuticals using drug administration protocols, for disinfectant environmental risk management. The public's environmental perceptions, attitudes and the related practices regarding household disinfectant consumption from an EPV perspective were also included in the study. The results showed that the COVID-19 outbreak caused a tremendous rise in the public's household disinfectant consumption and usage levels in China. After the COVID-19 outbreak, the chlorine-based and alcohol-based disinfectants were considered as the most preferred products for household disinfection and hand sanitization, respectively. Importantly, the Chinese public's environmental perceptions and practice on disinfectants were poor. Less than half respondents had positive attitudes toward the source control of disinfectant pollution. The population groups including females, the middle aged adults, those having healthcare professional background, as well as the higher-educated could be focused on to develop targeted efforts for the future control of disinfectant pollution in environment.

Impact of Phytoplankton Blooms on Concentrations of Antibiotics in Sediment and Snails in a Subtropical River, China

The present three-year field investigation on sediment in the eutrophic Pearl River in South China showed that concentrations of sulfonamides (SAs), fluoroquinolones (FQs), and macrolides (MLs) in the river areas where blooms occurred were 4.6, 2.4, and 3.4 times higher than those without blooms, respectively, but the respective concentrations of tetracycline (TC) and oxytetracycline (OTC) in the areas with blooms were 2.6 and 3.8 times lower than those without. Significant positive correlations were found between concentrations of chlorophyll a in water and most antibiotics in sediment. Further investigation in each season suggested that lower diffusion but higher sinking were possible reasons driving the burial of sulfapyridine (SPD), sulfamethoxazole (SMX), and trimethoprim (TMP) in sediment from areas where blooms occurred, with burial rates up to 14.86, 48.58, and 52.19 g month^-1, respectively. Concentrations of TCs in both water and sediment were inversely correlated with phytoplankton biomass, which might be related to the enhanced biodegradation capacity of bacteria caused by phytoplankton blooms. Phytoplankton also affected concentrations of antibiotics in the snail, Bellamya purificata, with higher values in March but lower values in September. The concentration of antibiotics in snails positively correlated with that in sediment when snails were dormant but with antibiotics in water after dormancy.

Targeted eco-pharmacovigilance as an optimized management strategy for adverse effects of pharmaceuticals in the environment

From a perspective of drug administration, eco-pharmacovigilance (EPV) has been proposed as a new approach to prevent the environmental risks posed by pharmaceutical emerging contaminants. However, it is impracticable to practice unitary and rigor EPV process for all the pharmaceutical substances with complex and diversified chemical, biological or toxicological properties. We proposed the "targeted EPV" that is the science and activities associated with the targeted detection, evaluation, understanding, and prevention of adverse effects of high-priority hazardous pharmaceuticals in the environment, especially focusing on the control of main anthropogenic sources of pharmaceutical emission among key stakeholders in high-risk areas could be used as an optimized management strategy for pharmaceutical pollution. "Targeted EPV" implementation should focus on the targeted monitoring of the occurrence of high-priority pharmaceuticals in environmental samples, the targeted reporting of over-standard discharge, the targeted management for main emission sources, the targeted legislation and researches on high-priority pharmaceutical pollutants, as well as the targeted educational strategies for specific key populations.

Environmental knowledge, behaviors, and attitudes regarding caffeine consumption among Chinese university students from the perspective of ecopharmacovigilance

Caffeine is considered the most representative pharmaceutical emerging contaminant (PEC) because of its ubiquity, high environmental abundance, uncovered ecological risks, and its indicator property for anthropogenic environmental inputs of PECs. Ecopharmacovigilance (EPV) targeting caffeine has been proposed as an optimized measure for the control of caffeine pollution sources and the related anthropogenic behaviors from the perspective of pharmacy administration. This cross-sectional study was conducted to evaluate the environmental knowledge, behaviors, and attitudes regarding caffeine consumption among university students, one of the groups with high caffeine consumption, from an EPV perspective. Three hundred and seven usable survey instruments were acquired. The mean score for environmental knowledge about caffeine consumption was 3.66 out of a total of 7. The consumption frequency of caffeinated drinks, food, or drugs among student respondents was low. Throwing away in "household garbage" was an important disposal mechanism for unconsumed caffeinated products. Most students showed positive attitudes and strong intentions toward caffeine pollution control from the perspective of targeted EPV. These data suggested high acceptance of EPV program targeting caffeine among university students. However, more should be done to enhance their related knowledge, and some strengthening interventions for the effective removal of residual caffeine in garbage are needed.

In-situ electro-generation and activation of hydrogen peroxide using a CuFeNLDH-CNTs modified graphite cathode for degradation of cefazolin

The modified multifunctional electrodes for electro-Fenton (EF) process are suggested to be promising cathodes for in situ electro-generation and activation of H₂O₂ to produce hydroxyl radicals (^•OH). However, heterogeneous EF process still faces the challenges of limited catalytic activity and releasing of massive amounts of transition metals to the solution after removal of organic pollutants. The main aim of the present investigation was to prepare a cathode containing carbon nanotubes (CNTs) and CuFe nano-layered double hydroxide (NLDH) for degradation and mineralization of cefazolin antibiotic through electro-Fenton process. Structural and electrochemical analyses demonstrated that CuFeNLDH-CNTs nanocomposite was successfully incorporated on the surface of graphite cathode. Due to the increased formation of ^•OH in the reactor, the incorporation of CNTs into NLDH matrix with a catalyst loading of 0.1 g substantially improved the degradation efficiency of cefazolin (89.9%) in comparison with CNTs-coated (28.7%) and bare graphite cathode (22.8%) within 100 min. In the presence of 15 mM of ethanol, the degradation efficiency of cefazolin was remarkably decreased to 43.7% by the process, indicating the major role of ^•OH in the destruction of target molecules. Acidic conditions favored the degradation efficiency of cefazolin by the modified EF process. Mineralization efficiency of the bio-refractory compound was obtained to be 70.1% in terms of chemical oxygen demand (COD) analysis after 300 min. The gas chromatography-mass spectroscopy (GC-MS) analysis was also implemented to identify the intermediate byproducts generated during the degradation of cefazolin in the CuFeNLDH-CNTs/EF reactor.

Chinese physicians' attitudes toward eco-directed sustainable prescribing from the perspective of ecopharmacovigilance: a cross-sectional study

INTRODUCTION

Eco-directed sustainable prescribing (EDSP) is an effective upstream way to reduce the environmental footprints of active pharmaceutical ingredients (APIs), a kind of emerging contaminants, from the patients' excretion. EDSP is one of the key steps in the programme of ecopharmacovigilance (EPV), a drug administration route on API pollution.

OBJECTIVE

To assess the attitudes of physicians prescribing medicines regarding EDSP from the perspective of EPV.

DESIGN

A cross-sectional study conducted from March 2019 to June 2019.

SETTING

5 government general hospitals in Hubei province, China.

PARTICIPANTS

405 physicians were randomly selected and 262 valid questionnaires were obtained.

OUTCOME MEASURES

A self-developed questionnaire, which inquired about the participant characteristics, perceptions and attitudes toward API pollution, EPV and EDSP from an EPV perspective, was emailed to collect data from physicians.

RESULTS

Most physicians agreed the existence of APIs in environment, worried about the potential environmental and ecological risks of API residues, supported the effectiveness and necessity of EDSP under an EPV perspective in decreasing environmental exposure of excreted APIs, and showed their willingness to participate in the EDSP practices. Nevertheless, no respondent identified the environmental impacts as the aspects regarding medicines affecting his(her) prescription decision, none was satisfied with knowledge on EDSP and showed confidence toward EDSP. The most important barrier to the effective implementation of EDSP was identified as 'poor awareness of EDSP and EPV'. Most responding physicians (97%) reported that they held the wait-and-see or conservative attitudes towards EDSP practice. The biggest concerns in low-dose prescribing and prescribing of drugs possessing environment-friendly excretion profiles, two EDSP approaches, were the possible negative impact on therapeutic outcomes and too complicated and professional drug evaluation process, respectively.

CONCLUSIONS

Chinese physicians had positive attitudes towards EDSP from the perspective of EPV. However, their environmental consciousness during prescribing and the related education were insufficient.

Risks of caffeine residues in the environment: Necessity for a targeted ecopharmacovigilance program

Due to the huge consumption of caffeinated food, beverages and medicines around the world, caffeine has been considered as a most representative pharmaceutically active compound (PhAC) pollutant based on its high abundance in environment and its indicator property for anthropogenic inputs of PhACs to water bodies. This review analyzed the existing literature about the bioaccumulation and environmental risks of caffeine residues in non-target organisms. There are 6 studies which were published in the last 5 years have reported the distribution of caffeine in tissues of aquatic organisms including fishes, clams, macroalgae and other aquatic plants, suggesting bioaccumulation of caffeine in organisms. The maximum detected levels of caffeine residues in tissues ranged from 1.55 to 344.9 ng/g. Importantly, definitive evidences have been provided that environmentally relevant caffeine concentrations exert adverse impacts on aquatic species and terrestrial insects, which included lethality, decreasing general stress, inducing oxidative stress and lipid peroxidation, affecting energy reserves and metabolic activity, neurotoxic effects, affecting reproduction and development, etc. In view of the severity and potential adverse impacts of caffeine pollution in the environment, we proposed that caffeine should be considered as a high-priority environmentally hazardous PhAC pollutant, and it is necessary to implement an ecopharmacovigilance (EPV) program targeting caffeine to minimize its environmental load from a pharmacy perspective.