Drivers of Resistance in Uganda and Malawi (DRUM): a protocol for the evaluation of One-Health drivers of Extended Spectrum Beta Lactamase (ESBL) resistance in Low-Middle Income Countries (LMICs)

In sub-Saharan Africa (sSA), there is high morbidity and mortality from severe bacterial infection and this is compounded by antimicrobial resistance, in particular, resistance to 3rd-generation cephalosporins. This resistance is typically mediated by extended-spectrum beta lactamases (ESBLs). To interrupt ESBL transmission it will be important to investigate how human behaviour, water, sanitation, and hygiene (WASH) practices, environmental contamination, and antibiotic usage in both urban and rural settings interact to contribute to transmission of ESBL E. coli and ESBL K. pneumoniae between humans, animals, and the environment. Here we present the protocol for the Drivers of Resistance in Uganda and Malawi (DRUM) Consortium, in which we will collect demographic, geospatial, clinical, animal husbandry and WASH data from a total of 400 households in Uganda and Malawi. Longitudinal human, animal and environmental sampling at each household will be used to isolate ESBL E. coli and ESBL K. pneumoniae. This will be complimented by a Risks, Attitudes, Norms, Abilities and Self-Regulation (RANAS) survey and structured observations to understand the contextual and psychosocial drivers of regional WASH practices. Bacterial isolates and plate sweeps will be further characterised using a mixture of short-,long-read and metagenomic whole-genome sequencing. These datasets will be integrated into agent-based models to describe the transmission of EBSL resistance in Uganda and Malawi and allow us to inform the design of interventions for interrupting transmission of ESBL-bacteria.

Establishment of local wastewater-based surveillance programmes in response to the spread and infection of COVID-19 - case studies from South Africa, the Netherlands, Turkey and England

The COVID-19 pandemic has resulted in over 340 million infection cases (as of 21 January 2022) and more than 5.57 million deaths globally. In reaction, science, technology and innovation communities across the globe have organised themselves to contribute to national responses to COVID-19 disease. A significant contribution has been from the establishment of wastewater-based epidemiological (WBE) surveillance interventions and programmes for monitoring the spread of COVID-19 in at least 55 countries. Here, we examine and share experiences and lessons learnt in establishing such surveillance programmes. We use case studies to highlight testing methods and logistics considerations associated in scaling the implementing of such programmes in South Africa, the Netherlands, Turkey and England. The four countries were selected to represent different regions of the world and the perspective based on the considerable progress made in establishing and implementing their national WBE programmes. The selected countries also represent different climatic zones, economies, and development stages, which influence the implementation of national programmes of this nature and magnitude. In addition, the four countries' programmes offer good experiences and lessons learnt since they are systematic, and cover extensive areas, disseminate knowledge locally and internationally and partnered with authorities (government). The programmes also strengthened working relations and partnerships between and among local and global organisations. This paper shares these experiences and lessons to encourage others in the water and public health sectors on the benefits and value of WBE in tackling SARS-CoV-2 and related future circumstances.

Monitoring occurrence of SARS-CoV-2 in school populations: A wastewater-based approach

Clinical testing of children in schools is challenging, with economic implications limiting its frequent use as a monitoring tool of the risks assumed by children and staff during the COVID-19 pandemic. Here, a wastewater-based epidemiology approach has been used to monitor 16 schools (10 primary, 5 secondary and 1 post-16 and further education) in England. A total of 296 samples over 9 weeks have been analysed for N1 and E genes using qPCR methods. Of the samples returned, 47.3% were positive for one or both genes with a detection frequency in line with the respective local community. WBE offers a low cost, non-invasive approach for supplementing clinical testing and can provide longitudinal insights that are impractical with traditional clinical testing.

Site Specific Relationships between COVID-19 Cases and SARS-CoV-2 Viral Load in Wastewater Treatment Plant Influent

Wastewater based epidemiology (WBE) has become an important tool during the COVID-19 pandemic, however the relationship between SARS-CoV-2 RNA in wastewater treatment plant influent (WWTP) and cases in the community is not well-defined. We report here the development of a national WBE program across 28 WWTPs serving 50% of the population of Scotland, including large conurbations, as well as low-density rural and remote island communities. For each WWTP catchment area, we quantified spatial and temporal relationships between SARS-CoV-2 RNA in wastewater and COVID-19 cases. Daily WWTP SARS-CoV-2 influent viral RNA load, calculated using daily influent flow rates, had the strongest correlation (ρ > 0.9) with COVID-19 cases within a catchment. As the incidence of COVID-19 cases within a community increased, a linear relationship emerged between cases and influent viral RNA load. There were significant differences between WWTPs in their capacity to predict case numbers based on influent viral RNA load, with the limit of detection ranging from 25 cases for larger plants to a single case in smaller plants. SARS-CoV-2 viral RNA load can be used to predict the number of cases detected in the WWTP catchment area, with a clear statistically significant relationship observed above site-specific case thresholds.

Impact of sulfamethoxazole on a riverine microbiome

The continued emergence of bacterial pathogens presenting antimicrobial resistance is widely recognised as a global health threat and recent attention focused on potential environmental reservoirs of antibiotic resistance genes (ARGs). Freshwater environments such as rivers represent a potential hotspot for ARGs and antibiotic resistant bacteria as they are receiving systems for effluent discharges from wastewater treatment plants (WWTPs). Effluent also contains low levels of different antimicrobials including antibiotics and biocides. Sulfonamides are antibacterial chemicals widely used in clinical, veterinary and agricultural settings and are frequently detected in sewage sludge and manure in addition to riverine ecosystems. The impact of such exposure on ARG prevalence and diversity is unknown, so the aim of this study was to investigate the release of a sub-lethal concentration of the sulfonamide compound sulfamethoxazole (SMX) on the river bacterial microbiome using a flume system. This system was a semi-natural in vitro flume using river water (30 L) and sediment (6 kg) with circulation to mimic river flow. A combination of 'omics' approaches were conducted to study the impact of SMX exposure on the microbiomes within the flumes. Metagenomic analysis showed that the addition of low concentrations of SMX (<4 μg L^-1) had a limited effect on the bacterial resistome in the water fraction only, with no impact observed in the sediment. Metaproteomics did not show differences in ARGs expression with SMX exposure in water. Overall, the river bacterial community was resilient to short term exposure to sub-lethal concentrations of SMX which mimics the exposure such communities experience downstream of WWTPs throughout the year.

Modeling the effects of dynamic range compression on signals in noise

Hearing aids use dynamic range compression (DRC), a form of automatic gain control, to make quiet sounds louder and loud sounds quieter. Compression can improve listening comfort, but it can also cause unwanted distortion in noisy environments. It has been widely reported that DRC performs poorly in noise, but there has been little mathematical analysis of these noise-induced distortion effects. This work introduces a mathematical model to study the behavior of DRC in noise. By making simplifying assumptions about the signal envelopes, we define an effective compression function that models the compression applied to one signal in the presence of another. Using the properties of concave functions, we prove results about DRC that have been previously observed experimentally: that the effective compression applied to each sound in a mixture is weaker than it would have been for the signal alone; that uncorrelated signal envelopes become negatively correlated when compressed as a mixture; and that compression can reduce the long-term signal-to-noise ratio in certain conditions. These theoretical results are supported by software experiments using recorded speech signals.

There is no market for new antibiotics: this allows an open approach to research and development

There is an increasingly urgent need for new antibiotics, yet there is a significant and persistent economic problem when it comes to developing such medicines. The problem stems from the perceived need for a “market” to drive commercial antibiotic development. In this article, we explore abandoning the market as a prerequisite for successful antibiotic research and development. Once one stops trying to fix a market model that has stopped functioning, one is free to carry out research and development (R&D) in ways that are more openly collaborative, a mechanism that has been demonstrably effective for the R&D underpinning the response to the COVID pandemic. New “open source” research models have great potential for the development of medicines for areas of public health where the traditional profit-driven model struggles to deliver. New financial initiatives, including major push/pull incentives, aimed at fixing the broken antibiotics market provide one possible means for funding an openly collaborative approach to drug development. We argue that now is therefore the time to evaluate, at scale, whether such methods can deliver new medicines through to patients, in a timely manner.

High data rate communications in vivo using ultrasound

The emergence of in-body medical devices has provided a means of capturing physiological or diagnostic information and streaming this information outside of the body. Currently, electromagnetic-based communications make up the bulk of in-body medical device communication protocols. Traditional electromagnetic-based solutions are limited in their data rates and available power. Recently, ultrasound was investigated as a communication channel for through-tissue data transmission. To achieve real-time video streaming through tissue, data rates of ultrasound need to exceed 1 Mbps. In a previous study, we demonstrated ultrasound communications with data rates greater than 30 Mbps with two focused ultrasound transducers using a large footprint laboratory system through slabs of lossy tissues. While the form factor of the transmitter is also crucial, it is obvious that a large, focused transducer cannot fit within the size of a small in-body medical device. Several other challenges for achieving high-speed ultrasonic communication through tissue include strong reflections leading to multipath effects and attenuation. In this work, we demonstrate ultrasonic video communications using a mm-scale microcrystal transmitter with video streaming supplied by a camera connected to a Field Programmable Gate Array (FPGA). The signals were transmitted through a tissue-mimicking phantom and through the abdomen of a rabbit in vivo. The ultrasound signal was recorded by an array probe connected to a Verasonics Vantage system and decoded back to video. To improve the received signal quality, we combined the signal from multiple channels of the array probe. Orthogonal frequency division multiplexing (OFDM) modulation was used to reduce the receiver complexity under a strong multipath environment.

Video-Capable Ultrasonic Wireless Communications Through Biological Tissues

The use of wireless implanted medical devices (IMDs) is growing because they facilitate monitoring of patients at home and during normal activities, reduce the discomfort of patients, and reduce the likelihood of infection associated with trailing wires. Currently, radio frequency (RF) electromagnetic waves are the most commonly used method for communicating wirelessly with IMDs. However, due to the restrictions on the available bandwidth and the employable power, data rates of RF-based IMDs are limited to 267 kb/s. Considering standard definition video streaming requires data rates of 1.2 Mb/s and high definition requires 3 Mb/s, it is not possible to use the RF electromagnetic communications for high data rate communication applications such as video streaming. In this work, an alternative method that utilizes ultrasonic waves to relay information at high data rates is introduced. An advanced quadrature amplitude modulation (QAM) modem with phase-compensating, sparse decision feedback equalizer (DFE) is tailored to realize the full potential of the ultrasonic channel through biological tissues. The proposed system is tested in a variety of scenarios, including both simulations with finite impulse response (FIR) channel models, and real physical transmission experiments with ex vivo beef liver and pork chop samples as well as in situ rabbit abdomen. Consequently, the simulations demonstrated that video-capable data rates can be achieved with millimeter-sized transducers. Real physical experiments confirmed data rates of 6.7, 4.4, 4, and 3.2 Mb/s through water, ex vivo beef liver, ex vivo pork chop, and in situ rabbit abdomen, respectively.

One Health drivers of antibacterial resistance: Quantifying the relative impacts of human, animal and environmental use and transmission

Objectives

Antibacterial resistance (ABR) is a major global health security threat, with a disproportionate burden on lower-and middle-income countries (LMICs). It is not understood how 'One Health', where human health is co-dependent on animal health and the environment, might impact the burden of ABR in LMICs. Thailand's 2017 "National Strategic Plan on Antimicrobial Resistance" (NSP-AMR) aims to reduce AMR morbidity by 50% through 20% reductions in human and 30% in animal antibacterial use (ABU). There is a need to understand the implications of such a plan within a One Health perspective.

Methods

A model of ABU, gut colonisation with extended-spectrum beta-lactamase (ESBL)-producing bacteria and transmission was calibrated using estimates of the prevalence of ESBL-producing bacteria in Thailand. This model was used to project the reduction in human ABR over 20 years (2020-2040) for each One Health driver, including individual transmission rates between humans, animals and the environment, and to estimate the long-term impact of the NSP-AMR intervention.

Results

The model predicts that human ABU was the most important factor in reducing the colonisation of humans with resistant bacteria (maximum 65.7-99.7% reduction). The NSP-AMR is projected to reduce human colonisation by 6.0-18.8%, with more ambitious targets (30% reductions in human ABU) increasing this to 8.5-24.9%.

Conclusions

Our model provides a simple framework to explain the mechanisms underpinning ABR, suggesting that future interventions targeting the simultaneous reduction of transmission and ABU would help to control ABR more effectively in Thailand.

Emergency ventilator for COVID-19

The COVID-19 pandemic disrupted the world in 2020 by spreading at unprecedented rates and causing tens of thousands of fatalities within a few months. The number of deaths dramatically increased in regions where the number of patients in need of hospital care exceeded the availability of care. Many COVID-19 patients experience Acute Respiratory Distress Syndrome (ARDS), a condition that can be treated with mechanical ventilation. In response to the need for mechanical ventilators, designed and tested an emergency ventilator (EV) that can control a patient's peak inspiratory pressure (PIP) and breathing rate, while keeping a positive end expiratory pressure (PEEP). This article describes the rapid design, prototyping, and testing of the EV. The development process was enabled by rapid design iterations using additive manufacturing (AM). In the initial design phase, iterations between design, AM, and testing enabled a working prototype within one week. The designs of the 16 different components of the ventilator were locked by additively manufacturing and testing a total of 283 parts having parametrically varied dimensions. In the second stage, AM was used to produce 75 functional prototypes to support engineering evaluation and animal testing. The devices were tested over more than two million cycles. We also developed an electronic monitoring system and with automatic alarm to provide for safe operation, along with training materials and user guides. The final designs are available online under a free license. The designs have been transferred to more than 70 organizations in 15 countries. This project demonstrates the potential for ultra-fast product design, engineering, and testing of medical devices needed for COVID-19 emergency response.

Making waves: Wastewater-based epidemiology for COVID-19 - approaches and challenges for surveillance and prediction

The presence of SARS-CoV-2 in the feces of infected patients and wastewater has drawn attention, not only to the possibility of fecal-oral transmission but also to the use of wastewater as an epidemiological tool. The COVID-19 pandemic has highlighted problems in evaluating the epidemiological scope of the disease using classical surveillance approaches, due to a lack of diagnostic capacity, and their application to only a small proportion of the population. As in previous pandemics, statistics, particularly the proportion of the population infected, are believed to be widely underestimated. Furthermore, analysis of only clinical samples cannot predict outbreaks in a timely manner or easily capture asymptomatic carriers. Threfore, community-scale surveillance, including wastewater-based epidemiology, can bridge the broader community and the clinic, becoming a valuable indirect epidemiological prediction tool for SARS-CoV-2 and other pandemic viruses. This article summarizes current knowledge and discusses the critical factors for implementing wastewater-based epidemiology of COVID-19.

Acoustic effects of medical, cloth, and transparent face masks on speech signals

Face masks muffle speech and make communication more difficult, especially for people with hearing loss. This study examines the acoustic attenuation caused by different face masks, including medical, cloth, and transparent masks, using a head-shaped loudspeaker and a live human talker. The results suggest that all masks attenuate frequencies above 1 kHz, that attenuation is greatest in front of the talker, and that there is substantial variation between mask types, especially cloth masks with different materials and weaves. Transparent masks have poor acoustic performance compared to both medical and cloth masks. Most masks have little effect on lapel microphones, suggesting that existing sound reinforcement and assistive listening systems may be effective for verbal communication with masks.

Low-Complexity System and Algorithm for an Emergency Ventilator Sensor and Alarm

In response to anticipated shortages of ventilators caused by the COVID-19 pandemic, many organizations have designed low-cost emergency ventilators. Many of these devices are pressure-cycled pneumatic ventilators, which are easy to produce but often do not include the sensing or alarm features found on commercial ventilators. This work reports a low-cost, easy-to-produce electronic sensor and alarm system for pressure-cycled ventilators that estimates clinically useful metrics such as pressure and respiratory rate and sounds an alarm when the ventilator malfunctions. A low-complexity signal processing algorithm uses a pair of nonlinear recursive envelope trackers to monitor the signal from an electronic pressure sensor connected to the patient airway. The algorithm, inspired by those used in hearing aids, requires little memory and performs only a few calculations on each sample so that it can run on nearly any microcontroller.

Setting the standard: multidisciplinary hallmarks for structural, equitable and tracked antibiotic policy

There is increasing concern globally about the enormity of the threats posed by antimicrobial resistance (AMR) to human, animal, plant and environmental health. A proliferation of international, national and institutional reports on the problems posed by AMR and the need for antibiotic stewardship have galvanised attention on the global stage. However, the AMR community increasingly laments a lack of action, often identified as an 'implementation gap'. At a policy level, the design of internationally salient solutions that are able to address AMR's interconnected biological and social (historical, political, economic and cultural) dimensions is not straightforward. This multidisciplinary paper responds by asking two basic questions: (A) Is a universal approach to AMR policy and antibiotic stewardship possible? (B) If yes, what hallmarks characterise 'good' antibiotic policy? Our multistage analysis revealed four central challenges facing current international antibiotic policy: metrics, prioritisation, implementation and inequality. In response to this diagnosis, we propose three hallmarks that can support robust international antibiotic policy. Emerging hallmarks for good antibiotic policies are: Structural, Equitable and Tracked. We describe these hallmarks and propose their consideration should aid the design and evaluation of international antibiotic policies with maximal benefit at both local and international scales.

Every fifth published metagenome is not available to science

Have you ever sought to use metagenomic DNA sequences reported in scientific publications? Were you successful? Here, we reveal that metagenomes from no fewer than 20% of the papers found in our literature search, published between 2016 and 2019, were not deposited in a repository or were simply inaccessible. The proportion of inaccessible data within the literature has been increasing year-on-year. Noncompliance with Open Data is best predicted by the scientific discipline of the journal. The number of citations, journal type (e.g., Open Access or subscription journals), and publisher are not good predictors of data accessibility. However, many publications in high-impact factor journals do display a higher likelihood of accessible metagenomic data sets. Twenty-first century science demands compliance with the ethical standard of data sharing of metagenomes and DNA sequence data more broadly. Data accessibility must become one of the routine and mandatory components of manuscript submissions-a requirement that should be applicable across the increasing number of disciplines using metagenomics. Compliance must be ensured and reinforced by funders, publishers, editors, reviewers, and, ultimately, the authors.

(Inter)nationalising the antibiotic research and development pipeline

In this Personal View, we critically examine the wider context of international efforts to stimulate commercial antibiotic research and development via public-private initiatives. Despite these efforts, antibiotics remain a global resource without an international support structure that is commensurate to the risks from antibiotic-resistant infections and the long-term nature of required solutions. To protect this resource, we propose a two-pronged antibiotic research and development strategy based on a short-term strengthening of incentives (such as market entry rewards) to maximise the delivery of existing opportunities in the pipeline, and on a concurrent medium-term to long-term establishment of a global, publicly funded antibiotic research and development institute. Designed sustainably to deliver novel and first-in-class antibiotics targeting key human health gaps, the institute and its staff would become a global resource that, unlike the private pharmaceutical sector, would be managed as an open science platform. Our model of internationalised public research and development would maximise scientific synergy and cross-fertilisation, minimise replication of effort, acquire and preserve existing know-how, and ensure equitable and sustainable access to novel and effective antibiotics. Its genuinely global focus would also help counteract tendencies to equate donor with global health priorities. Our proposal is not radical. Historical precedent and developments in other research areas show that sustained international funding of publicly owned research can hasten the delivery of critically needed drugs and lower barriers to access.

Translating antibiotic prescribing into antibiotic resistance in the environment: A hazard characterisation case study

The environment receives antibiotics through a combination of direct application (e.g., aquaculture and fruit production), as well as indirect release through pharmaceutical manufacturing, sewage and animal manure. Antibiotic concentrations in many sewage-impacted rivers are thought to be sufficient to select for antibiotic resistance genes. Yet, because antibiotics are nearly always found associated with antibiotic-resistant faecal bacteria in wastewater, it is difficult to distinguish the selective role of effluent antibiotics within a 'sea' of gut-derived resistance genes. Here we examine the potential for macrolide and fluoroquinolone prescribing in England to select for resistance in the River Thames catchment, England. We show that 64% and 74% of the length of the modelled catchment is chronically exposed to putative resistance-selecting concentrations (PNEC) of macrolides and fluoroquinolones, respectively. Under current macrolide usage, 115 km of the modelled River Thames catchment (8% of total length) exceeds the PNEC by 5-fold. Similarly, under current fluoroquinolone usage, 223 km of the modelled River Thames catchment (16% of total length) exceeds the PNEC by 5-fold. Our results reveal that if reduced prescribing was the sole mitigating measure, that macrolide and fluoroquinolone prescribing would need to decline by 77% and 85%, respectively, to limit resistance selection in the catchment. Significant reductions in antibiotic prescribing are feasible, but innovation in sewage-treatment will be necessary for achieving substantially-reduced antibiotic loads and inactivation of DNA-pollution from resistant bacteria. Greater confidence is needed in current risk-based targets for antibiotics, particularly in mixtures, to better inform environmental risk assessments and mitigation.

Water and sanitation: an essential battlefront in the war on antimicrobial resistance

Water and sanitation represent a key battlefront in combatting the spread of antimicrobial resistance (AMR). Basic water sanitation infrastructure is an essential first step towards protecting public health, thereby limiting the spread of pathogens and the need for antibiotics. AMR presents unique human health risks, meriting new risk assessment frameworks specifically adapted to water and sanitation-borne AMR. There are numerous exposure routes to AMR originating from human waste, each of which must be quantified for its relative risk to human health. Wastewater treatment plants play a vital role in centralized collection and treatment of human sewage, but there are numerous unresolved issues in terms of the microbial ecological processes occurring within them and the extent to which they attenuate or amplify AMR. Research is needed to advance understanding of the fate of resistant bacteria and antibiotic resistance genes in various waste management systems, depending on the local constraints and intended reuse applications. World Health Organization and national AMR action plans would benefit from a more holistic 'One Water' understanding. In this article we provide a framework for research, policy, practice and public engagement aimed at limiting the spread of AMR from water and sanitation in low-, medium- and high-income countries.

Reinventing the antimicrobial pipeline in response to the global crisis of antimicrobial-resistant infections

The pipeline for new antibiotics is dry. Despite the creation of public/private initiatives like Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator (Carb-X) and the Antimicrobial Resistance (AMR) Centre, the current focus on ‘push-pull’ incentives for the pharmaceutical industry still relies on economic return. We propose a joint, internationally-funded antimicrobial development institute that would fund permanent staff to take on roles previously assigned to pharmaceutical companies. This institute would receive ring-fenced, long-term, core funding from participating countries as well as charities, with the aim to focus on transforming the largely dormant antimicrobial pipeline. Resulting drugs would be sold globally and according to a principle of shared burdens. Our proposed model for antimicrobial development aims to maximise society’s investment, through open science, investment in people, and the sharing of intellectual property.

A Modulo-Based Architecture for Analog-to-Digital Conversion

Systems that capture and process analog signals must first acquire them through an analog-to-digital converter. While subsequent digital processing can remove statistical correlations present in the acquired data, the dynamic range of the converter is typically scaled to match that of the input analog signal. The present paper develops an approach for analog-to-digital conversion that aims at minimizing the number of bits per sample at the output of the converter. This is attained by reducing the dynamic range of the analog signal by performing a modulo operation on its amplitude, and then quantizing the result. While the converter itself is universal and agnostic of the statistics of the signal, the decoder operation on the output of the quantizer can exploit the statistical structure in order to unwrap the modulo folding. The performance of this method is shown to approach information theoretical limits, as captured by the rate-distortion function, in various settings. An architecture for modulo analog-to-digital conversion via ring oscillators is suggested, and its merits are numerically demonstrated.

Review of antibiotic resistance in China and its environment

Antibiotic resistance is a global health crisis linked to increased, and often unrestricted, antibiotic use in humans and animals. As one of the world's largest producers and consumers of antibiotics, China is witness to some of the most acute symptoms of this crisis. Antibiotics and antibiotic resistance genes (ARGs) are widely distributed in surface water, sewage treatment plant effluent, soils and animal wastes. The emergence and increased prevalence of ARGs in the clinic/hospitals, especially carbapenem-resistant gram negative bacteria, has raised the concern of public health officials. It is important to understand the current state of antibiotic use in China and its relationship to ARG prevalence and diversity in the environment. Here we review these relationships and their relevance to antimicrobial resistance (AMR) trends witnessed in the clinical setting. This review highlights the issues of enrichment and dissemination of ARGs in the environment, and also future needs in mitigating the spread of antibiotic resistance in the environment, particularly under the 'planetary health' perspective, i.e., the systems that sustain or threaten human health.

Linking changes in antibiotic effluent concentrations to flow, removal and consumption in four different UK sewage treatment plants over four years

The arrival and discharge of seven antibiotics were monitored at two trickling filter sewage treatment plants of 6000 and 11,000 population equivalents (PE) and two activated sludge plants of 33,000 and 162,000 PE in Southern England. The investigation consisted of 24 h composite samples taken on two separate days every summer from 2012 to 2015 and in the winter of 2015 (January) from influent and effluent. The average influent concentrations generally matched predictions based on England-wide prescription data for trimethoprim, sulfamethoxazole, azithromycin, oxytetracycline and levofloxacin (within 3-fold), but were 3-10 times less for clarithromycin, whilst tetracycline influent concentrations were 5-17 times greater than expected. Over the four years, effluent concentrations at a single sewage plant varied by up to 16-fold for clarithromycin, 10-fold for levofloxacin and sulfamethoxazole, 7-fold for oxytetracycline, 6-fold for tetracycline, 4-fold for azithromycin and 3-fold for trimethoprim. The study attempted to identify the principal reasons for this variation in effluent concentration. By measuring carbamazepine and using it as a conservative indicator of transport through the treatment process, it was found that flow and hence concentration could alter by up to 5-fold. Measuring influent and effluent concentrations allowed assessments to be made of removal efficiency. In the two activated sludge plants, antibiotic removal rates were similar for the tested antibiotics but could vary by several-fold at the trickling filter plants. However, for clarithromycin and levofloxacin the variations in effluent concentration were above that which could be explained by either flow and/or removal alone so here year on year changes in consumption are likely to have played a role.