Community infectious disease treatment with antimicrobial agents - A longitudinal one year study of antimicrobials in two cities via wastewater-based epidemiology

Impact of easing COVID-19 restrictions on antibiotic usage in Eastern China using wastewater-based epidemiology

Coronavirus Disease 2019 (COVID-19) emerged in December 2019, prompting the implementation of a "zero-COVID" policy in Mainland China. The easing of this policy in December 2022 led to a surge in COVID cases, which was believed to significantly increase antibiotic usage, potentially due to antibiotic misuse or increased coinfections. Our study aimed to compare antibiotic consumption and patterns before and after this policy adjustment. We utilised wastewater-based epidemiology (WBE) to analyse antibiotic levels in samples collected from five wastewater treatment plants in Eastern China during January and February of 2021 and 2023. 27 antibiotics were quantified using ultra-high performance liquid chromatography coupled with triple quadrupole tandem mass spectrometry (UPLC-MS/MS) and analysed via WBE, with the resulting estimates compared with catchment-specific prescription data. 23 antibiotics were detected in wastewater samples, with a substantial increase in usage in 2023 (ranging from 531% to 3734%), consistent with prescription data. Here, we show a significant rise in antibiotic consumption during the COVID-19 surge and this underscores the need for further investigation into the impacts of inappropriate antibiotic use in China.

Occurrence and distribution of emerging contaminants in wastewater treatment plants: A globally review over the past two decades

Emerging contaminants are pervasive in aquatic environments globally, encompassing pharmaceuticals, personal care products, steroid hormones, phenols, biocides, disinfectants and various other compounds. Concentrations of these contaminants are detected ranging from ng/L to μg/L. Even at trace levels, these contaminants can pose significant risks to ecosystems and human health. This article systematically summarises and categorizes data on the concentrations of 54 common emerging contaminants found in the influent and effluent of wastewater treatment plants across various geographical regions: North America, Europe, Oceania, Africa, and Asia. It reviews the occurrence and distribution of these contaminants, providing spatial and causal analyses based on data from these regions. Notably, the maximum concentrations of the pollutants observed vary significantly across different regions. The data from Africa, in particular, show more frequent detection of pharmaceutical maxima in wastewater treatment plants.

Predicting pharmaceutical concentrations and assessing risks in the aquatic environment using PERK: A case study of a catchment area in South-West England

The aim of this study was to introduce a model to predict pharmaceuticals concentrations in the aquatic environment and their environmental impacts using the Risk Quotient (RQ) approach. The model was trained using: (i) high resolution dataset on pharmaceuticals' concentration in wastewater and receiving environment in a river catchment, (ii) understanding of pharmaceuticals' discharge points in the catchment, (iii) fate of pharmaceuticals during wastewater treatment and in the receiving environment, (iv) high resolution per-postcode pharmaceutical prescription data. A total of 41 pharmaceuticals were evaluated, with successful predictions achieved for concentrations falling within the range of 0.7 (influent: 37 %, effluent: 39 %, river: 29 %) to 1 % (influent: 56 %, effluent: 58 %, river: 48 %) of the measured values. Importantly, our risk assessment demonstrates significant environmental risks associated with specific pharmaceuticals, with strong alignment (86 %) between assessments based on predicted and measured data, underscoring the reliability of our model in assessing environmental risks. The observed variability in predicted and measured concentrations underscores the necessity for ongoing model refinement, particularly in regions with notable discrepancies such as wastewater treatment plant (WWTP) C. Overall, our study illustrates the intricate dynamics of pharmaceutical contamination in aquatic ecosystems, emphasizing the crucial need for continued research in this field.

Antimicrobials and antimicrobial resistance genes in the shadow of COVID-19 pandemic: A wastewater-based epidemiology perspective

Higher usage of antimicrobial agents in both healthcare facilities and the communities has resulted in an increased spread of resistant bacteria. However, the improved infection prevention and control practices may also contribute to decreasing antimicrobial resistance (AMR). In the present study, wastewater-based epidemiology (WBE) approach was applied to explore the link between COVID-19 and the community usage of antimicrobials, as well as the prevalence of resistance genes. Longitudinal study has been conducted to monitor the levels of 50 antimicrobial agents (AAs), 24 metabolites, 5 antibiotic resistance genes (ARGs) and class 1 integrons (intI 1) in wastewater influents in 4 towns/cities over two years (April 2020 - March 2022) in the South-West of England (a total of 1,180 samples collected with 87,320 individual AA measurements and 8,148 ARG measurements). Results suggested higher loads of AAs and ARGs in 2021-22 than 2020-21, with beta-lactams, quinolones, macrolides and most ARGs showing statistical differences. In particular, the intI 1 gene (a proxy of environmental ARG pollution) showed a significant increase after the ease of the third national lockdown in England. Positive correlations for all quantifiable parent AAs and metabolites were observed, and consumption vs direct disposal of unused AAs has been identified via WBE. This work can help establish baselines for AMR status in communities, providing community-wide surveillance and evidence for informing public health interventions. Overall, studies focused on AMR from the start of the pandemic to the present, especially in the context of environmental settings, are of great importance to further understand the long-term impact of the pandemic on AMR.

Understanding associations between antimicrobial agents usage and antimicrobial resistance genes prevalence at the community level using wastewater-based epidemiology: A Spanish pilot study

Understanding the development and spread of antimicrobial resistance (AMR) is important for combating this global threat for public health. Wastewater-based epidemiology (WBE) is a complementary approach to current surveillance programs that minimizes some of the existing limitations. The aim of the present study is to explore WBE for monitoring antibiotics and antibiotic resistance genes (ARGs) in wastewater samples collected during 2021/2022 from the city of Castellon (Spain). Eighteen commonly prescribed antibiotics have been selected and measured by liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS), with triple quadrupole mass analysers. Moreover, qPCR for specific ARGs has been performed to obtain information of these genes in co-presence with antibiotics. All selected ARGs, along with a total of 11 antibiotics, were identified. The highest population-normalized daily loads were observed for the macrolide azithromycin, followed by the quinolones ciprofloxacin and levofloxacin. Subsequently, daily consumption estimates based on wastewater data were compared with prescription data of antibiotics. Statistical analyses were conducted to explore if there is correlation between antibiotics and ARGs. While no correlations were found between antibiotics and their corresponding ARGs, certain correlations (p < 0.05) were identified among non-corresponding ARGs. In addition, a strong positive correlation was found between the sum of all antibiotics and the intl1 gene. Moreover, population-normalized ARG loads significantly correlate with the 16S rRNA-normalized ARG loads, serving as an indicator for population size. Results provide a baseline for future work and a proof-of-concept emphasising the need for future work and long-term surveillance, and highlight the need of similar programs at a regional and global levels worldwide.

In-sewer stability assessment of 140 pharmaceuticals, personal care products, pesticides and their metabolites: Implications for wastewater-based epidemiology biomarker screening

The monitoring of pharmaceuticals, personal care products (PCPs), pesticides, and their metabolites through wastewater-based epidemiology (WBE) provides timely information on pharmaceutical consumption patterns, chronic disease treatment rates, antibiotic usage, and exposure to harmful chemicals. However, before applying them for quantitative WBE back-estimation, it is necessary to understand their stability in the sewer system to screen suitable WBE biomarkers thereby reducing research uncertainty. This study investigated the in-sewer stability of 140 typical pharmaceuticals, PCPs, pesticides, and their metabolites across 15 subcategories, using a series of laboratory sewer sediment and biofilm reactors. For the first time, stability results for 89 of these compounds were reported. Among the 140 target compounds, 61 biomarkers demonstrated high stability in all sewer reactors, while 41 biomarkers were significantly removed merely by sediment processes. For biomarkers exhibiting notable attenuation, the influence of sediment processes was generally more pronounced than biofilm, due to its stronger microbial activities and more pronounced diffusion or adsorption processes. Adsorption emerged as the predominant factor causing biomarker removal compared to biodegradation and diffusion. Significantly different organic carbon-water partitioning coefficient (Koc) and distribution coefficient at pH = 7 (logD) values were observed between highly stable and unstable biomarkers, with most hydrophobic substances (Koc > 100 or logD > 2) displaying instability. In light of these findings, we introduced a primary biomarker screening process to efficiently exclude inappropriate candidates, achieving a commendable 77 % accuracy. Overall, this study represents the first comprehensive report on the in-sewer stability of 89 pharmaceuticals, PCPs, pesticides, and their metabolites, and provided crucial reference points for understanding the intricate sewer sediment processes.

Quantifying community-wide antibiotic usage via urban water fingerprinting: Focus on contrasting resource settings in South Africa

There has been a significant increase in antimicrobial agents (AAs) usage, globally - however the relative consumption is unevenly distributed between nations. Inappropriate use of antibiotics can harbour inherent antimicrobial resistance (AMR); therefore, it is important to understand and monitor community-wide prescribing and consumption behaviours throughout different communities around the world. Wastewater-Based Epidemiology (WBE) is a novel tool enabling low cost and large scale studies focussed on AA usage patterns. The back-calculation of community antimicrobial intake was performed from quantities measured in municipal wastewater and informal settlement discharge in the city of Stellenbosch, utilising WBE. Seventeen antimicrobials, and their human metabolites, were evaluated, in concordance with prescription records corresponding to the catchment region. The proportional excretion, biological/chemical stability, and method recovery of each analyte were all crucial factors in the efficacy of the calculation. Mass per day measurements were normalised to the catchment area via population estimates. Municipal wastewater treatment plant population estimates were used to normalise the wastewater samples and prescription data (mg/day/1000 inhabitants). Population estimates for the informal settlements were less accurate due to a lack of reliable sources that were relevant to the sampling time period. Both mass loads and normalised loads suggested higher than average usage throughout the settlements, relative to municipal wastewater. This was seen most prominently in emtricitabine and lamivudine; but also, sulfamethoxazole, trimethoprim, sulfadiazine, clindamycin, ciprofloxacin, ofloxacin, and doxycycline. Urban water fingerprinting (UWF) data triangulation with prescription datasets showed good correlations for several antimicrobial agents (AAs) (e.g., clindamycin, clarithromycin, ofloxacin, and doxycycline). It also revealed discrepancies in usage for some compounds (e.g., tetracycline and sulfapyridine). This might be linked with a lack of pharma compliance in prescription datasets; erroneous association of prescription boundaries with the sewerage catchment; and/or uncertainties within the sewerage catchment (e.g., population estimations). The UWF tool provided a comprehensive overview of multiclass AAs usage, both prescription and over-the counter. For example, tetracycline was not reported in available prescription statistics, but was detected at an average of 18.4 mg/day/1000inh; and no antiviral prescriptions were obtained, but emtricitabine and lamivudine were quantified at 2415.4 and 144.4 mg/day/1000inh, respectively. A lack of clarity regarding prescriptions and a lack of inclusion of several critical (often over-the-counter) medications in public health databases makes WBE a useful and comprehensive epidemiology tool for tracking pharma usage within a catchment.