Mass flows of X-ray contrast media and cytostatics in hospital wastewater

The GREENWATER study: patients' green sensitivity and potential recovery of injected contrast agents

OBJECTIVES

The environmental footprint of iodinated contrast agents (ICAs) and gadolinium-based contrast agents (GBCAs) is noteworthy. This study assesses: (1) patients' "green sensitivity" as measured by their acceptance in a sustainability study and (2) the resulting potential reduction of contrast residuals in wastewater.

MATERIALS AND METHODS

After ethical approval, participants scheduled for administration of ICAs or GBCAs for diagnostic purposes were enrolled in this prospective observational study from July 2022 to October 2023. They were asked to prolong their hospital stay by up to 60 min to collect their first urine in dedicated canisters, thereby measuring the recovery rates of ICAs and GBCAs as found/theoretical ratio of concentrations. Mann-Whitney U, χ2 tests, and multivariable regression analysis were used.

RESULTS

Patients scheduled for contrast-enhanced CT or MRI (n = 455) were screened; 422 (92.7%) accepted to participate. We enrolled 212 patients administered with ICAs and 210 administered with GBCAs. The median recovery rate was 51.2% (interquartile range 29.2-77.9%) for ICAs and 12.9% (9.0-19.3%) for GBCAs. At multivariable analysis, a significant effect of patient age (ICAs, p = 0.001; GBCAs, p = 0.014), urine volume (p < 0.001 for both), and time interval from contrast administration to urine collection (p < 0.001 for both) on recovery rates was found for both contrast agents; injected contrast volume (p = 0.046) and saline flushing usage (p = 0.008) showed a significant effect only for ICAs.

CONCLUSION

The high patient enrollment compliance (93%) and potential recovery rates of 51% (ICAs) and 13% (GBCAs) play in favor of sustainable practices in reducing the environmental footprint of contrast agents.

KEY POINTS

Question How many patients are willing to extend their stay in radiology by up to 60 min to help reduce the environmental impact of contrast agents? Findings Over 90% of screened patients agreed to extend their stay by up to 60 min and collect their urine in dedicated containers. Clinical relevance Patients demonstrated a high willingness to cooperate in reducing the environmental impact of contrast agents, allowing for a potential recovery of approximately 51% for iodinated and 13% for gadolinium-based contrast agents.

Fate and impact at molecular level of diatrizoic acid and iohexol contrast agents in Dreissena polymorpha mollusks

Iodinated contrast media (ICMs) used in X-ray imaging for medical diagnostics are released into wastewater and then encountered in river water at concentrations ranging from several dozen to hundreds of µg/L, and even thousands of µg/L in hospital effluents. ICMs are considered as emerging pollutants as their occurrence and impact on ecosystems and the environment are poorly documented. Even if they are considered inert for humans, aquatic organisms are continuously exposed to ICMs, and their potential deleterious effects are therefore questioned as we have recently demonstrated that they enter into organisms such as the zebra mussels. To answer this question, Dreissena polymorpha were exposed to two ICMs of different osmolality, diatrizoic acid and iohexol, at an environmental concentration (100 µg/L) for 21 days before a depuration phase of 4 days. The occurrence, fate, and impact of both ICMs in these organisms were studied using a metallomic approach. Thus, iodine as well as endogenous copper and zinc were quantified and analyzed in cytosolic extracts of digestive glands, gills, and gonads of mussels by size exclusion chromatography coupled to ICP MS. This work shows that a subcellular fractionation is necessary to distinguish variations in total element content. The cytosolic iodoprotein chromatographic pattern was consistent for the three organs and confirmed the presence of ICMs in cytosols. Additionally, this exploratory work tends to show a weak biological effect of ICMs with a substantial variation of the profile of Cu-binding proteins mostly in the gill cytosol and to a lesser extent, in the digestive gland cytosol.

Occurrence and environmental risk assessment of pharmaceuticals in the Mondego river (Portugal)

In this case study pharmaceuticals were analysed in the Mondego river (Portugal) and their environmental risk assessed by means of risk quotients based on an extensive retrieval of ecotoxicological data for freshwater and saltwater species. The Mondego river crosses Coimbra, the most populated city in the Portuguese Centro Region hosting a complex of regional hospitals. Environmentally relevant and prioritised pharmaceuticals were investigated in this study and their potential hazards were evaluated by conducting a separate risk assessment for the freshwater and estuary parts of the examined river section. A target analysis approach with method detection limits down to 0.01 ng L-1 was used to determine pharmaceuticals. Twenty-one prioritised target analytes out of seven therapeutical classes (antibiotics, iodinated X-ray contrast media (ICM), analgesics, lipid reducers, antiepileptics, anticonvulsants, beta-blockers) were investigated by applying ultra-high pressure liquid chromatography coupled to a triple quadrupole mass spectrometer equipped with an electrospray ionisation source. The relative pattern of pharmaceuticals along the middle to the lower Mondego showed a quite uniform picture while an approximately 40fold increase of absolute concentrations was observed downstream of the wastewater treatment plant (WWTP) discharge of Coimbra. The most frequently measured substance groups were the ICM, represented by the non-ionic ICM iopromide (βmin: 3.03 ng L-1 - βmax: 2,810 ng L-1). Environmentally more critical substances such as carbamazepine, diclofenac, and bezafibrate, with concentrations up to and 52.6 ng L-1, 59.8 ng L-1, and 10.2 ng L-1 respectively, may potentially affect aquatic wildlife. Carbamazepine revealed elevated risk quotients (RQs >1) along the middle and lower Mondego with a maximum RQ of 53 downstream of Coimbra. Especially for saltwater species, carbamazepine and clarithromycin pose high potential risks. Especially in periods of low water discharge of the Mondego river, other pharmaceuticals as diclofenac and bezafibrate may pose additional risks downstream of the WWTP.

Adsorptive removal of anticarcinogen pazopanib from aqueous solutions using activated carbon: isotherm, kinetic and thermodynamic studies

Pazopanib, which is dangerous for aquatic environments due to its toxic and bioaccumulation potential, has been detected at different concentrations in oncology hospital wastewater, sewage, and surface waters. This study aimed to remove pazopanib from wastewater by activated carbon adsorption technique. The effect of the main variables such as initial concentration, pH of pazopanib solution, adsorbent dose, contact time of the phases, and temperature on the adsorption process was evaluated and the optimum adsorption conditions were determined. The experimental data were applied to Langmuir, Freundlich, Temkin, and Dubinin-Radushkevich adsorption isotherm models to describe the adsorption behavior. The experimental data were applied to pseudo-first-order, pseudo-second-order, and intra-particle diffusion kinetic models to describe the adsorption kinetics. Isotherms were established in the 20-50 °C temperature range to study the adsorption equilibrium. According to the results, the highest removal efficiency of pazopanib (95.87%) was obtained at initial concentration (100 mg L-1), adsorbent dose (0.30 g L-1), temperature (20 °C), contact time (120 min) and pH (7.0). The adsorption kinetics was well described by the pseudo-second-order kinetic model (R2 = 0.9998) and the adsorption isotherm by the Langmuir model (R2 = 0.9999). In thermodynamic studies, the negative values of standard enthalpy (ΔH°), standard free enthalpy (ΔG°), and free entropy (ΔS°) indicate that the adsorption process is spontaneous and favorable, i.e. the disorder is reduced. These results indicate that the developed adsorption process can be efficiently and spontaneously applied for the removal of pazopanib from aqueous solutions.

A thorough analysis of the occurrence, removal and environmental risks of organic micropollutants in a full-scale hybrid membrane bioreactor fed by hospital wastewater

The Urban Wastewater Treatment Directive recent draft issued last October 2022 pays attention to contaminants of emerging concern including organic micropollutants (OMPs) and requires the removal of some of them at large urban wastewater treatment plants (WWTPs) calling for their upgrading. Many investigations to date have reported the occurrence of a vast group of OMPs in the influent and many technologies have been tested for their removal at a lab- or pilot-scale. Moreover, it is well-known that hospital wastewater (HWW) contains specific OMPs at high concentration and therefore its management and treatment deserves attention. In this study, a 1-year investigation was carried out at a full-scale membrane bioreactor (MBR) treating mainly HWW. To promote the removal of OMPs, powdered activated carbon (PAC) was added to the bioreactor at 0.1 g/L and 0.2 g/L which resulted in the MBR operating as a hybrid MBR. Its performance was tested for 232 target and 90 non-target OMPs, analyzed by UHPLC-QTOF-MS using a direct injection method. A new methodology was defined to select the key compounds in order to evaluate the performance of the treatments. It was based on their frequency, occurrence, persistence to removal, bioaccumulation and toxicity. Finally, an environmental risk assessment of the OMP residues was conducted by means of the risk quotient approach. The results indicate that PAC addition increased the removal of most of the key OMPs (e.g., sulfamethoxazole, diclofenac, lidocaine) and OMP classes (e.g., antibiotics, psychiatric drugs and stimulants) with the highest loads in the WWTP influent. The hybrid MBR also reduced the risk in the receiving water as the PAC dosage increased mainly for spiramycin, lorazepam, oleandomycin. Finally, uncertainties and issues related to the investigation being carried out at full-scale under real conditions are discussed.

Spatial and temporal variability of micropollutants within a wastewater catchment system

Treated wastewater effluent is a major contributor to concentrations of many anthropogenic chemicals in the environment. Examining patterns of these compounds measured from different catchment areas comprising the influent to a wastewater treatment plant, across many months, may reveal patterns in compound sources and seasonality helpful to management efforts. This study considers a wastewater catchment system that was sampled at six sub-catchment sites plus the treatment plant influent and effluent at seven time points spanning nine months. Wastewater samples were analyzed with LC-QTOF-MS using positive electrospray ionization and GC-QTOF-MS using negative chemical ionization and electron ionization. MS data were screened against spectral libraries to identify micropollutants. As expected, multiple classes of chemicals were represented, including pharmaceuticals, plasticizers, personal care products, and flame retardants. Patterns in the compounds seen at different sampling sites and dates reflect the varying uses and down-the-drain routes that influence micropollutant loading in sewer systems. Patterns in examined compounds revealed little spatial variation, and greater temporal variation. For example, the greatest loads of DEET were found to occur in the summer months. Additionally, groups of compounds exhibited strong correlation with each other, which could be indicative of similar down-the-drain routes (such as a group intercorrelated chemicals that are components of cleaning products) or the influence of similar physicochemical processes within the sewer system. This study contributes to the understanding of dynamics of micropollutants in sewer systems.

Investigating the biodegradability of iodinated X-ray contrast media in simultaneous nitrification and denitrification system

The present study investigated the biodegradation of three iodinated X-ray contrast media (ICM), namely, iopamidol, iohexol, and iopromide, in simultaneous nitrification-denitrification (SND) system maintained in a sequencing batch reactor (SBR). The results showed that variable aeration patterns (anoxic-aerobic-anoxic) and micro-aerobic condition were most effective in the biotransformation of ICM while achieving organic carbon and nitrogen removal. The highest removal efficiencies of iopamidol, iohexol, and iopromide were 48.24%, 47.75%, and 57.46%, respectively, in micro-aerobic condition. Iopamidol was highly resistant to biodegradation and possessed the lowest K_bio value, followed by iohexol and iopromide, regardless of operating conditions. The removal of iopamidol and iopromide was affected by the inhibition of nitrifiers. The transformation products after hydroxylation, dehydrogenation, and deiodination of ICM were detected in the treated effluent. Due to the addition of ICM, the abundance of denitrifier genera Rhodobacter and Unclassified Comamonadaceae increased, and the abundance of class TM7-3 decreased. The presence of ICM affected the microbial dynamics, and the diversity of microbes in SND resulted in improving the biodegradability of the compounds.

Performance of a Pilot-Scale Continuous Flow Ozone-Based Hospital Wastewater Treatment System

Antimicrobial resistance (AMR) is becoming a global concern. Recently, research has emerged to evaluate the human and environmental health implications of wastewater from medical facilities and to identify acceptable wastewater treatment methods. In this study, a disinfection wastewater treatment system using an ozone-based continuous flow system was installed in a general hospital located in Japan. The effectiveness of antimicrobial-resistant bacteria (ARB) and antimicrobials in mitigating the environmental impact of hospital wastewater was evaluated. Metagenomic analysis was conducted to characterize the microorganisms in the wastewater before and after treatment. The results demonstrated that ozone treatment enables effective inactivation of general gut bacteria, including Bacteroides, Prevotella, Escherichia coli, Klebsiella, DNA molecules, and ARGs, as well as antimicrobials. Azithromycin and doxycycline removal rates were >99% immediately after treatment, and levofloxacin and vancomycin removal rates remained between 90% and 97% for approximately one month. Clarithromycin was more readily removed than the other antimicrobials (81-91%), and no clear removal trend was observed for ampicillin. Our findings provide a better understanding of the environmental management of hospital wastewater and enhance the effectiveness of disinfection wastewater treatment systems at medical facilities for mitigating the discharge of pollutants into aquatic environments.

Reducing contrast agent residuals in hospital wastewater: the GREENWATER study protocol

The potential enviromental impact of iodinated (ICAs) and gadolinium-based contrast agents (GBCAs) have recently come under scrutiny, considering the current nonselective wastewater treatment. However, their rapid excretion after intravenous administration could allow their potential recovery by targeting hospital sewage. The GREENWATER study aims to appraise the effective quantities of ICAs and GBCAs retrievable from patients' urine collected after computed tomography (CT) and magnetic resonance imaging (MRI) exams, selecting ICA/GBCA per-patient urinary excretion and patients' acceptance rate as study endpoints. Within a prospective, observational, single-centre, 1-year framework, we will enrol outpatients aged ≥ 18 years, scheduled to perform contrast-enhanced CT or MRI, willing to collect post-examination urine in dedicated canisters by prolonging their hospital stay to 1 h after injection. Collected urine will be processed and partially stored in the institutional biobank. Patient-based analysis will be performed for the first 100 CT and 100 MRI patients, and then, all analyses will be conducted on the pooled urinary sample. Quantification of urinary iodine and gadolinium will be performed with spectroscopy after oxidative digestion. The evaluation of the acceptance rate will assess the "environmental awareness" of patients and will aid to model how procedures to reduce ICA/GBCA enviromental impact could be adapted in different settings. Key points • Enviromental impact of iodinated and gadolinium-based contrast agents represents a growing point of attention.• Current wastewater treatment is unable to retrieve and recycle contrast agents.• Prolonging hospital stay may allow contrast agents retrieval from patients' urine.• The GREENWATER study will assess the effectively retrievable contrast agents' quantities.• The enrolment acceptance rate will allow to evaluate patients' "green sensitivity".

Peracetic acid activation via the synergic effect of Co and Fe in CoFe-LDH for efficient degradation of pharmaceuticals in hospital wastewater

As an oxidant, peracetic acid (PAA) is gradually applied in advanced oxidation processes (AOPs) for pollutants degradation due to its high oxidation and low toxicity. In this study, the prepared Co₂Fe₁-LDH showed excellent PAA activation ability for efficient degradation of various pharmaceuticals with a removal efficiency ranging from 82.3% to 100%. Taking sulfamethoxazole (SMX) as a model pharmaceutical, it's found that organic radical (R-O^•) with high concentration of 5.27 × 10^-13 M is the dominant ROS responsible for contaminants degradation. Further analysis demonstrated that bimetallic synergistic effect between Co and Fe can improve electron transfer ability of Co₂Fe₁-LDH, resulting in the accelerated conversion of Co from +3 to +2 valence state with a high reaction rate (4.3 × 10¹-1.483 × 10² M^-1 s^-1) in this system. Density functional theory (DFT) reveals that C1, C3, C5 and N11 with higher ƒ⁰ and ƒ^-values concentrated on aniline group of SMX are the main attack sites, which is consistent with the results of degradation products. Besides, Co₂Fe₁-LDH/PAA system can effectively reduce biological toxicity after reaction, due to lower biotoxicity of degradation products and the carbon sources provided by PAA. In application, Co₂Fe₁-LDH/PAA system was capable of resisting the influence of water matrix and effectively removing pollutants in actual hospital wastewater. Importantly, this study comprehensively evaluated the ability of Co₂Fe₁-LDH/PAA system to remove organics and improve the biodegradability of actual hospital wastewater, providing guidance for application of PAA activation system.

Assessing the risks of capecitabine and its active metabolite 5-fluorouracil to freshwater biota

Capecitabine (CAP, prodrug) and 5-fluorouracil (5-FU, its active metabolite) are two of the most prominent cytostatics, for which no clear picture can be drawn regarding potential concentrations of effect for freshwater biota, with CAP being grouped in the least studied cytostatic, whereas 5-FU has been classified as of no and of high environmental risk. Accordingly, the present work aimed to assess the ecotoxicity of CAP and 5-FU in three freshwater species, which included a 72-h assay with the producer Raphidocelis subcapitata; a 96-h assay with the invertebrate secondary consumer Hydra viridissima; and a 96-h assay with embryos of the vertebrate secondary consumer Danio rerio. The following endpoints were monitored: yield and population growth rate for the algae; mortality, morphological alterations, and post-exposure feeding rates for the cnidarian; and mortality, hatching, and malformations for the fish. Overall, organisms' sensitivity to CAP decreased in the following order: R. subcapitata > H. viridissima > D. rerio, whereas for 5-FU, it decreased in the following order: H. viridissima > D. rerio > R. subcapitata. For CAP, no median lethal effective concentrations (LC/EC₅₀) were possible to compute for D. rerio, with no significant mortality or malformations registered in embryos exposed at concentrations up to 800 mg L^-1. For R. subcapitata, the EC₅₀s were 0.077 and 0.63 mg L^-1 for yield and growth rate, respectively, and for H. viridissima, the EC_50,30 min for feeding was 22.0 mg L^-1. For 5-FU, no EC_50s could be computed for R. subcapitata, whilst the EC_50s for H. viridissima mortality and feeding were 55.4 and 67.9 mg L^-1, respectively, and for D. rerio, the LC_50,96 h and EC_50,96 h (hatching and abnormalities) were 4546, 4100, and 2459 mg L^-1, respectively. Assuming similar modes of action for both compounds and their co-occurrence, the combined risk quotient of the two chemicals was determined to be 7.97, which represents a risk for freshwater biota. Anticipating the increased consumption of these compounds and cancer development trends worldwide, these impacts may be further aggravated.

Occurrence of pharmaceuticals in the wastewater of a Greek hospital: Combining consumption data collection and LC-QTOF-MS analysis

In this article we applied drug consumption approach and chemical analysis in parallel to investigate the concentrations of a large number of pharmaceuticals in different streams of a General Hospital. Drugs consumption data was collected during two periods (Period 1, 2) and the predicted environmental concentrations (PECs) were estimated for the wastewater of a building housing specific medical services (Point A) and for the entire hospital (Point B). Hospital wastewater samples (HWW) samples were also collected from these points and periods and the measured environmental concentrations (MEC) were determined using UHPLC-ESI-QTOF-MS/MS. According to consumption data, the highest number of drugs was consumed in the departments of Hematology, Intensive Care Unit, Cardiology, Internal Medicine, and Oncology, while the number of active substances used in the hospital was 413 (Period 1) and 362 (Period 2). For most substances, much higher PEC and MEC values were found at the HWW of Point A indicating that on-site treatment of this stream could be examined in the future. The application of wide-scope target analysis allowed the quantification of 122 compounds, while 21 additional substances were identified using suspect screening. The highest mean concentrations in Period 1 were found for acetaminophen (1100 μg/L) and rifaximin (723 μg/L), while in Period 2 for iopromide (458 μg/L) and acyclovir (408 μg/L). Among the detected compounds, 19 metabolites were determined. Atenolol acid, 1-hydroxy-midazolam and clopidogrel carboxylic acid were quantified at concentrations much higher than parent compounds indicating the importance of metabolites' monitoring in HWW. Calculation of PEC/MEC ratio for 36 pharmaceuticals showed sufficient correlation of these values for 19 % to 33 % of the substances depending on the examined period and sampling point. The parallel collection of drugs consumption data and chemical analysis give a thorough picture of the substances present in HWW and their main sources, facilitating decision-making for their better management.

Removal of Iodine-Containing X-ray Contrast Media from Environment: The Challenge of a Total Mineralization

Iodinated X-ray contrast media (ICM) as emerging micropollutants have attracted considerable attention in recent years due to their high detected concentration in water systems. It results in environmental issues partly due to the formation of toxic by-products during the disinfection process in water treatment. Consequently, various approaches have been investigated by researchers in order to achieve ICM total mineralization. This review discusses the different methods that have been used to degrade them, with special attention to the mineralization yield and to the nature of formed by-products. The problem of pollution by ICM is discussed in the first part dedicated to the presence of ICM in the environment and its consequences. In the second part, the processes for ICM treatment including biological treatment, advanced oxidation/reductive processes, and coupled processes are reviewed in detail. The main results and mechanisms involved in each approach are described, and by-products identified during the different treatments are listed. Moreover, based on their efficiency and their cost-effectiveness, the prospects and process developments of ICM treatment are discussed.

Occurrence and Quantitative Microbial Risk Assessment of Methicillin-Resistant Staphylococcus aureus (MRSA) in a Sub-Catchment of the Yodo River Basin, Japan

The occurrence of Staphylococcus aureus (S. aureus) and methicillin-resistant S. aureus (MRSA) in a sub-catchment of the Yodo River Basin, a representative water system of a drinking water source in Japan, was investigated. The chromogenic enzyme-substrate medium method was used for the detection of S. aureus and MRSA by the presence or absence of antimicrobials in the medium for viable bacteria in a culture-based setting. The contributions of S. aureus and MRSA from wastewater to the rivers were estimated based on mass flux-based analysis, and quantitative microbial risk assessment (QMRA) was further conducted for S. aureus and MRSA in river environments. The mean abundance of S. aureus and MRSA was 31 and 29 CFU/mL in hospital effluent, 124 and 117 CFU/mL in sewage treatment plant (STP) influent, 16 and 13 CFU/mL in STP effluent, and 8 and 9 CFU/mL in river water, respectively. Contribution of the pollution load derived from the target STP effluent to river water ranged from 2% to 25%. The QMRA showed that to achieve the established health benchmarks, the drinking water treatment process would need to yield 1.7 log10 and 2.9 log10 inactivation in terms of infection risk and disability-adjusted life year (DALY) indexes, respectively. These findings highlight the link between medical environment and the importance of environmental risk management for antimicrobial-resistant bacteria in aquatic environments.

Distribution and characteristics of carbapenem-resistant and extended-spectrum β-lactamase (ESBL) producing Escherichia coli in hospital effluents, sewage treatment plants, and river water in an urban area of Japan

Occurrence of profiles of the carbapenem-resistant Escherichia coli (CRE-E) and extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (ESBL-E) in an urban river in a sub-catchment of the Yodo River Basin, one of the representative water systems of Japan was investigated. We conducted seasonal and year-round surveys for the antimicrobial-resistant bacteria (AMRB) and antimicrobial-resistance genes (AMRGs) in hospital effluents, sewage treatment plant (STP) wastewater, and river water; subsequently, contributions to wastewater discharge into the rivers were estimated by analyses based on the mass flux. Furthermore, the characteristics of AMRB in the water samples were evaluated on the basis of antimicrobial susceptibility tests. CRE-E and ESBL-E were detected in all water samples with mean values 11 and 1900 CFU/mL in the hospital effluent, 58 and 4550 CFU/mL in the STP influent, not detected to 1 CFU/mL in the STP effluent, and 1 and 1 CFU/mL in the STP discharge into the river, respectively. Contributions of the pollution load derived from the STP effluent discharged into the river water were 1 to 21%. The resistome profiles for bla_IMP, bla_TEM, and bla_CTX-M genes in each water sample showed that AMRGs were not completely removed in the wastewater treatment process in the STP, and the relative abundances of bla_IMP, bla_TEM, and bla_CTX-M genes were almost similar (P<0.05). Susceptibility testing of antimicrobial-resistant E. coli isolates showed that CRE-E and ESBL-E detected in wastewaters and river water were linked to the prevalence of AMRB in clinical settings. These results suggest the importance of conducting environmental risk management of AMRB and AMRGs in the river environment. To our knowledge, this is the first detailed study that links the medical environment to CRE-E and ESBL-E for evaluating the AMRB and AMRGs in hospital effluents, STP wastewater, and river water at the basin scale on the basis of mass flux as well as the contributions of CRE-E and ESBL-E to wastewater discharge into the river.

Comprehensive assessment of chemical residues in surface and wastewater using passive sampling, chemical, biological, and fish behavioral assays

Effluents from ten full-scale municipal wastewater treatment plants (WWTPs) that discharge into the Hudson River, surface waters, and wild-caught fish samples were analyzed using liquid chromatography with tandem mass spectrometry (LC/MS/MS) to examine the influence of wastewater discharge on the concentrations of contaminants of emerging concern (CECs) and their ecological impacts on fish. Analysis was based on targeted detection of 41 pharmaceuticals, and non-targeted analysis (suspect screening) of CECs. Biological effects of treated WWTP effluents were assessed using a larval zebrafish (Danio rerio) swimming behavior assay. Concentrations of residues in surface waters were determined in grab samples and polar organic chemical integrative samplers (POCIS). In addition, vitellogenin peptides, used as biomarkers of endocrine disruption, were quantified using LC/MS/MS in the wild-caught fish plasma samples. Overall, 94 chemical residues were identified, including 63 pharmaceuticals, 10 industrial chemicals, and 21 pesticides. Eight targeted pharmaceuticals were detected in 100% of effluent samples with median detections of: bupropion (194 ng/L), carbamazepine (91 ng/L), ciprofloxacin (190 ng/L), citalopram (172 ng/L), desvenlafaxine (667 ng/L), iopamidol (3790 ng/L), primidone (86 ng/L), and venlafaxine (231 ng/L). Over 30 chemical residues were detected in wild-caught fish tissues. Notably, zebrafish larvae exposed to chemical extracts of effluents from 9 of 10 WWTPs, in at least one season, were significantly hyperactive. Vitellogenin expression in male or immature fish occurred 2.8 times more frequently in fish collected from the Hudson River as compared to a reference site receiving no direct effluent input. Due to the low concentrations of pharmaceuticals detected in effluents, it is likely that chemicals other than pharmaceuticals measured are responsible for the behavioral changes observed. The combined use of POCIS and non-target analysis demonstrated significant increase in the chemical coverage for CEC detection, providing a better insight on the impacts of WWTP effluents and agricultural practices on surface water quality.

An assessment of hospital wastewater and biomedical waste generation, existing legislations, risk assessment, treatment processes, and scenario during COVID-19

Hospitals release significant quantities of wastewater (HWW) and biomedical waste (BMW), which hosts a wide range of contaminants that can adversely affect the environment if left untreated. The COVID-19 outbreak has further increased hospital waste generation over the past two years. In this context, a thorough literature study was carried out to reveal the negative implications of untreated hospital waste and delineate the proper ways to handle them. Conventional treatment methods can remove only 50%-70% of the emerging contaminants (ECs) present in the HWW. Still, many countries have not implemented suitable treatment methods to treat the HWW in-situ. This review presents an overview of worldwide HWW generation, regulations, and guidelines on HWW management and highlights the various treatment techniques for efficiently removing ECs from HWW. When combined with advanced oxidation processes, biological or physical treatment processes could remove around 90% of ECs. Analgesics were found to be more easily removed than antibiotics, β-blockers, and X-ray contrast media. The different environmental implications of BMW have also been highlighted. Mishandling of BMW can spread infections, deadly diseases, and hazardous waste into the environment. Hence, the different steps associated with collection to final disposal of BMW have been delineated to minimize the associated health risks. The paper circumscribes the multiple aspects of efficient hospital waste management and may be instrumental during the COVID-19 pandemic when the waste generation from all hospitals worldwide has increased significantly.

Hazardous drugs (NIOSH's list-group 1) in healthcare settings: Also a hazard for the environment?

Healthcare workers can be exposed to dangerous drugs during their daily practice. The National Institute for Occupational Safety and Health (NIOSH) considers "hazardous drugs" as those that had shown one or more of the following characteristic in studies with animals, humans or in vitro systems: carcinogenicity, teratogenicity or other toxicity for development, reproductive toxicity, organ toxicity at low doses, or genotoxicity. In the actual list (draft list 2020), drugs classified in group 1 are those with carcinogenic effects. Moreover, the global human and veterinary cancer is expected to grow, so antineoplastic drug consumption may consequently grow, leading to an increase of anticancer pharmaceuticals in the environment. Not all drugs pertaining to group 1 can be classified as "antineoplastic" or "cytostatic". Since most of the research on environment presence and ecotoxicological effects of pharmaceuticals has been focused on this therapeutic class, other carcinogenic drugs belonging to different therapeutic groups may have been omitted in previous studies. In this study we aim to review the presence in the environment of the hazardous drugs (NIOSH group 1) and their possible environmental impact. Of the 90 drugs considered, there is evidence of presence in the environment for 19. Drugs with more studies reporting positive detections are: the antibiotic chloramphenicol (55), the alkylating agents cyclophosphamide (39) and ifosfamide (30), and the estrogen receptor modulator tamoxifen (18). Although the original purpose of the NIOSH list and related documents is to provide guidance to healthcare professionals in order to adequately protect them from the hazards posed by these drugs in healthcare settings, we believe they can be useful for environmentalists too. Absence of data regarding the potential of environmental risk of certain hazardous drugs might tell us which drugs ought to be prioritized in the future.

A Fully Automated Online SPE-LC-MS/MS Method for the Determination of 10 Pharmaceuticals in Wastewater Samples

The increasing use of pharmaceuticals, their presence in the aquatic environment, and the associated toxic effects, have raised concerns in recent years. In this work, a new multi-residue analytical method was developed and validated for the determination of 10 pharmaceuticals in wastewaters using online solid-phase extraction (online SPE) and liquid chromatography-tandem mass spectrometry (LC-MS/MS). The compounds included in the method were antineoplastics (cabazitaxel, docetaxel, doxorubicin, etoposide, irinotecan, methotrexate, paclitaxel, and topotecan), renin inhibitors (aliskiren), and antidepressants (maprotiline). The method was developed through several experiments on four online SPE cartridges, three reversed phase chromatography columns, and four combinations of mobile phase components. Under optimal conditions, very low limits of detection (LODs) of 1.30 to 10.6 ng L⁻¹ were obtained. The method was repeatable, with relative standard deviations (RSD, %) for intraday and interday precisions ranged from 1.6 to 7.8 and from 3.3 to 13.2, respectively. Recovery values ranged from 78.4 to 111.4%, indicating the reproducibility of the method. Matrix effects were mainly presented as signal suppression, with topotecan and doxorubicin being the two most affected compounds (31.0% signal suppression). The proposed method was successfully applied to hospital effluents, detecting methotrexate (4.7–9.3 ng L⁻¹) and maprotiline (11.2–23.1 ng L⁻¹). Due to the shorter overall run time of 15 min, including sample preparation, and reduced sample volume (0.9 mL), this on-line SPE-LC-MS/MS method was extremely convenient and efficient in comparison to the classical off-line SPE method. The proposed method was also highly sensitive and can be used for ultratrace quantification of the studied pharmaceuticals in wastewaters, providing useful data for effective environmental monitoring.

Upgrading residues from wastewater and drinking water treatment plants as low-cost adsorbents to remove extracellular DNA and microorganisms carrying antibiotic resistance genes from treated effluents

Wastewater treatment is challenged by the continuous emergence of chemical and biological contaminants. Disinfection, advanced oxidation, and activated carbon technologies are accessible in high-income countries to suppress them. Low-cost, easily implementable, and scalable solutions are needed for sanitation across regions. We studied the properties of low-cost absorbents recycled from drinking water and wastewater treatment plant residues to remove environmental DNA and xenogenetic elements from used water. Materials characteristics and DNA adsorption properties of used iron-oxide-coated sands and of sewage-sludge biochar obtained by pyrolysis of surplus activated sludge were examined in bench-scale batch and up-flow column systems. Adsorption profiles followed Freundlich isotherms, suggesting a multilayer adsorption of nucleic acids on these materials. Sewage-sludge biochar exhibited high DNA adsorption capacity (1 mg g^-1) and long saturation breakthrough times compared to iron-oxide-coated sand (0.2 mg g^-1). Selected antibiotic resistance genes and mobile genetic elements present on the free-floating extracellular DNA fraction and on the total environmental DNA (i.e., both extra/intracellular) were removed at 85% and 97% by sewage-sludge biochar and at 54% and 66% by iron-oxide-coated sand, respectively. Sewage-sludge biochar is attractive as low-cost adsorbent to minimize the spread of antimicrobial resistances to the aquatic environment while strengthening the role of sewage treatment plants as resource recovery factories.

Comprehensive review on iodinated X-ray contrast media: Complete fate, occurrence, and formation of disinfection byproducts

Iodinated contrast media (ICM) are drugs which are used in medical examinations for organ imaging purposes. Wastewater treatment plants (WWTPs) have shown incapability to remove ICM, and as a consequence, ICM and their transformation products (TPs) have been detected in environmental waters. ICM show limited biotransformation and low sorption potential. ICM can act as iodine source and can react with commonly used disinfectants such as chlorine in presence of organic matter to yield iodinated disinfection byproducts (IDBPs) which are more cytotoxic and genotoxic than conventionally known disinfection byproducts (DBPs). Even highly efficient advanced treatment systems have failed to completely mineralize ICM, and TPs that are more toxic than parent ICM are produced. This raises issues regarding the efficacy of existing treatment technologies and serious concern over disinfection of ICM containing waters. Realizing this, the current review aims to capture the attention of scientific community on areas of less focus. The review features in depth knowledge regarding complete environmental fate of ICM along with their existing treatment options.

Geo-referenced simulation of pharmaceuticals in whole watersheds: application of GREAT-ER 4.1 in Germany

The geo-referenced regional exposure assessment tool for European rivers (GREAT-ER) is designed to support river basin management or the implementation process within the EU Water Framework Directive by predicting spatially resolved exposure concentrations in whole watersheds. The usefulness of the complimentary application of targeted monitoring and GREAT-ER simulations is demonstrated with case studies for three pharmaceuticals in selected German watersheds. Comparison with monitoring data corroborates the capability of the probabilistic model approach to predict the expected range of spatial surface water concentrations. Explicit consideration of local pharmaceutical emissions from hospitals or private doctor's offices (e.g., for X-ray contrast agents) can improve predictions on the local scale without compromising regional exposure assessment. Pharmaceuticals exhibiting low concentrations hardly detectable with established analytical methods (e.g., EE2) can be evaluated with model simulations. Management scenarios allow for a priori assessment of risk reduction measures. In combination with targeted monitoring approaches, the GREAT-ER model can serve as valuable support tool for exposure and risk assessment of pharmaceuticals in whole watersheds.

Detailed characterization, antibiotic resistance and seasonal variation of hospital wastewater

This study investigates the presence of the different classes of micro-pollutants such as pharmaceutical active compounds (PhACs) (20 antibiotics, 8 analgesics and anti-inflammatories, 5 cytostatic agents, 7 β-blockers, 4 lipid regulators, 13 psychiatrics, 1 antidiabetic, 1 receptor antagonist, 1 local anaesthetic, 1 antihypertensive and their 5 metabolites), hormones (8 compounds), X-ray contrast agents (6 compounds), benzotriazoles (3 compounds) and pesticides (6 compounds), and antibiotic resistance in hospital wastewater (HWW) of a medical faculty in Istanbul, Turkey. In addition, the seasonal variations of the selected PhACs and X-ray contrast agents and antibiotic resistance were evaluated for 2 years in a total of eight samples. In the PhACs, sulfamethoxazole and its metabolite (4 N-acethyl-sulfamethoxazole) in the antibiotic group and paracetamol in the analgesic and anti-inflammatory group were found at 100% of frequency and the highest concentrations as 35, 43 and 210 μg/L, respectively. The mean concentrations of psychiatric compounds were found less than 0.25 μg/L except carbamazepine (1.36 μg/L). Bisphenol A in hormone group had the highest concentration up to 14 μg/L. In the hormone group compounds, 17-α-Ethinylestradiol and 17-β-Estradiol were detected at lower mean concentrations of 0.2 and 0.05 μg/L, respectively. 1H-benzotriazole had the highest concentration with the mean concentration of 24.8 μg/L in benzotriazole group compounds. The compounds in X-ray contrast agents group were noted as compounds detected at the highest concentration in HWW up to 3000 μg/L. Antibiotic resistance against azithromycin, clindamycin and trimethoprim-sulfamethoxazole antibiotics was observed around 50% in the winter period. The seasonal variation was detected for the most of the investigated PhACs, especially in antibiotic group which was in line with those significant differences in antibiotic resistance rates in the studied antibiotics between winter and summer seasons.

Indicator Compounds Representative of Contaminants of Emerging Concern (CECs) Found in the Water Cycle in the United States

The presence of contaminants of emerging concern (CECs) in the aquatic environment has recently become a global issue. The very large number of CECs reported in the literature makes it difficult to interpret potential risks as well as the removal efficiencies, especially for the more recalcitrant compounds. As such, there is a need for indicator compounds that are representative of CECs detected in systems worldwide. In an effort to develop such a list, five criteria were used to address the potential for applying indicator compounds; these criteria include usage, occurrence, resistance to treatment, persistence, and physicochemical properties that shed light on the potential degradability of a class of compounds. Additional constraints applied included the feasibility of procuring and analyzing compounds. In total, 22 CECs belonging to 13 groups were selected as indicator compounds. These compounds include acetaminophen and ibuprofen (analgesic); erythromycin, sulfamethoxazole, and trimethoprim (antibiotics); diazepam and fluoxetine (antidepressants); carbamazepine (antiepileptic); atenolol and propranolol (β-blockers); gemfibrozil (blood lipid regulator); tris(2-chloroethyl)phosphate (TCEP) (fire retardant); cotinine (nicotine metabolite); atrazine, metolachlor, and N,N-diethyl-meta-toluamide (DEET) (pesticides); 17β-estradiol and cholesterol (steroids); caffeine (psychomotor stimulant); perfluorooctane sulfonate (PFOS) and perfluorooctanoic acid (PFOA) (surfactants); and iopromide (X-ray contrast agent). These thirteen groups of compounds represent CECs with the greatest resistance to treatment processes, most persistent in surface waters, and detected with significant frequency throughout the water cycle. Among the important implications of using indicator compounds are the ability to better understand the efficacy of treatment processes as well as the transport and fate of these compounds in the environment.

Threat and sustainable technological solution for antineoplastic drugs pollution: Review on a persisting global issue

In the past 20 years, the discharge of pharmaceuticals and their presence in the aquatic environment have been continuously increasing and this has caused serious public health and environmental concerns. Antineoplastic drugs are used in chemotherapy, in large quantities worldwide, for the treatment of continuously increasing cancer cases. Antineoplastic drugs also contaminate water sources and possess mutagenic, cytostatic and eco-toxicological effects on microorganisms present in the aquatic environment as well as on human health. Due to the recalcitrant nature of antineoplastic drugs, the commonly used wastewater treatment processes are not able to eliminate these drugs. Globally, various anticancer drugs are being consumed during chemotherapy in hospitals and households by out-patients. These anti-cancer agents enter the water bodies in their original form or as metabolites via urine and faeces of the out-patients or the patients admitted in hospitals. Due to its high lipid solubility, the antineoplastic drugs accumulate in the fatty tissues of the organisms. These drugs enter through the food chain and cause adverse health effects on humans due to their cytotoxic and genotoxic properties. The United States Environmental Protection Agency (US-EPA) and the Organization for Economic Cooperation and Development (OECD) elucidated new regulations for the management of hazardous pharmaceuticals in the water environment. In this paper, the role of antineoplastic agents as emerging water contaminants, its transfer through the food chain, its eco-toxicological properties and effects, technological solutions and management aspects were reviewed.

Municipal wastewater treatment targeting pharmaceuticals by a pilot-scale hybrid attached biofilm and activated sludge system (Hybas™)

A hybrid wastewater treatment process with combined attached biofilm (moving bed biofilm reactor) and activated sludge, named as Hybas™, was implemented for the treatment of municipal wastewater. The system consisted of six staged reactors in series including pre-denitrification and nitrification in the Hybas™ line and post-denitrification in a pure MBBR. In addition to the significant removal of nutrients and organic matter from municipal wastewater, Hybas™ also showed removal capacity for pharmaceuticals. Of particular interest was the enhanced removal for pharmaceuticals (i.e. X-ray contrast media) compared to other biological systems. Spiking experiments showed that the maximum removal rate constants (k, h^-1) for 10 out of the 21 investigated pharmaceuticals (including diclofenac) were observed to occur within the two aerobic Hybas ™ reactors, operated in a flow-shifting mode that allows even biofilm growth of nitrifying bacteria. In total, 14 out of the 21 pharmaceuticals were removed by more than 50% during continuous flow operation in the all Hybas™ line and post-denitrification MBBR. The calculated and estimated removal contributions of pharmaceuticals by each individual reactor were also assessed.

Environmental Remediation of Antineoplastic Drugs: Present Status, Challenges, and Future Directions

The global burden of cancer is on the rise, and as a result, the number of therapeutics administered for chemotherapy is increasing. The occupational exposure, recalcitrant nature and ecotoxicological toxicity of these therapeutics, referred to as antineoplastic (ANP) drugs, have raised concerns about their safe remediation. This review provides an overview of the environmental source of ANPs agents, with emphasis on the currently used remediation approaches. Outpatient excreta, hospital effluents, and waste from pharmaceutical industries are the primary source of ANP waste. The current review describes various biotic and abiotic methods used in the remediation of ANP drugs in the environment. Abiotic methods often generate transformation products (TPs) of unknown toxicity. In this light, obtaining data on the environmental toxicity of ANPs and its TPs is crucial to determine their toxic effect on the ecosystem. We also discuss the biodegradation of ANP drugs using monoculture of fungal and bacterial species, and microbial consortia in sewage treatment plants. The current review effort further explores a safe and sustainable approach for ANP waste treatment to replace existing chemical and oxidation intensive treatment approaches. To conclude, we assess the possibility of integrating biotic and abiotic methods of ANP drug degradation.

Assessing Emissions from Pharmaceutical Manufacturing Based on Temporal High-Resolution Mass Spectrometry Data

This study presents a nontarget approach to detect discharges from pharmaceutical production in municipal wastewater treatment plant (WWTP) effluents and to estimate their relevance on the total emissions. Daily composite samples were collected for 3 months at two WWTPs in Switzerland, measured using liquid chromatography high-resolution mass spectrometry, and time series were generated for all features detected. The extent of intensity variation in the time series was used to differentiate relatively constant domestic inputs from highly fluctuating industrial emissions. We show that an intensity variation threshold of 10 correctly classifies compounds of known origin and reveals clear differences between the two WWTPs. At the WWTP receiving wastewater from a pharmaceutical manufacturing site, (i) 10 times as many potential industrial emissions were detected as compared to the WWTP receiving purely domestic wastewater; (ii) for 11 pharmaceuticals peak concentrations, >10 μg/L and up to 214 μg/L were quantified, which are clearly above typical municipal wastewater concentrations; and (iii) a pharmaceutical not authorized in Switzerland was identified. Signatures of potential industrial emissions were even traceable at the downstream Rhine monitoring station at a >4000-fold dilution. Several of them occurred repeatedly, suggesting that they were linked to regular production, not to accidents. Our results demonstrate that small wastewater volumes from a single industry not only left a clear signature in the effluents of the respective WWTP but also influenced the water quality of one of Europe's most important river systems. Overall, these findings indicate that pharmaceutical production is a relevant emission source even in highly developed countries with a strong focus on water quality, such as Switzerland.

A direct injection liquid chromatography tandem mass spectrometry method for the kinetic study on iodinated contrast media (ICMs) removal in natural water

Iodinated contrast media (ICMs) are a class of X-ray contrast media worldwide utilized for radiographic procedures. Since they cannot be removed efficiently during water treatment, they can be found in surface and groundwater. In this work, a rapid and sensitive direct injection liquid chromatography-tandem (LC-MS/MS) method for the simultaneous analysis of seven ICMs media (iopamidol, ioxitalamic acid, diatrizoic acid, iothalamic acid, iohexol, iomeprol and iopromide) in complex aqueous matrices has been developed and validated. The MDLs for the analytes ranged from 0.7 to 21 ng L^-1 in ultrapure water, and recoveries ranged from 86 to 100% in drinking water, 85-103% in groundwater and 84-105% in WWTP effluent. A stereo-isomer for iopromide was separated. This analytic method was applied to investigate the removal of target ICMs by low pressure ultra violet light (LPUV) advanced oxidation processes with three oxidants, hydrogen peroxide, free chlorine and monochloramine in groundwater. Results showed that the addition of oxidants did not enhance attenuation of ICMs, since fluence-based decay apparent rate constants were similar (K_UV = 3.2 × 10^-3, K_UV-Cl2 = 3.6 × 10^-3 and K_UV-NH2 = 3.4 × 10^-3 10^-3 cm² mJ^-1). This yielded direct photolysis is the main mechanism to attenuate target ICMs.

Hospital wastewater treatment scenario around the globe

Wastewaters generated from hospitals contain pharmaceuticals residues, pathogens, chemical reagents, radionuclide, and other harmful matter. The wastewater characteristics, quantity, and handling methods have not only variations among countries but also within a country. Some hazardous substances of hospital wastewaters (HWWs) may have a regulatory status and should be treated accordingly while others have characteristics similar to that of domestic sewage. At a global level, guidelines do exist for treatment of these HWWs. But literatures have shown that legislation has various loopholes in implementation. This chapter outlines the current status of management and handling of HWWs around the major industrial hubs of worlds in two categories of developed (the United States, United Kingdom, and Europe) and developing (India, China, Iran, and Bangladesh) countries. Various literatures and guidelines of these countries have been referred which mainly highlight different treatment scenarios and status of coverage of HWW management guidelines.

Occurrence of anticancer drugs in the aquatic environment: a systematic review

Water contamination with pharmaceutical products is a well-studied problem. Numerous studies have demonstrated the presence of anticancer drugs in different water resources that failed to be eliminated by conventional wastewater treatment plants. The purpose of this report was to conduct a systematic review of anticancer drugs in the aquatic environment. The methodology adopted was carried out in compliance with the PRISMA guidelines. From the 75 studies that met the specific requirements for inclusion, data extracted showed that the most common anticancer drugs studied are cyclophosphamide, tamoxifen, ifosfamide and methotrexate with concentrations measured ranging between 0.01 and 86,200 ng/L. There was significant variation in the methodologies employed due to lack of available guidelines to address sampling techniques, seasonal variability and analytical strategy. The most routinely used technique for quantitative determination was found to be solid-phase extraction followed by LC-MS analysis. The lowest reported recovery percentage was 11%, and the highest limit of detection was 1700 ng/L. This indicated the inadequacy of some methods to analyse anticancer drugs and the failure to obtain reliable results. The significant heterogeneity within methodologies made it difficult to compare results and draw conclusions, nevertheless, this study aids in the extrapolation of proposed recommendations to guide future studies and reviews. Graphical abstract.

Prioritised pharmaceuticals in German estuaries and coastal waters: Occurrence and environmental risk assessment

In this study a target analysis approach with method detection limits down to 0.01 ng L^-1 was developed in order to determine ultra-trace pharmaceuticals in seawater of the German coast and their estuaries. The selection of target analytes based on a prioritisation commissioned by the German Environmental Agency considering occurrence in German surface waters, production volumes and ecotoxicological data. Using ultra-high pressure liquid chromatography coupled to a triple quadrupole mass spectrometer equipped with an electrospray ionisation source 21 prioritised pharmaceuticals out of seven therapeutical classes (antibiotics, iodinated X-ray contrast media (ICM), analgesics, lipid reducers, antiepileptics, anticonvulsants, beta-blockers) have been detected in the low to medium ng L^-1-range. The most frequently measured substance groups in the German Baltic Sea and German Bight are the ICM, represented by the non-ionic ICM iomeprol (German Bight_max: 207 ng L^-1; Baltic Sea_max: 34.5 ng L^-1) and the ionic ICM amidotrizoic acid (German Bight: 86.9 ng L^-1), respectively. The same pattern of substance distribution could be detected in the German Bight, the German Baltic Sea and their inflows with lower concentrations in the offshore region that are partly a result of dilution with marine water. Pharmaceuticals entering the estuaries and coastal regions are an environmental issue since data on the ecotoxicological effects on aquatic marine organisms is limited. Especially the antibiotics clarithromycin and sulfamethoxazole could be ecotoxicologically/environmentally critical.

Binding of iodinated contrast media (ICM) and their transformation products with hormone receptors: Are ICM the new EDCs?

Iodinated contrast media (ICM) have been detected at high concentrations (as high as about 3 μg/L) in surface water systems, and recently in fish brains and gonad. The mismatch between the polarity of ICM and the high lipid content of brain raises questions on whether their bioaccumulation is receptor-mediated. Furthermore, the structural similarity of ICM to the natural thyroid hormones thyroxine and triiodothyronine suggest potential binding of ICM to nuclear receptors in the endocrine system. Therefore, an in silico approach based on Surflex-Dock module of SYBYL was used to investigate the molecular docking of selected ICM (diatrizoic acid, iohexol, iopamidol, and iopromide). These ICM showed interaction with nuclear receptors that play key roles in endocrine regulation, including the androgen and estrogen receptors. Furthermore, the results indicate peroxisome proliferator-activated receptor gamma (PPARg) as one of the viable targets in the endocrine disrupting potential of ICM with higher Cscores for the ICM and iopromide transformation products than the reference ligand for the receptor. The data obtained from in silico calculations showed stronger binding of iohexol to the transthyretin-binding pocket compared to the natural hormones, thyroxine and triiodothyronine, suggesting the potential of ICM to act as endocrine disrupting chemicals (EDCs) in the environment.

Removal of anthracycline cytostatics from aquatic environment: Comparison of nanocrystalline titanium dioxide and decontamination agents

Anthracyclines are a class of pharmaceuticals used in cancer treatment have the potential to negatively impact the environment. To study the possibilities of anthracyclines (represented by pirarubicin and valrubicin) removal, chemical inactivation using NaOH (0.01 M) and NaClO (5%) as decontamination agents and adsorption to powdered nanocrystalline titanium dioxide (TiO2) were compared. The titanium dioxide (TiO2) nanoparticles were prepared via homogeneous precipitation of an aqueous solution of titanium (IV) oxy-sulfate (TiOSO4) at different amount (5-120 g) with urea. The as-prepared TiO2 samples were characterized by XRD, HRSEM and nitrogen physisorption. The adsorption process of anthracycline cytostatics was determined followed by high-performance liquid chromatography coupled with mass spectrometry (LC-MS) and an in-situ Diffuse Reflectance Infrared Fourier Transform Spectroscopy (DRIFTS) technique. It was found that NaClO decomposes anthracyclines to form various transformation products (TPs). No TPs were identified after the reaction of valrubicin with a NaOH solution as well as in the presence of TiO2 nanoparticles. The best degree of removal, 100% of pirarubicin and 85% of valrubicin, has been achieved in a sample with 120 grams of TiOSO4 (TIT120) and TiO2 with 60 grams (TIT60), respectively.

Occurrence of Micropollutants in Wastewater and Evaluation of Their Removal Efficiency in Treatment Trains: The Influence of the Adopted Sampling Mode

The monitoring of micropollutants in water compartments, in particular pharmaceuticals and personal care products, has become an issue of increasing concern over the last decade. Their occurrence in surface and groundwater, raw wastewater and treated effluents, along with the removal efficiency achieved by different technologies, have been the subjects of many studies published recently. The concentrations of these contaminants may vary widely over a given time period (day, week, month, or year). In this context, this paper investigates the average concentration and removal efficiency obtained by adopting four different sampling modes: grab sampling, 24-h time proportional, flow proportional and volume proportional composite sampling. This analysis is carried out by considering three ideal micropollutants presenting different concentration curves versus time (day). It compares the percentage deviations between the ideal concentration (and removal efficiencies) and the differently measured concentrations (removal efficiencies) and provides hints as to the best sampling mode to adopt when planning a monitoring campaign depending on the substances under study. It concludes that the flow proportional composite sampling mode is, in general, the approach which leads to the most reliable measurement of concentrations and removal efficiencies even though, in specific cases, the other modes can also be correctly adopted.

Environmental fate of pharmaceutical compounds and antimicrobial-resistant bacteria in hospital effluents, and contributions to pollutant loads in the surface waters in Japan

Environmental fate of 58 pharmaceutical compounds (PhCs) grouped into 11 therapeutic classes in the three different waters, hospital effluent, sewage treatment plant (STP) and river water, was estimated by combination of their quantitative concentration analysis and evaluation of their extent of contribution as loading sources. At the same time, distribution of six classes of antimicrobial-resistant bacteria (AMRB) in the same water samples was estimated by screening of individual PhC-resistant microbes grown on each specific chromogenic medium. The results indicate that 48 PhCs were detected ranged from 1 ng/L (losartan carboxylic acid) to 228 μg/L (acetaminophen sulfate) in hospital effluent, and contribution of the pollution load derived from hospital effluent to STP influent was estimated as 0.1% to 15%. On the other hand, contribution of STP effluent to river water was high, 32% to 60% for antibacterials, antipertensives and X-ray contrast media. In the cases for AMRB, detected numbers of colonies of AMRB in hospital effluent ranged from 29 CFU/mL to 1805 CFU/mL, and the estimated contribution of the AMRB pollution load derived from hospital effluent to STP influent was as low as 0.1% (levofloxacin and olmesartan) to 5.1% (N-desmethyl tamoxifen). Although the contribution of STPs as loading sources of PhCs and AMRB in surface waters was large, ozonation as an advanced water treatment system effectively removed a wide range of both PhCs and AMRB in water samples. These results suggest the importance of reducing environmental pollutant loads (not only at STPs but also at medical facilities) before being discharged into the surface waters, to both conserve water and keep the water environment safe. To our knowledge, this is the first report to show the distribution and contribution of AMRB from hospital effluent to the surface waters.

Detection of artificial sweeteners and iodinated X-ray contrast media in wastewater via LC-MS/MS and their potential use as anthropogenic tracers in flowing waters

The detection of wastewater impact on stream chemistry is often hindered by high background concentrations of ubiquitous solutes. In the present study we tested the applicability of artificial sweeteners (AS) and iodinated X-ray contrast media (ICM) as tracers to detect this impact by examining wastewater treatment plant (WWTP) effluents and surface water samples. The developed direct injection LC-MS/MS method enabled the detection of these anthropogenic micropollutants in aqueous samples down to trace level concentrations. The 2-h-composite sampling of WWTP effluent revealed fluctuating ICM concentrations between and within days with highest concentrations at the end of the week. Diatrizoic acid (DTZ) and iopromide (IOP) were the predominant ICM with concentrations up to 7 μg/L. Concentrations of the AS acesulfame (ACE) fluctuated between 0.5 μg/L and 1 μg/L. Concentrations of AS and ICM in surface water were both associated with wastewater impact. DTZ contamination was more widespread whereas some sampling points exhibited a more pronounced contamination with non-ionic ICM. Surface water was frequently contaminated with AS. Particularly ACE was detected in every surface water sample indicating that it is chemically stable and that inputs to the aquatic environment via WWTP effluents are widespread. The broad application of ACE as food additive enables its application as a tracer throughout Germany. Furthermore, the developed LC-MS/MS method enables rapid detection of ACE down to the low ng/L-range. Nonetheless, DTZ or IOP could be used in addition to ACE to verify anthropogenic influences on natural waters.

Iohexol Degradation by Biogenic Palladium Nanoparticles Hosted in Anaerobic Granular Sludge

To improve the degradation ability of anaerobic granular sludge (AGS) toward the iodinated contrast media (ICM) iohexol, biogenic nanoscale palladium (Pd) was formed in AGS via microbial reduction. The Pd hosted in AGS (Pd-AGS) was used for iohexol degradation. The effects of the electron donor, reaction medium, iodide ion fouling, and polymer embedding of the Pd-AGS on the reactivity were investigated. Our results showed the Pd-AGS increased the degradation rate of iohexol, with a conversion rate constant increased by 86.3-fold compared to the AGS control. Various organic compounds were investigated as electron donors to initiate the catalytic activity of Pd-AGS and the promotion achieved with the tested electron donors was in the following order: formate > lactate > ethanol > glucose > acetate. The Pd-AGS had high reactivity in deionized water at mild pH, and almost no reactivity under acidic (pH = 1.2) and alkaline (pH > 11) conditions. The presence of iodide ions in the medium inhibited the catalytic activity of Pd-AGS toward iohexol because of catalyst fouling. Embedding the Pd-AGS in alginate, chitosan, or polyvinyl alcohol (PVA) could prevent Pd loss but it also retarded the iohexol degradation rate. The Pd-AGS, as a combination of Pd catalyst and AGS, provides a novel strategy for iohexol degradation in polluted water and wastewater.

A case study to identify priority cytostatic contaminants in hospital effluents

This study analyses the presence of 17 cytostatic agents from seven different groups, based on their different mechanisms of action, in the effluent from a medium-sized hospital located in eastern Spain. Analysis of the compounds found in the effluents studied involved solidphase extraction (SPE) coupled on-line to a high performance liquid chromatograph tandem mass spectrometer (HPLC-MS/MS). The environmental risk of the compounds studied was then assessed by calculating the hazard quotient (HQ), combining the measured environmental concentrations (MECs) with dose-response data based on the predicted no effect concentrations (PNECs). In addition, the environmental hazard associated was evaluated in accordance with their intrinsic characteristics by calculating the PBT (Persistence Bioaccumulation Toxicity) index. The results of this study showed the presence of seven of the 17 compounds analysed in a range of between 25 and 4761 ng/L. The highest concentrations corresponded to ifosfamide (58-4761 ng/L), methotrexate (394-4756 ng/L) and cyclophosphamide (46-3000 ng/L). Assessment of the environmental hazard showed that the three hormonal agents (tamoxifen and its metabolites endoxifen and hydroxytamoxifen) exhibited a maximum PBT value of 9 due to their inherent harm to the environment resulting from their characteristics of persistence, bioaccumulation and toxicity. A combined evaluation of the risk and environmental hazard showed that three of the 17 compounds studied, namely, ifosfamide, imatinib and irinotecan, all of which exhibited HQ values higher than 10 and PBT indices of 6, indicative of a particularly high potential to harm the environment, deserve special attention.

Consumption-based approach for pharmaceutical compounds in a large hospital

Hospital wastewater contains a great variety of pharmaceutical compounds (PhCs), mainly due to excretion by patients. These PhCs, called emerging pollutants, are not fully eliminated in treatment plants, and are consequently detected in various environmental matrices, contributing to bacterial resistance and adverse environmental impacts on water resources. This study explores a consumption-based approach to predict the contribution of PhCs to a Brazilian hospital's wastewater. This approach identifies the consumption of major pharmaceutical classes in the studied hospital. Overall, this approach demonstrates a unique opportunity to screen PhCs used in hospitals and identify priority pollutants in hospital wastewater.

Iohexol degradation in wastewater and urine by UV-based Advanced Oxidation Processes (AOPs): Process modeling and by-products identification

In this work, an Iodinated Contrast Medium (ICM), Iohexol, was subjected to treatment by 3 Advanced Oxidation Processes (AOPs) (UV, UV/H₂O₂, UV/H₂O₂/Fe²⁺). Water, wastewater and urine were spiked with Iohexol, in order to investigate the treatment efficiency of AOPs. A tri-level approach has been deployed to assess the UV-based AOPs efficacy. The treatment was heavily influenced by the UV transmittance and the organics content of the matrix, as dilution and acidification improved the degradation but iron/H₂O₂ increase only moderately. Furthermore, optimization of the treatment conditions, as well as modeling of the degradation was performed, by step-wise constructed quadratic or product models, and determination of the optimal operational regions was achieved through desirability functions. Finally, global chemical parameters (COD, TOC and UV-Vis absorbance) were followed in parallel with specific analyses to elucidate the degradation process of Iohexol by UV-based AOPs. Through HPLC/MS analysis the degradation pathway and the effects the operational parameters were monitored, thus attributing the pathways the respective modifications. The addition of iron in the UV/H₂O₂ process inflicted additional pathways beneficial for both Iohexol and organics removal from the matrix.

Biological and photochemical degradation of cytostatic drugs under laboratory conditions

Cytostatic drugs, used in chemotherapy, have emerged as new environmental contaminants due to their recurrent presence in surface waters and genotoxic effects. Yet, their degradability and environmental fate is largely unknown. The aim of this study was to determine the degradation kinetics of 16 cytostatic drugs, prioritized according to their usage and occurrence in hospital and wastewater treatment plants (WWTP) effluents, through the following laboratory scale processes: hydrolysis, aerobic biodegradation, UV-C photolysis, UV-C/H₂O₂ and simulated solar radiation. Some drugs were unstable in milli-Q water (vincristine, vinblastine, daunorubicin, doxorubicin and irinotecan); others were photodegraded under UV-C light (melphalan and etoposide) but some others were found to be recalcitrant to biodegradation and/or UV-C, making necessary the use of advanced oxidation processes (AOPs) such as UV-C/H₂O₂ for complete elimination (cytarabine, ifosfamide and cyclophosphamide). Finally, radiation in a solar box was used to simulate the fate of cytostatic drugs in surface waters under natural radiation and complete removal was not observed for any drug. The degradation process was monitored using liquid chromatography coupled to high resolution mass spectrometry and pseudo-first order kinetic degradation constants were calculated. This study provides new data on the degradability of cytostatic compounds in water, thus contributing to the existing knowledge on their fate and risk in the environment.

Photo-Fenton and Fenton-like processes for the treatment of the antineoplastic drug 5-fluorouracil under simulated solar radiation

In the present study, photo-Fenton and Fenton-like processes were investigated for the degradation and mineralization of the antineoplastic drug 5-fluorouracil (5-FU). For the optimization of photo-Fenton treatment under simulated solar light (SSL) radiation, the effects of several operating parameters (i.e., 5-FU concentration, Fe³⁺, and oxidant concentration) on the treatment efficiency were studied. According to the results, SSL/[Fe(C₂Ο₄)₃]^3-/Η₂Ο₂ process was the most efficient, since faster degradation of 5-FU and higher mineralization percentages were achieved. All the applied processes followed quite similar transformation routes which include defluorination-hydroxylation as well as pyrimidine ring opening, as demonstrated by the transformation products identified by high resolution mass spectrometry analysis. The toxicity of the treated solutions was evaluated using the Microtox assay. In general, low toxicity was recorded for the initial solution and the solution at the end of the photocatalytic treatment, while an increase in the overall toxicity was observed only at the first stages of SSL/Fe³⁺/Η₂Ο₂ and SSL/Fe³⁺/S₂O₈^2- processes.

Removal of Antibiotics in Biological Wastewater Treatment Systems-A Critical Assessment Using the Activated Sludge Modeling Framework for Xenobiotics (ASM-X)

Many scientific studies present removal efficiencies for pharmaceuticals in laboratory-, pilot-, and full-scale wastewater treatment plants, based on observations that may be impacted by theoretical and methodological approaches used. In this Critical Review, we evaluated factors influencing observed removal efficiencies of three antibiotics (sulfamethoxazole, ciprofloxacin, tetracycline) in pilot- and full-scale biological treatment systems. Factors assessed include (i) retransformation to parent pharmaceuticals from e.g., conjugated metabolites and analogues, (ii) solid retention time (SRT), (iii) fractions sorbed onto solids, and (iv) dynamics in influent and effluent loading. A recently developed methodology was used, relying on the comparison of removal efficiency predictions (obtained with the Activated Sludge Model for Xenobiotics (ASM-X)) with representative measured data from literature. By applying this methodology, we demonstrated that (a) the elimination of sulfamethoxazole may be significantly underestimated when not considering retransformation from conjugated metabolites, depending on the type (urban or hospital) and size of upstream catchments; (b) operation at extended SRT may enhance antibiotic removal, as shown for sulfamethoxazole; (c) not accounting for fractions sorbed in influent and effluent solids may cause slight underestimation of ciprofloxacin removal efficiency. Using tetracycline as example substance, we ultimately evaluated implications of effluent dynamics and retransformation on environmental exposure and risk prediction.

Predicted and measured concentrations of pharmaceuticals in hospital effluents. Examination of the strengths and weaknesses of the two approaches through the analysis of a case study

This study deals with the chemical characterization of hospital effluents in terms of the predicted and measured concentrations of 38 pharmaceuticals belonging to 11 different therapeutic classes. The paper outlines the strengths and weaknesses of the two approaches through an analysis of a case study referring to a large hospital. It highlights the observed (and expected) ranges of variability for the parameters of the adopted model, presents the results of an uncertainty analysis of direct measurements (due to sampling mode and frequency and chemical analysis) and a sensitivity analysis of predicted concentrations (based on the annual consumption of pharmaceuticals, their excretion rate and annual wastewater volume generated by the hospital). Measured concentrations refer to two sampling campaigns carried out in summer and winter in order to investigate seasonal variability of the selected compounds. Predicted concentrations are compared to measured ones in the three scenarios: summer, winter and the whole year. It was found that predicted and measured concentrations are in agreement for a limited number of compounds (namely atenolol, atorvastatin and hydrochlorothiazide), and for most compounds the adoption of the model leads to a large overestimation in all three periods. Uncertainties in predictions are mainly due to the wastewater volume and excretion factor, whereas for measured concentrations, uncertainties are mainly due to sampling mode.

Tracer tests and uncertainty propagation to design monitoring setups in view of pharmaceutical mass flow analyses in sewer systems

The development of a strategic approach to manage pollution of surface waters with pharmaceutical residues is in centre of interest in Europe. In this context a lack of reliable standard procedures for sampling and subsequent assessment of pharmaceutical mass flows in the water cycle has been identified. Authoritative assessment of relevant substance concentrations and flows is essential for environmental risk assessments and reliable efficiency analysis of measures to reduce or avoid emissions of drugs to water systems. Accordingly, a detailed preparation of monitoring campaigns including an accuracy check for the sampling configuration provides important information on the reliability of the gathered data. It finally supports data analysis and interpretation for evaluations of the efficiency of measures as well as for cost benefit assessments. The precision of mass flow balances is expected to be particularly weak when substances with high short-term variations and rare upstream emissions are considered. This is especially true for substance flow analysis in sewers close to source because of expectable highly dynamic flow conditions and emission patterns of pollutants. The case study presented here focusses on the verification of a monitoring campaign in a hospital sewer in Luxembourg. The results highlight the importance for a priori accuracy checks and provide a blueprint for well-designed monitoring campaigns of pharmaceutical trace pollutants on the one hand. On the other hand, the study provides evidence that the defined and applied continuous flow proportional sampling procedure enables a representative monitoring of short-term peak loads of the x-ray contrast media iobitridol close to source.