Working with hospitals to tackle antibiotic residue in water

The WHO has identified antimicrobial resistance (AMR) as one of the main global threats to health and food security. According to the WHO report No Time to Wait, resistant bacteria already cause 700,000 deaths around the world each year. By 2050, this number could have climbed to more than 10 million deaths as a result of antibiotics no longer being effective. This is partly due to the ease with which antibiotics and resistant bacteria can become distributed through surface water. A pilot study by the Dutch Consortium Antibiotics & Pharmaceutical Residues from Water has calculated that in the Netherlands, 40% of this spread can be attributed to wastewater from hospitals. The consortium is led by AMR Insights, EWS and the sustainable pharmacy coalition, including the Dutch Generic and Biosimilar Medicines Association (BOGIN), The Dutch Association Innovative Medicines (VIG), Neprofarm and the Royal Dutch Pharmacists Association (KNMP).

Existing solutions are expensive

Hospitals in the Netherlands are aware of the problem. But at the same time, most hospitals aren’t doing enough about it according to the most recent version of the kitemark scheme Environmental Thermometer for Care Institutions and Hospitals. This is partly because existing solutions are expensive. However, a handful of hospitals have built dedicated purification systems to treat their wastewater. “These large-scale, decentralised systems are an effective solution, but they are expensive and take up a lot of space, so they only work for large hospitals,” says Irma Steemers, programme manager for Water Treatment & Technology at Wageningen Food & Biobased Research. According to her, some smaller-scale solutions are available, but there's still a lack of evidence for their effectiveness. The need for such evidence means they are not being widely implemented. The water boards are working on centralised solutions for removing micro-contaminants such as medicines. However, the technology required for this is expensive, and is only being provided for water treatment plants designated as hotspots. As such, this approach offers only a partial solution to the emergence of anti-microbial resistance. It’s therefore still useful to try and come up with decentralised solutions preventing discharge at the source.

Similarities to greenhouse horticulture

According to Steemers, the problem with pharmaceutical residues in hospital wastewater has a lot in common with the problem that until recently plagued greenhouse horticulture. Greenhouse horticulture businesses were identified as the source of large quantities of nutrients and crop protection agents running off into surface water, so in 2012 the sector took the lead in getting businesses, research institutes, and government agencies to work together on implementing a solution. This collaboration led to the introduction of affordable, certified and even mandatory water purification technologies, whereby at least 95 per cent of active ingredients are removed from the water. It’s anticipated that by 2027 this will result in the Netherlands having good quality surface water which also complies with the European Water Framework Directive.

Consortium with support from Invest.NL

Could this collective approach, echoing the experience of the greenhouse horticulture sector, be applied to hospitals? “Yes,” says Steemers. “And not just in hospitals, but also in other care facilities such as nursing homes and care homes for people with special needs. The Dutch Consortium Antibiotics and Pharmaceutical Residues from Water has started a research project, funded by Invest.NL, to assess the nature and scale of the problem among different types of care facilities. The next step will be to work with supply chain partners to come up with workable and affordable solutions that can also be easily scaled up or down.”

The Dutch Consortium Antibiotics and Pharmaceutical Residues from Water currently has 18 members from the water sector, healthcare sector and pharmaceuticals sector, along with universities and research institutes including Wageningen Food & Biobased Research. The Consortium’s initial approach to the problem will be to maximise the removal of antibiotics and pharmaceutical residues from wastewater. The pathogenic bacteria and plasmids – genetic carriers of resistance – also need to be removed from the water in order to prevent the emergence and spread of antimicrobial resistance (AMR) as much as possible. This calls for decentralised solutions to treat hospital wastewater as well as a centralised approach 'at the end of the pipe' in wastewater treatment plants. The Consortium is researching techniques to prevent antibiotics and antibiotic-resistant genes ending up in the wastewater, for example by capturing them before they are flushed away from toilets.

Training bacteria

According to Irma Steemers, the healthcare sector could match the success of the greenhouse horticulture sector: “Many of the approved chemical technologies for binding or neutralising hazardous substances are applicable to hospitals and other care facilities. In Wageningen we’re focusing in particular on hybrid and organic, environmentally friendly ways of removing pharmaceutical residues from wastewater. We have a platform with various bacterial strains which we can train to break down the most recalcitrant substances and neutralise them. To do this, we start by letting the bacteria get used to those substances in the lab. What you then see is that each subsequent generation of bacteria gets better at it. The first laboratory results with pharmaceutical residues are very promising. As part of the Consortium, we’ve applied for a Top Sector grant to fund further development and implementation.”