Human Pharmaceuticals in Wastewater Trea

Critical Reviews in Environmental Science and Technology, 35:401–427, 2005
Copyright © Taylor & Francis Inc.

ISSN: 1064-3389 print / 1547-6537 online
DOI: 10.1080/10643380590956966
Human Pharmaceuticals in Wastewater

Treatment Processes
O. A. H. JONES, N. VOULVOULIS, and J. N. LESTER

Department of Environmental Science and Technology, Faculty of Life Sciences, Imperial
College, London, United Kingdom
The presence of human pharmaceutical compounds in surface wa-

ters is an emerging issue in environmental science. In this study
the occurrence and behavior of human pharmaceuticals in a va-
riety of wastewater treatment processes is reviewed. Although some
groups are not affected by sewage treatment processes others are
amenable to degradation, albeit incomplete. While water purifica-
tion techniques such as granular activated carbon could potentially
remove these pollutants from wastewater streams, the high cost in-
volved suggests that more attention should be given to the potential
for the optimization of current treatment processes, and reduction
at source in order to reduce environmental contamination.
KEY WORDS: fate, pharmaceuticals, pollution, sewage treatment

plants, wastewater
I. INTRODUCTION
The term “pharmaceutical” covers a wide-ranging class of compounds with

substantial variability in structures, function, behavior, and activity.27 De-
veloped to elicit a biological effect, they are used in both humans and
animals to cure disease, fight infection, and/or reduce symptoms. Many
drugs are not fully metabolized in the body and so may be excreted to
the sewer system. Numerous pharmaceutical compounds have been shown
to pass through sewage treatment plants (STPs) and contaminate the aquatic
environment.9,15,19,20,33,38,56,64,67,72,90,94,115,117,120,126,131
Address correspondence to J. N. Lester, Department of Environmental Science and

Technology, Faculty of Life Sciences, Imperial College, London, SW7 2BP, UK. E-mail:
[email protected]
401
402 O. A. H. Jones et al.
The use of other organic pollutants, such as pesticides, has fallen in

recent years as new laws have been introduced to minimize their use.23
However, even if they should prove problematic, pharmaceuticals are un-
likely to be restricted in this way, due to their beneficial human (and animal)
health effects and economic importance. Indeed, their use is expected to
grow with the increasing average age of the population and the publishing
of the human genome.25 They and their metabolites are therefore likely to
be found in the environment adjacent to human activity.107
The first reports of human drugs in the environment appeared in the
late 1970s,36,55 although it is not unreasonable to suppose that aquatic pol-
lution from medicinal compounds dates back much further.63 The growing
importance worldwide of reducing potential impacts on water supplies has
ensured that this issue has been steadily gaining attention in recent years both
within the academic community and among the general public, although it
is only with the comparatively recent advent of more reliable and sensitive
analytical techniques that detailed research in this area has become possible.
In this article the term “drugs” is taken to exclude both natural and
synthetic hormones. While these compounds are an important subgroup of
pharmaceuticals, there is already an abundance of work available in the
literature on this topic4,11,14,61,80−83,95,121,124,130
From published occurrence data, it seems probable that most if not
all urban wastewater is contaminated with medicinal compounds, differ-
ing only in the type and abundance of the substances present.24 The
existence of drugs in surface waters9,15,19,20,33,38,56,67,72,90,94,115,117,120,126,131
groundwater,1,21,32,58,89,99,103,108 and even marine systems18,115 has also been
confirmed. It is probable that the presence of these compounds stems pri-
marily from the consumption and use of such products rather than from
manufacturing.35
Medicinal compounds are generally excreted after being partially or
completely converted to water-soluble metabolites,29,42,92,98 but a significant
amount of the original substance may also be excreted unchanged.57 This
has previously been regarded as inconsequential because of the dilution re-
ceived in the sewerage system. However, recent studies on pharmaceutical
residues (primarily in Germany) have demonstrated that elimination of high
to medium polar pharmaceuticals in municipal STPs is often incomplete,
ranging between 60 and 90%.116,117,120 One of the most comprehensive stud-
ies of this type was performed by Kolpin et al.72 who chronicled the de-
tection of over 95 organic chemicals in U.S. streams and rivers. Measured
concentrations from this study were generally low (nanograms per liter) and
rarely exceeded drinking-water guidelines, drinking-water health advisories,
or aquatic-life criteria, although it is worth noting that no such guidelines
have been established for the majority of pharmaceutical compounds de-
tected. The detection of multiple organic pollutants was relatively common
in this study, with a median of 7 and as many as 38 compounds being found
Pharmaceuticals in Wastewater Treatment Processes 403
in a given water sample. These results demonstrate the importance of ob-

taining data on metabolites as well as parent compounds in order to fully
understand the fate and transport of individual pollutants in the hydrological
cycle.
Compounds having relatively short half-lives would likely survive in
only the freshest of sewage sludge samples,7 but it is important to un-
derstand the fate and behavior of these compounds during wastewater
treatment in order to assess the likely concentration of contaminants in
sludges and effluents, and hence their potential contribution to the pollu-
tion of the environment. Some drugs may be removed from wastewater
by adsorption onto solids, but can then enter the aquatic environment, in
particular groundwaters, via sludge application to land, landfilling, or soil
erosion. There have been many reviews on the topic of environmental pol-
lution by drug compounds,6,25,44,50,64,96 all of which note that no quantitative
data were found on concentrations of pharmaceuticals in sewage sludge
or soil amended with sewage sludge, although some modeling has been
attempted.65,70 This is surprising, considering that this is a potential route
for lipophilic substances to the terrestrial environment. However, it is most
probably a consequence the extreme difficulty in extraction and analysis of
pollutants from sludge samples on a quantitative basis.70,101,106
II. DEGRADATION WITHIN STPs

A. Biodegradation
There is an obvious potential for biological degradation (aerobic/anaerobic
by micro-organisms) of drug substances leading to a reduction of the parent
compounds and/or their metabolites during wastewater treatment.128 Some
biodegradation may also occur during in-pipe transport to the STP, but most
will probably occur in the secondary stage of treatment when the compound
is exposed to large concentrations of micro-organisms. Biodegradation tests
can be performed following test protocols such as the closed bottle test
(OECD 301D)78 or the Zahn–Wellens test (OECD 302B).77 In general, these
tests are carried out with several hundred milligrams of a substance as the
carbon source. Therefore, they give answers for only fairly extreme condi-
tions, which, despite their intention, simulate only the maximum potential
and not the most probable environmental outcome. Therefore, conclusions
on the degradability of drugs in STPs from these tests are of limited value
and further research is necessary.76
Al-Ahmad et al.2 assessed the biodegradability of the clinically impor-
tant antibiotics cefotiam, ciprofloxacin, meropenem, penicillin G, and sul-
famethoxazole using the closed bottle test (CBT). None of the test com-
pounds met the criteria for ready biodegradability. Of all the compounds
studied, only penicillin G was found to be biodegradable to some degree,
with approximately 27% being removed after 28 days. Even when the test was
prolonged to 40 days, the removal rate was only increased to 35% indicating
the compound was relatively stable.
Kümmerer and Al-Ahmad77 used the CBT and the modified Zahn–
Wellens test (ZWT) to examine the biodegradability of the widely used anti-
tumor agents 5-fluorouracil, cytarabine, and gemcitabine. 5-Fluorouracil was
not biodegradable in either of these tests. Gemcitabine was biodegraded by
42% in the CBT, but prolonging the test period to 40 days only improved
this to 45%. Cytarabine was also partially biodegraded in the CBT (50%). In
the ZWT, the biodegradation of gemcitabine was also 50% but only after an
adaptation period of 20 days, which is not normally included in such tests.
Prolonging the test to 40 days improved the degree of biodegradation to 80%,
and in the ZWT the biodegradability was over 95%.
Henschel et al.54 investigated the biodegradability of paracetamol and
methotrexate and the two drug metabolites salicylic acid and clofibric acid.
Their results were in agreement with other studies and demonstrated that sal-
icylic acid and (to a lesser extent) paracetamol were biodegradable, whereas
clofibric acid and methotrexate were not.
Kümmerer78 studied the biodegradability of three clinically important
antibiotics (ciprofloxacin, ofloxacin, and metronidazole) and found none
of the compounds were biodegraded. As a consequence the genotoxicity
of these compounds (as measured by the SOS chromotest) remained unaf-
fected after treatment. A more comprehensive review of antibiotics in the
environment is available in Hirsch et al.57 This article describes the anal-
ysis of various water samples for 18 antibiotic substances, from several
groups, including macrolid antibiotics, sulfonamides, penicillins, and tetra-
cyclines. Both STP effluents and surface-water samples were frequently con-
taminated with sulfamethoxazole and roxithromycin (a degradation product
of erythromycin) at concentrations up to 6 µg L−1 . The highest concentra-
tions detected for tetracyclines and penicillins were 50 and 20 ng L−1 , re-
spectively. Except for two sites, no contamination by antibiotics was de-
tected from a large number of groundwater samples that were taken from
agricultural areas in Germany. This suggests that contamination of ground-
water by antibiotics from veterinary applications is relatively minor. Other
drugs that have been investigated for their biodegradability include ifos-
famide and cyclophosphamide.79,112 Both of these compounds exhibited
poor biodegradability in the CBT and the ZWT as well as in laboratory-scale
activated sludge plants.
Degradation may also occur during bank filtration, if it is used. Heberer
et al.52 found clofibric acid, phenazone, propyphenazone, diclofenac, ibupro-
fen, and fenofibrate, and two metabolites, N -methylphenacetin (probably
originating from phenacetin) and also a derivative of clofibric acid at concen-
trations up to the micrograms per liter level in groundwater samples taken
from beneath a drinking-water treatment plant. These contaminants were
found to leach from the neighboring sewage contaminated surface water by

bank filtration through the subsoil.53
Molecules with long, highly branched side chains are generally less
amenable to biodegradation than unbranched compounds with shorter side
chains.105 Unsaturated aliphatic compounds are generally more accessible to
biodegradation than saturated analogues or aromatic compounds with com-
plicated aromatic ring structures and sulfate or halogen groups.101 Examples
of the latter are the x-ray contrast media. Since these compounds are exclu-
sively utilized in human medicine, contaminated STP effluents are presum-
ably the sole sources for these compounds in the aquatic environment. The
occurrence of four iodinated x-ray contrast media (diatrizoate, iopamidol,
iopromide, and iomeprol) in eight German STPs was examined by Ternes
et al.120 These compounds were found to be ubiquitously distributed in the
raw sewage and were not significantly degraded or absorbed during the
sewage treatment processes and so remained in the aqueous phase. The
concentrations of diatrizaote, iopromide, and iomeprol frequently exceeded
1 µg L−1 in the raw sewages, and these were found at comparable concentra-
tions in the final effluents, with the maximum concentration measured being
15 µg L−1 for iopamidol.
A similar study by Steger-Hartmann et al.111 demonstrated that while
these compounds are not readily biodegradable, iopromide was amenable
to photodegradation. The resulting degradation product (5-amino-N ,N -
bis(2,3-dihydroxypropyl)-2,4,6-triiodo-N -methyliso-phthalamide) also exhib-
ited a faster rate of photolysis than the parent compound and was further
degraded in a test system simulating surface-water conditions. However, the
predicted environmental concentration (PEC) in surface water was still high
at 2 µg L−1 .
Some degradation of iopamidol in activated sludge has also been ob-
served with 85% being transformed into two metabolites.68 Degradation of
the same compound in river water was even more significant, with a half-life
of 3.1 days. However, for other, similar compounds such as diatrizoate the
half-life was longer, suggesting there is potential for some compounds to
reach rivers and lakes. Although of low toxicity, x-ray contrast media may
contribute significantly to the absorbable organic halogen compound (AOX)
load in receiving waters. This is of concern because of the high persistence,
mobility, and potential of these substances to biotransform to toxic break-
down products.
It is also possible that the biota of a STP may gradually become ac-
climatized to certain chemicals and therefore may degrade them more ef-
fectively given time.132 For instance Zwiener et al.133 investigated the bi-
ological degradation of pharmaceutical residues (clofibric acid, ibuprofen,
diclofenac). In this study both a pilot sewage plant and biofilm reactors op-
erating under oxic and anoxic conditions were run as model systems for
municipal sewage treatment, with synthetic sewage and pharmaceuticals in
concentrations of 10 µg L−1 . Clofibric acid displayed persistence in all cases.

The pilot sewage plant and the anoxic biofilm reactor showed comparable
results for diclofenac and ibuprofen, which both were partially degraded.
A high degree of degradation was found for ibuprofen in the oxic biofilm
reactor, which was attributed to adaptation of the biofilm to the residue. This
effect has also been show to occur for other compounds, for example, ni-
trilotriacetic acid, where a period of acclimatization has been shown to be
required before biodegradation can begin.102 In addition, the phenomenon
of co-metabolism—the oxidation and degradation of nongrowth substrates
by micro-organisms—is well documented.45,46
B. Deconjugation
Pharmaceutical compounds are often metabolized in the liver, and as a conse-
quence gluconoride and sulfate conjugates of the parent drugs are excreted.98
Conjugates of other organic compounds such as steroid hormones have been
shown to be readily deconjugated in domestic wastewater and within STPs
due to the large amounts of β-glucuridase enzyme present (produced by the
fecal bacterium Escherichia coli).10 It seems probable that gluconoride and
sulfate conjugates of drug compounds will be degraded by the same process.
The effect will be to increase the excreted contribution of the active drugs
to sewage and effluents.117
C. Partitioning
Partitioning between the aqueous and organic biomass phases is a key com-
ponent in determining the ultimate concentrations of organic pollutants.49
Compounds with high log K ow values are known to sorb to sludge,84 while
substances with lower values are more likely to stay in the aquatic phase, de-
pending on the individual compound,40 and substances sorbing to solids may
also be remobilized if they are not strongly bound. It is also well known that
bacterial, algal, and fungal cells are capable of adsorbing and accumulation
organic pollutants.10 The activated sludge biomass is able to adsorb organic
pollutants such as lindane, and adsorption of these compounds generally
fits the Freundlich isotherm. There is a good correlation between compound
adsorption and the octanol/water partition coefficient. However, since most
drugs are soluble with low log K ow and K oc values, they exist primarily in
the aqueous phase and transfer to sewage sludge is probably of only minor
concern for the majority of compounds.
There are few studies in the literature detailing potential sorption in-
teractions of drug compounds. Hua et al.60 studied the removal of chemi-
cal oxygen demand (COD), micro-organisms, and selected pharmaceutical
compounds by trickling wastewater through a sandy soil from the Rhine
valley in glass columns. The sewage contained low concentrations of at
least 10 different pharmaceuticals and x-ray media. Some of the compounds
were removed by adsorption onto sand and/or biodegradation. The rate

of removal varied from complete (e.g., ibuprofen and naproxen), to al-
most none, for several x-ray contrast media. Some of the compounds
were removed as effectively by this method as by conventional sewage
treatment.
Jones et al.65 estimated physicochemical values for the top 25 pharma-
ceuticals in England in 2000 using a computer model. Of the top 25 com-
pounds, 16 had low predicted sorption potential and were thought unlikely
to bind to sludge solids. Five compounds had medium sorption potential
and two (quinine sulfate and mefenamic acid) were predicted to have a high
capacity to bind to solids (no data were available for the remaining two
compounds). Although this study indicated some removal to solids for mefe-
namic acid, it did not demonstrate that all would be removed and in fact this
compound has been found to be present in sewage effluent. The concentra-
tions of mefenamic acid in three sewage effluents as well as upstream and
downstream of the effluent discharge point have been reported by Hilton and
Thomas.56 The report does not, however, quote influent concentrations, so it
is impossible to say how much was lost during treatment. For instance, if the
concentration in the influent was double the concentration in the effluent,
this would indicate a potentially high binding capacity (or biodegradation
rate). A second paper by Soulet et al.110 indicates a high degree of varia-
tion in the removal of mefenamic acid depending on the STP studied. Some
exhibited a high removal, while others showed almost none indicating the
importance of design and operational factors and/or climatic conditions. This
means a definitive conclusion cannot be reached with regard to the removal
rates of this drug within STPs, other than that it is potentially highly depen-
dent on plant design, wastewater characteristics, and, most importantly, the
operational regime.
Bester 8 studied the fate of the antimicrobial triclosan (2,4,4 -trichloro-

2 -hydroxyphenyl ether) in a German sewage treatment plant that pro-
cessed 200,000 m3 wastewater per day. The concentrations in the influent
(∼1000 ng L−1 ) were compared to those in the effluent and the sludge, and
a mass balance of the works was prepared. Thirty percent of the triclosan
was found to sorb to the sludge with weak bonds, but only about 5% of the
influent concentration was found in the effluent. Thus, most of the incoming
material was not recovered as the parent compound, and the authors sug-
gest that it is likely that it is transformed to other metabolites or unrecovered
bound residues. This compares well with a study by Singer et al.,109 who,
during a field study, attributed the fate of triclosan in a wastewater treat-
ment plant to be 79% biological degradation, 15% sorption to sludge, with
6% being discharged to the receiving surface water. Despite the high overall
removal rate, the concentration in the wastewater effluents were in the range
of 42–213 ng L−1 , leading to concentrations of 11–98 ng L−1 in the receiving
rivers.
A recent review of veterinary drugs by Tolls127 suggests that mecha-

nisms other than hydrophobic partitioning play a significant role in sorption
of animal (and potentially human) medications. A number of hydrophobicity-
independent mechanisms such as cation exchange, cation bridging at clay
surfaces, surface complexation, and hydrogen bonding also appear to be
involved. These processes are not accounted for by organic carbon normal-
ization, suggesting that this data treatment is conceptually inappropriate and
fails to describe the sorption behavior. In addition, some drug compounds
may be anions at the pH values in STPs and the environment. This will lower
the effective Kow and decrease their sorption potential.
D. Removal During Sludge Treatment

Drugs may also be degraded during sewage treatment processes. Many phar-
maceuticals are not thermally stable118 and so might be expected to break
down during processes such as composting due to heat (as well as chemical
and biodegradation). A study by Guerin43 investigated soil composting as
an alternative to incineration for the treatment of a silty clay soil that had
become contaminated with residues of Probenecid (an antigout drug) and
Methaqualone (a barbiturate substitute no longer available due to harmful
side effects). In pilot scale trials, Probenecid was reduced from 5100 mg kg−1
to <10 mg kg−1 within 20 weeks during mesophilic treatments. The study also
confirmed that thermophilic composting was effective under field conditions.
In the full-scale treatment, 180 tons of soil were composted. Initial concentra-
tions of the major contaminants in the full-scale compost treatment facility for
Probenecid and Methaqualone were 1160 mg kg−1 and 210 mg kg−1 , respec-
tively. Probenecid concentration reached the target level of 100 mg kg−1 in
6 weeks, and removal of Methaqualone to <100 mg kg−1 was achieved after
14 weeks. The study concluded that composting was effective in reducing
soil concentrations of Probenecid and Methaqualone residues to acceptable
values and hence is a technology that has potential application in the remedi-
ation of pharmaceutical contaminants in sludge/soil, although further testing
using other drug compounds and soils would be necessary.
E. Photodegradation
Several pharmaceutical compounds have been shown to degrade due to the
action of sunlight.12,97 The most extensively studied of these compounds is
the analgesic/anti-inflammatory drug diclofenac, which has been shown to
degrade in the aquatic environment due to ultraviolet (UV) light. Other com-
pounds such as the topical antimycotic drugs naftifine, sulbentine, cloxiquin,
tolnaftate, and chlorphenesin have also been shown to be light sensitive,125
and an overall elimination rate of 0.03 day−1 due to photochemical degra-
dation was observed for triclosan in the epilimnion of Lake Greifensee by
Singer et al.109
Andreozzi et al.5 carried out a monitoring survey of STP effluents in

Italy, France, Greece, and Sweden and found more than 20 individual phar-
maceuticals. The photodegradation of six compounds (carbamazepine, di-
clofenac, clofibric acid, ofloxacin, sulfamethoxazole, and propranolol) was
tested. Carbamazepine and clofibric acid were found to have the longest half-
lives (of the order of 100 days at the most northerly areas sampled), whereas
sulfamethoxazole, diclofenac, ofloxacin, and propranolol were found to un-
dergo faster degradation with half-lives of 2.4, 5.0, 10.6, and 16.8 days, re-
spectively. For almost all the studied compounds, except propranolol, the
presence of nitrate ions in aqueous solutions resulted in a reduction of the
measured half life. This effect may be ascribed to the formation of HO radicals
due to photolysis of nitrate. The authors point out that besides pharmaceutical
residues, other species targeted by OH radicals, such as naturally occurring
organic constituents, are present in rivers and lakes. For this reason, the ef-
fect caused by nitrate on the degradation rates of the pharmaceuticals found
in this study should be interpreted only as a tendency if no other organic
molecules but the substrate are present in the test solution.
A more complex situation arose when humic acids were added to the
solutions containing the pharmaceuticals. Humic acids are known to exert
two opposite effects on the rate of photodegradation of organic molecules
in water. Due to their capability to absorb UV radiation in a broad range of
wavelengths, they can reduce the available energy for the organic molecules
present in the solution, thus acting as an inner filter (thus decreasing pho-
todegradation). At the same time, the molecules of humic acids submitted
to UV irradiation are promoted to a transient, excited state, in which they
may react with oxygen in the solution, forming reactive species as singlet
oxygen, or react directly with other organic species, thus promoting their
phototransformation. The overall effect of humic acids on the phototrans-
formation rate of an organic substance will therefore depend on the bal-
ance between these two opposite contributions. In the study, humic acids
were found to act as inner filters toward carbamazepine and diclofenac, but
as photosensitizers toward sulfamethoxazole, clofibric acid, oflaxocin, and
propranolol.
Buser et al.19 established that up to 90% of diclofenac entering a Swiss
lake was degraded with a half-life of less than 1 h−1 . Incubation of lake
water, fortified with diclofenac, exhibited no reduction in the dark, suggest-
ing minimal chemical and biological degradation. However, when the for-
tified water was exposed to sunlight, rapid degradation was observed that
indicated that this was the result of photodegradation. The use of sewage
lagoons may therefore increase the removal of light sensitive compounds
as demonstrated by Kreuzinger et al.,74 who showed that removal rates of
diclofenac were only 14% with just activated sludge treatment, while after
further polishing in a sewage lagoon concentrations decreased to below the
limits of detection. Adsorption and biodegradation were ruled out as the
cause of the decrease, as there was no developed/active sludge flock in the

lagoon, leaving photodegradation as the most likely cause.
Latch et al.85 studied the photochemical fates of the histamine H2 -
receptor antagonists cimetidine and ranitidine. Each displayed high rates of
reaction with both single oxygen and hydroxyl radicals, with two transient
oxidants being formed in sunlit natural waters. Ranitidine was degraded in
direct photolysis experiments with a half-life of 35 min under noon sum-
mertime sunlight at 45◦ latitude, while cimetidine was shown to be resis-
tant to direct photolysis. The results of these experiments, combined with
the expected steady state near-surface concentrations of single oxygen and
hydroxyl radicals, indicate that photo-oxidation mediated by single oxygen
radicals is the likely degradation pathway for cimetidine in most natural wa-
ters, while photodegradation by direct photolysis is expected to be the major
pathway for ranitidine. However, the extent of photo-induced degradation
of pharmaceuticals can vary significantly for different pharmaceuticals, and
it strongly depends on the aqueous constituents (such as humic and fulvic
acids) present in solution.28 In addition, light levels within STPs are likely to
be much lower than in the environment (effectively zero), due to the higher
solids content. Indeed, Koutsouba et al.73 found diclofenac to be widespread
in Greek domestic sewage effluent, with concentrations in effluent ranging
from 10 to 365 ng L−1 . Given the inherent photosensitivity of this compound,
its presence in sewage effluent would seem to indicate that photodegrada-
tion is highly unlikely to take place within STPs where light penetration is
minimal at best.
III. FATE OF COMPOUNDS WITHIN SEWAGE WORKS
Because of the complexity of most environmental matrices (i.e., wastew-

ater and sludge samples), analytical techniques with very high resolving
power are needed to provide the required sensitivity and detection limits.34
Metcalfe et al.93 analyzed for residues of selected prescription and nonpre-
scription drugs in samples of influent and effluent from 18 STPs across 14
municipalities in Canada. Several neutral and acidic drugs were detected
in effluents, including analgesic/anti-inflammatory agents, lipid regulators,
and antiepileptics. Drugs such as ibuprofen and naproxen, as well as sali-
cylic acid (the metabolite of aspirin), were often detected in final effluents
at micrograms per liter concentrations. The rates of elimination of ibupro-
fen and naproxen appeared to be elevated in STPs with hydraulic reten-
tion times of over 12 h, indicating that this could be a factor in increas-
ing drug removal rates, although it is more likely factors that affect HRT
(such as SRT) were responsible for the observed effect. The lipid regula-
tor clofibric acid and the analgesic drug diclofenac were not detected in
any final effluent samples. This is not consistent with data from European
studies which often report their presence. This may reflect different pre-
scribing practices in the two areas. For instance, the precursors to clofibric
acid (e.g., clofibrate) are not widely prescribed for use as lipid regulators in
Canada.93
Soulet et al.110 studied five acidic drugs (clofibric acid, ibuprofen,
ketoprofen, mefenamic acid, and diclofenac) at three STPs in order to de-
termine their behavior during treatment. Each plant consisted of a physical
and a biological treatment stage, with one of the plants also having addi-
tional treatment before the biological treatment stage. In addition, two of
the three received wastewater from the pharmaceutical industry. The re-
sults demonstrated that four of the pharmaceuticals (clofibric acid, ketopro-
fen, mefenamic acid, and diclofenac) are not well removed by treatment in
Swiss STPs. Indeed, although recovery rates in the influent were low (35 ±
10%, versus 86 ± 8% for the effluent), possibly due to interferences during
detection, the maximum concentration for mefenamic acid in the effluent
determined was 1.0 µg/L−1 . This level of contamination indicates it would
also be present in surface waters. However, it should be noted that the re-
moval efficiencies for this compound (as well as the others in the study)
varied depending on the STP in question. In one instance there was more
than twice the amount in the influent as there was in the effluent, while in
other cases more of the compound was found in the effluent than in the
influent, perhaps because of remobilization of previously absorbed material
from biological solids retained in the system. This indicates that removal of
these compounds is not uniform and may be dependent on a number of
factors.
Kanda et al.69 utilized a number of analytical procedures to investigate
the presence of a number of pharmaceuticals in six UK sewage treatment
works. The work established that many pharmaceuticals occurred in influent
at nanograms per liter levels and were removed by wastewater treatment
processes. Ibuprofen was detected in all influent sample as well as in all but
one effluent sample. Removal of ibuprofen by the different STPs was gen-
erally between 80 and 100%, with the exception of one STP where removal
was poor (14.4 to 44%). Similar results were also reported by Jones et al.,62
who found five drug compounds (ibuprofen, paracetamol, salbutamol, pro-
pranolol HCl, and mefenamic acid) present at nanograms per liter levels in
a large English STP.
Samples from eight STPs in southern Ontario, Canada were analyzed
by Lee et al.86 for 11 acidic drug compounds: salicylic acid, clofibric acid,
ibuprofen, acetaminophen, gemfibrozil, fenoprofen, naproxen, ketoprofen,
diclofenac, fenofibrate, and indomethacin, as well as the antibacterial agent
triclosan. While clofibric acid, acetaminophen, fenoprofen, and fenofibrate
were not detected, the other eight compounds were found in nearly all the in-
fluent and effluent samples, from low micrograms to low nanograms per liter
levels. Eight STPs removed from 0 to 98% of these drugs from the influent.
Measured concentrations of nine pharmaceutical and personal care

products (PPCPs) in samples from two surface-water bodies, a sewage treat-
ment plant effluent, and various stages of a drinking-water treatment plant
in Louisiana, and from one surface-water body, a drinking-water treatment
plant and a pilot plant in Ontario, Canada, were reported by Boyd et al.15
Naproxen was detected in Louisiana sewage treatment plant effluent at 81–
106 ng L−1 and in Louisiana and Ontario surface waters at 22–107 ng L−1 .
Triclosan was detected in Louisiana sewage treatment plant effluent at 10–
21 ng L−1 . Of the three surface waters sampled, clofibric acid was detected
in Detroit River water at 103 ng L−1 , but not in Mississippi River or Lake
Pontchartrain waters. None of the other target analytes were detected above
their method detection limits.
Based on results at various stages of treatment, conventional drinking-
water treatment processes (coagulation, flocculation and sedimentation)
plus continuous addition of powdered activated carbon at a dosage of
2 mg L−1 did not remove naproxen from Mississippi River water. How-
ever, chlorination, ozonation, and dual-media filtration processes reduced
the concentration of naproxen below the limit of detection in Mississippi
River and Detroit River waters and reduced clofibric acid in Detroit River
waters. Results of this study demonstrate that existing water treatment
technologies can effectively remove certain pharmaceuticals. In addition,
the study demonstrates the importance of obtaining data on removal
mechanisms and by-products associated with pharmaceuticals and other
endocrine-disrupting chemicals in drinking-water and sewage treatment
processes.
The most pressing concern with regard to antibiotics in the environment
is, at present, the continued spread of resistance of bacterial pathogens to
the many compounds presently used to control infections,104 a phenomenon
that may be assisted by repeated doses at the low concentrations found in
the environment.66 Antibiotics also have the potential to affect the microbial
community in sewage treatment systems, and the inhibition of wastewa-
ter bacteria has the potential to seriously affect organic matter degradation
as well as nitrification and denitrification. Although one study has shown
that bacteria isolated from treated sewage and digested sludge were gen-
erally not significantly more resistant to antibiotics than isolates from raw
sewage, others have shown the opposite.22,41,88,100,104 Therefore, the oc-
currence of antibiotics in sewage effluent and receiving waters, as well as
their potential effects on exposed microbial populations, is of interest and
concern.
Certain antibiotics may also have a toxic effect. For instance, Hartmann
et al.47 identified fluoroquinolone antibiotics as the main source of geno-
toxicity in hospital wastewater using a bacterial short-term genotoxicity as-
say, based on a umuC:lacZ fusion gene (umuC assay). The ratio of theoret-
ical mean wastewater concentrations (derived from consumption data) and
lowest-observable-effect concentrations of selected pharmaceuticals were

used to calculate umuC induction probabilities. The fluoroquinolone antibi-
otics ciproxin and noroxin exhibited the highest induction probabilities and
exceeded all other investigated drugs by at least one order of magnitude in
significance. Antineoplastic drugs, originally thought to be the main effec-
tors, were found to be of marginal significance using this technique. These
findings were further supported by investigation of urine samples from hos-
pital patients with the umuC assay. The determination of ciprofloxacin in
hospital wastewater by reverse-phase high-performance liquid chromatogra-
phy and fluorescence detection revealed concentrations from 3 to 87 µg L−1 .
Ciprofloxacin concentrations and umuC induction factors in 16 hospital
wastewater samples exhibited a log-linear correlation. The authors suggest
that the previously measured umuC genotoxicity in the wastewater of the
hospital under investigation is caused mainly by fluoroquinolone antibiotics,
especially by ciprofloxacin. However, follow-up work by Hartmann et al.
suggested this could also be due to the presence of additional mutagens that
are yet to be identified.48
Ternes et al.123 assessed the removal of pharmaceuticals, iodinated x-ray
contrast media, and musk fragrances from municipal wastewater using a
pilot ozonation and UV-disinfection plant recieving effluent from a Ger-
man STP. In the original STP effluent, 5 antibiotics (0.34–0.63 µg L−1 ),
5 beta-blockers (0.18–1.7 µg L−1 ), 4 antiphlogistics (0.10–1.3 µg L−1 ), 2
lipid regulator metabolites (0.12–0.13 µg L−1 ), the antiepileptic drug car-
bamazepine (2.1 µg L−1 ), 4 ICMs (1.1–5.2 µg L−1 ), the natural estrogen
estrone (0.015 µg L−1 ), and 2 musk fragrances (0.1–0.73µg L−1 ) were de-
tected. X-ray contrast media were present with the highest concentrations
(diatrizoate, 5.7 µg L−1 ; iopromide, 5.2 µg L−1 ).
By applying 10–15 mg L−1 ozone (contact time 18 min), all the pharma-
ceuticals investigated as well as musk fragrances (HHCB, AHTN) and estrone
were no longer detected. However, ICMs (diatrizoate, iopamidol, iopromide,
and iomeprol) were still detected in appreciable concentrations. Even with a
15 mg L−1 ozone dose, the ionic diatrizoate exhibited a maximum removal
efficiency of only 14%, while the nonionic media were removed by more
than 80%. Advanced oxidation processes (O3 /UV-low-pressure mercury arc,
O3 /H2 O2 ), which were nonoptimized for wastewater treatment, did not lead
to a significantly higher removal efficiency for the x-ray media than ozone
alone.
This work demonstrated that it may be possible to remove pharmaceu-
ticals and other organic contaminants from sewage using available technolo-
gies. It is not clear, however, how much upgrading STPs in this way would
cost. Capital and operational costs are high for ozonation plants and other
tertiary treatment options,87 and if water companies do not see a benefit to
such investment they are unlikely to be inclined to treat wastewater in this
way.
IV. DISCUSSION
Drugs in the environment are an emerging environmental issue.56 Although

some contamination may come from landfill leachates or via the incorrect
disposal of waste drugs, these are likely to be relatively small sources of
pollution.13 Most human pharmaceuticals are released after excretion from
the patient or, to a lesser extent, in aqueous waste produced by manufac-
turing. Sewage treatment plants may therefore be reasonably expected to be
the main point of collection and subsequent release into the environment.
However, conventional sewage treatment facilities were never designed to
deal with pharmaceutical compounds, and due to their highly variable physi-
cal and chemical properties, the efficiencies by which they are removed may
vary substantially. It is also not known if sewage treatment facilities could be
cost-effectively modified to reduce pharmaceutical emissions.
Another factor to consider is the sheer number of compounds involved.
A pharmaceutical may be described as any chemical used for the diagnosis,
treatment (cure/mitigation), alteration, or prevention of disease, health condi-
tion, or structure/function of the body.20 There are literally thousands of com-
pounds that maybe taken for medicinal purposes throughout the world, with
more than 3000 individual pharmaceutical substances currently licensed for
use in the United Kingdom alone.6 Thus the terms “pharmaceutical,” “phar-
maceutically active compounds” (PhAC), and “pharmaceuticals and personal
care products” (PPCP) are somewhat general, catch-all terms for an extremely
broad group of compounds with wide-ranging physical and chemical prop-
erties. Clearly it is not feasible to monitor sewage for all the compounds
that might potentially be found. Therefore, some form of selection process is
needed to narrow down interest to those compounds likely to do most harm,
through either their sheer volume of use (e.g., painkillers such as ibuprofen)
or their potential for toxicity (e.g., anticancer drugs). This could conceivably
be achieved via computer modeling.
Although there is a paucity of data on the behavior of pharmaceuticals,
their fate is likely to be dependent on their physicochemical properties (e.g.,
chemical structure, aqueous solubility, octanol/water partition coefficient,
and Henry’s law constant). Their behavior during wastewater treatment will
therefore comply with the pathways outlined by Meakins et al.,91 and there
have been attempts to model fate and behavior in the literature.65,70,71
In general, the more hydrophobic a chemical is, the greater the amount
that will accumulate in the solid phase (e.g., sludge), and the more hy-
drophilic, the greater the amount that will stay in the aqueous phase. The
following guide to the significance of sorption can be used.101 :
r Log K ow <2.5 Low sorption potential

r Log K ow >2.5 but <4.0 Medium sorption potential
r Log K ow >4.0 High sorption potential
For instance, some polybrominated diphenyl ethers with high log K ow

values26 of around 9 are known to partition to sludge,84 whereas steroid
estrogens with lower log K ow values of 2–4 may sorb to solids or stay in
the aquatic phase depending on the individual compound.40 Some workers,
however, have expressed doubts over the usefulness of this method with
regard to pharmaceuticals.127
The K oc is also an important parameter which can be used when con-
sidering potential losses of a chemical due to sorption. As with K ow values,
the higher the log K oc , the higher is the likelihood that a compound will
sorb to matter containing organic carbon such as suspended solids as well
as the nonpolar fats and lipids, mineral oils, greases, and surfactants gen-
erally present in domestic sewage.75 Those with lower values will tend to
remain in the liquid phase and may be more easily leached from sludge
or sediments.3 However, it is worth noting that predicted concentrations
of drug compounds in sludge based on K ow , sludge-water partition coef-
ficients (K d ), or acid–base constants (pKa) and measured in effluent vary
extensively.65,114 This may be because the values were calculated using equa-
tions originally designed for lipophilic compounds containing no functional
groups.119
The extent to which individual compounds are accumulated or degraded
will be influenced both by the properties of the compound in question and of
the unit treatment process employed at the STP itself; individual compounds
may be lost at any one of several treatment stages.106 Typical sewage treat-
ment usually consists of primary sedimentation followed by secondary (bi-
ological) treatment and final sedimentation. There may also be facilities for
removing nutrients (e.g., nitrogen and phosphorus) and/or pathogens. This
may include processes with anaerobic and anoxic zones or tertiary treatment
processes such as slow sand filtration and in some cases UV disinfection or
chlorination. Treatment of sewage sludge to reduce pathogens and pollutants
is also often mandatory.59
Typically, there is very little elimination of organic micropollutants from
the preliminary treatment of wastewater,91,101 and it is also unlikely that many
pharmaceutical compounds will be removed during screening or primary
sedimentation. As there is little biological activity, any pollutant removal
at this stage will rely on both the tendency of the individual drug to ad-
sorb to solids and the degree of suspended solid removal from the primary
sedimentation tank.17 The removal of organic compounds may also be af-
fected by factors such as pH, retention time, temperature, and amount of
solids present, as has already been demonstrated for metals.113 Normally
there is little change in dissolved polar organics, such as pharmaceuti-
cals, at this point,87 so little to no loss of polar drugs may be expected
here.
Activated sludge and trickling, filters are the principle types of secondary
biological treatment usually used following primary sedimentation.87 Losses
of drugs in both processes may be by the same mechanisms as other or-

ganic micropollutants and include adsorption to and removal in waste sludge
and/or biological or chemical degradation and biotransformation. Little loss
by volatilization during aeration is expected, but field data suggest that ac-
tivated sludge removes greater amounts of pharmaceutical compounds than
percolating filters,117 probably due to the greater bacterial activity in the
former.
Since sewage treatment plants are the principal method by which hu-
man pharmaceuticals enter the environment there are, theoretically at least,
a number of potential opportunities to control their release. For example,
certain compounds have been shown to be removed more efficiently by
reducing the sludge loading rate (SLR) and/or increasing the hydraulic reten-
tion time (HRT).93 Both these factors are ultimately determined by the sludge
age (θc) of the plant. Increasing sludge age results in a reduction of the SLR
and an increase in HRT. This enables populations of slower growing bacteria
to develop and also serves to increase the potential for the acclimatization of
the population to the compounds encountered. This change in the bacterial
population with time means any chemicals in the sewage are exposed to
a greater array of bacteria and bacterial enzymes, increasing the likelihood
that they will be degraded to less harmful compounds; however, recalcitrant
polar organics may still pass through.129
STPs employing nitrification and denitrification also exhibit significantly
lower concentrations of drugs such as ibuprofen and naproxen in their
effluent.30 This is probably a consequence of the diverse bacterial compo-
sitions within a nitrifying and denitrifying system. Nitrification is a highly
oxygenated process, while denitrification requires anoxic and anaerobic
conditions. These differences give rise to a sequence of differing bacterial
populations, which may act synergistically and result in a greater degree
of degradation being achieved. For example, a compound may be partially
biodegraded during nitrification, with the resulting product then degraded
fully in the denitrified system.
Utilization of nitrification–denitrification and increasing the sludge age
of the majority of sewage treatment plants would (along with most other
options) be likely to involve a number of associated environmental costs in
terms of resource and energy consumption, which would need to be bal-
anced against the potential benefits of a reduced pharmaceutical load in the
effluent. However, most modern treatment facilities already have these sys-
tems in place (often in conjunction with biological phosphorus removal) to
control nutrient release. Therefore the cost would be offset somewhat by ex-
isting legal requirements. It may be that moves to limit nutrients to receiving
waters have also reduced pharmaceutical and other related contaminants.
However, there may be scope to optimize pharmaceutical removal at little
extra cost.
In order to develop effective management strategies to minimize the

risks of the release of compounds to the environment, it is necessary to fully
understand the potential sources and the subsequent fate and behavior of
the compounds in question, as well as the associated costs and benefits of
effecting a change in treatment options.37 This necessarily includes consider-
ation of how local conditions are likely to influence their impact. Strategies
that are developed also need to be evaluated in terms of their overall effec-
tiveness, including both environmental and economic considerations. While
the latter are likely to be easily identified (although at present there are no
economic or legal incentives for water companies to remove medicinal com-
pounds from wastewater), the environmental aspects are more difficult to
determine.
Drugs left in the effluent after primary and secondary treatment may
be eliminated by tertiary treatment. However, in most countries only a small
proportion of sewage treatment facilities have these adaptations. Advanced
treatment techniques such as ozonation and membrane treatment have been
shown to remove pharmaceuticals to below detection limits in a water treat-
ment works,122 but how effectively they do so varies with the treatment
conditions employed. In addition, these processes have not been applied to
the treatment of wastewater and would prove costly and pose maintenance
problems if they were used.59
Those compounds not removed in sludge or degraded during treatment
will be released in the final effluent with unknown effects on the receiv-
ing aquatic systems. Compounds that do sorb to the solid phase (such as
the fluoroquinolone antibiotics39 ) still have the potential to return to the
environment via the landfilling of sludge or the application of biosolids as
a fertilizer/soil conditioner.70 In each case, compounds could be removed
via leaching and enter groundwater and/or surface water. This scenario is
likely to be mitigated to some extent by the treatment that sewage sludge
must undergo before disposal. Various techniques are utilized, all of which
may influence the loss, or potential formation, of organic contaminants. The
main form of treatment is digestion (anaerobic or aerobic).87 Temperatures
are usually elevated during these processes, and nonthermally stable com-
pounds (such as many drugs) may be broken down at this point; however,
there is no evidence regarding the fate of pharmaceutical compounds be-
fore and after sludge digestion. While disposal of sludge to land is desirable
for a variety of reasons, both environmental and economic, concern over
pollutants has led many to be cautious over its use, and as yet the data are
inadequate to assess the need for land utilization guidelines for organic con-
taminants such as pharmaceuticals. As analytical surveys for organic residues
are expensive, environmental modeling may assist in identifying pharmaceu-
ticals, that should potentially be analyzed in sewage sludge and/or treated
soils.31
Where pharmaceuticals are released into the environment there is the

risk of exposure to humans via potable water supplies. Although the as-
sociated risks are likely to be relatively minor, the increasing demands on
the worlds freshwater supplies will likely lead to greater incidences of indi-
rect and direct water reuse situations, and the potential for adverse effects
should not be overlooked,51 especially since little is known regarding the
environmental or human health hazards that might be posed by chronic,
subtherapeutic levels of pharmaceutical substances or their transformation
products. In addition, the presence of pharmaceuticals, however small, will
likely increase the general public’s already negative attitude to water reuse.
This is because it is impossible to prove there will never be any negative ef-
fects from their presence. For example, a water reuse scheme in San Diego,
California, recently failed precisely because the onus was put on the operator
to prove the negative regarding quality, health, and local media effects, even
though none were detected during the scheme.16
To conclude, if pharmaceuticals are proved to be problem pollutants,
it is theoretically possible that contemporary STPs can be upgraded to deal
with them but in practice it is very unlikely that this will be economical.
Therefore, controlling pollution sources (such as disposal practices and ther-
apeutic usage) may prove a more effective tool to control this problem, since
prevention of contamination is generally preferable to remediation.
V. CONCLUSIONS
r Pharmaceuticals are used in large amounts in human (and veterinary)
medicine and reach the aquatic environment mainly through sewage treat-
ment systems, where their concentrations can reach micrograms per liter
levels.
r Although some predictions can be made based on their physical and chem-
ical properties, pharmaceuticals display a variety of removal efficiencies
during wastewater treatment and their fate and behavior are not clear.
r There is little experimental evidence showing levels of pharmaceutical
compounds in sewage effluent or sludge and even less showing they
should be of concern. However, their biological activity alone may sup-
port ecotoxicity assessments of chemicals with high production volumes,
especially in view of the increasing importance of freshwater resources
and use of drug compounds.
r If receiving waters are used for potable supplies, the presence of these
compounds (although this is unlikely) may represent a potential hazard
to human health, especially in areas without advanced water treatment.
r Despite the increasing research activities in this field, there is still a con-
siderable need for future work and further investigation in order to assess
the significance of residues in terms of their persistence and potential
environmental impact. The development of markers for wastewater con-

tamination of surface waters with pharmaceuticals would also be useful.
r A possible recommendation to protect the aquatic and terrestrial environ-
ment is that hazard, biodegradability, and fate assessment should be re-
quired for all new synthetic chemicals, irrespective of their purpose or end
use, in order to determine the potential for them to transfer to wastewater
or sewage sludge and the subsequent implications for the environment.
Specified criteria regarding toxicity and biodegradation could be set for
compounds that exhibit a propensity to enter STWs, and restrictions could
be enforced regarding production and use if these criteria were not met.
r Any changes to sewage treatment parameters would need to be offset
against the economic costs. Likewise, any restrictions or drug use must
be balanced against the potential loss of health benefits derived from the
administration of those drugs.
ACKNOWLEDGMENTS
The authors are grateful to the two anonymous reviewers whose comments
on the original manuscript greatly improved the quality of the final article.
One of the authors (O. A. H. J.) is also grateful to the UK Engineering
and Physical Sciences Research Council (EPSRC) for the award of a PhD
scholarship.
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Critical Reviews in Environmental Science and Technology, 35:401–427, 2005

Copyright © Taylor & Francis Inc.

Human Pharmaceuticals in Wastewater

O. A. H. JONES, N. VOULVOULIS, and J. N. LESTER

The presence of human pharmaceutical compounds in surface wa-

KEY WORDS: fate, pharmaceuticals, pollution, sewage treatment

The term “pharmaceutical” covers a wide-ranging class of compounds with

Address correspondence to J. N. Lester, Department of Environmental Science and

The use of other organic pollutants, such as pesticides, has fallen in

in a given water sample. These results demonstrate the importance of ob-

II. DEGRADATION WITHIN STPs

found to leach from the neighboring sewage contaminated surface water by

concentrations of 10 µg L−1 . Clofibric acid displayed persistence in all cases.

were removed by adsorption onto sand and/or biodegradation. The rate

A recent review of veterinary drugs by Tolls127 suggests that mecha-

D. Removal During Sludge Treatment

Andreozzi et al.5 carried out a monitoring survey of STP effluents in

cause of the decrease, as there was no developed/active sludge flock in the

III. FATE OF COMPOUNDS WITHIN SEWAGE WORKS

Because of the complexity of most environmental matrices (i.e., wastew-

Measured concentrations of nine pharmaceutical and personal care

lowest-observable-effect concentrations of selected pharmaceuticals were

Drugs in the environment are an emerging environmental issue.56 Although

r Log K ow <2.5 Low sorption potential

For instance, some polybrominated diphenyl ethers with high log K ow

of drugs in both processes may be by the same mechanisms as other or-

In order to develop effective management strategies to minimize the

Where pharmaceuticals are released into the environment there is the

environmental impact. The development of markers for wastewater con-

[8] Bester, K. Triclosan in a sewage treatment process-balances and monitoring

Enterobacteriaceae and Aeromonas spp, Appl. Environ. Microbiol. 66, 125–

liquid chromatography-electrospray tandem mass spectrometry, J. Chromatogr.

Greece by gas chromatography–mass spectrometry, Chemosphere 51, 69–75,

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