PharmaLundensis is developing EcoFilter, which is a system that eliminates all release of drug residues and multi-resistant bacteria in hospital waste water. In addition, it removes all multi-resistant bacteria from hospital sewage pipes, thereby eliminating the risk of multi-resistant bacteria that are growing in the pipes can infect patients in the hospital wards. Drug residues isolated from the sewage water will be sent for high-temperature destruction, while purified water can be released to the municipal waste-water system. We know of no other project or system that has all these capacities.
The increasing resistance to antimicrobial medicinal products represents one of the major emerging threats to human health. Antibacterial medicinal products can be found with increasing frequency in wastewater and sewage sludge, and in parallel, an increased level and frequency of resistant bacteria in the environment has been observed. In a study on the occurrence of E. coli in sewage and sludge, it was shown that microorganisms with resistances to antibacterial medicinal products accumulated in the sludge. E. coli strains were found which were resistant to 16 out of 24 tested antibacterial medicinal products (penicillins, cephalosporins, aminoglycosides, quinolones, and others); the highest resistance rate (up to 57%) was found for tetracycline1.
Current municipal sewage treatment plants are unable to remove drug residues and antibiotic resistant bacteria. On the contrary, it has been suggested that these plants promote the spread of antibiotic resistance2+3. If inadequately treated sludge is used as fertiliser, agricultural products used as food or animal feed may be contaminated, and such phenomena have been the sources of several outbreaks of enteropathogenic infections4.
In particular, hospital effluents are important contributors to the medicines released in the environment through urban effluents. In the EU, hospitals contribution to medicinal products environmental load is estimated at about 10% of urban effluents5. However, this share can be higher, as shown for instance in Denmark, where it is estimated that 24% of the total antibiotic load in the Capital Region originates from hospitals. This figure rises to 43% if non-problematic penicillins are disregarded. When it comes to life-saving broad-spectrum antibiotics, most are used primarily in hospitals. As a result, hospitals are hotspots for antimicrobial-resistant bacteria and play a major role in both their emergence and spread6. Large numbers of resistant bacteria will be ejected from hospitals via wastewater systems. To make matters even worse, in waste-water treatment plants antibiotic resistance genes are transferred between bacterial species. Consequently, large amounts of multi-resistant bacteria are released in the environment.
1. Reinthaler FF, Posch J, Feierl G, Wüst G, Haas D, Ruckenbauer G, Mascher F, Marth E. Antibiotic resistance of E. coli in sewage and sludge. Water Res. 2003 Apr;37(8):1685-90.
2. Karen L. Jury , Stuart J. Khan , Tony Vancov , Richard M. Stuetz & Nicholas J. Ashbolt. Are Sewage Treatment Plant Promoting Antibiotic Resistance? Critical Reviews in Environmental Science and Technology Volume 41, 2011 – Issue 3, Pages 243-270.
3. Rizzo L, Manaia C, Merlin C, Schwartz T, Dagot C, Ploy MC, Michael I, Fatta-Kassinos D. Urban wastewater treatment plants as hotspots for antibiotic resistant bacteria and genes spread into the environment: a review. Sci Total Environ. 2013 Mar 1;447:345-60.
4. Heaton JC, Jones K. Microbial contamination of fruit and vegetables and the behaviour of enteropathogens in the phyllosphere: a review. J Appl Microbiol. 2008 Mar;104(3):613-26. Epub 2007 Oct 9.
5. Kümmerer K. Antibiotics in the aquatic environment–a review–part I. Chemosphere. 2009 Apr;75(4):417-34.
6. Hocquet D, Muller A, Bertrand X. What happens in hospitals does not stay in hospitals: antibiotic-resistant bacteria in hospital wastewater systems. J Hosp Infect. 2016 Aug;93(4):395-402.
Problems with today´s hospital wastewater systems
Hospital sewage systems today have four important problems that must be addressed by a new wastewater treatment system:
1. Release of large amounts of antibiotics (mainly broad-spectrum) and other pharmaceutical drugs in the hospital wastewater.
2. Release of multi-resistant bacteria and resistance genes in the hospital wastewater.
3. Epidemics in hospital patients caused by spread of multi-resistant bacteria from the hospital wastewater system.
4. Spread of multi-resistant bacteria from patients carrying them.
1. Release of antibiotics and other pharmaceutical drugs in the hospital wastewater.
Most patients are treated with pharmaceutical drugs at the hospital. The drugs are excreted in urine and faeces and flushed down the patients toilets. As a result, the wastewater contains high amounts of many pharmaceuticals which can have ecotoxic effects1. An especially important group is broad-spectrum antibiotics, which can lead to the development of multi-resistant bacteria in the nature2.
1. Frédéric O, Yves P. Pharmaceuticals in hospital wastewater: their ecotoxicity and contribution to the environmental hazard of the effluent. Chemosphere. 2014 Nov;115:31-9.
2. Gullberg E, Cao S, Berg OG, Ilbäck C, Sandegren L, Hughes D, et al. (2011) Selection of Resistant Bacteria at Very Low Antibiotic Concentrations. PLoS Pathog7(7): e1002158.
2. Release of multi-resistant bacteria and resistance genes in the hospital waste water.
Large amounts of antibiotics are used in hospitals to treat patients with infections. The antibiotics are excreted in the urine and faeces and flushed down the patients toilets. This leads to a continuous presence of large amounts of antibiotics in the hospital sewage pipes. As is always the case when large amounts of bacteria are exposed to antibiotics for a long time, the bacteria in the hospital sewage system become resistant to the drugs. Consequentially, hospital sewage water contains large amounts of multi-resistant bacteria1. These bacteria can spread and infect humans and animals. In addition, resistant bacteria supply antibiotic resistance genes that can spread to other bacteria especially in municipal treatment plants, which subsequently can infect vegetables, animals and people2. Furthermore, it has been shown that animal vectors such as Rattus norvegicus living in hospital sewage systems carry pathogens responsible for fatal diseases in humans as a result of the large outflow of antibiotics and antibiotic-resistant bacteria into the wastewater systems3.
1. Hocquet D, Muller A, Bertrand X. What happens in hospitals does not stay in hospitals: antibiotic-resistant bacteria in hospital wastewater systems. J Hosp Infect. 2016 Aug;93(4):395-402.
2. Rizzo L, Manaia C, Merlin C, Schwartz T, Dagot C, Ploy MC, Michael I, Fatta-Kassinos D. Urban wastewater treatment plants as hotspots for antibiotic resistant bacteria and genes spread into the environment: a review. Sci Total Environ. 2013 Mar 1;447:345-60. doi: 10.1016/j.scitotenv.2013.01.032. Epub 2013 Feb 7.
3. Hansen TA, Joshi T, Larsen AR, Andersen PS, Harms K, Mollerup S, Willerslev E, Fuursted K, Nielsen LP, Hansen AJ. Vancomycin gene selection in the microbiome of urban Rattus norvegicus from hospital environment. Evol Med Public Health. 2016 Aug 3;2016(1):219-26.
There are many factors that have been found to contribute to contamination of clinical areas resulting in serious epidemics in hospital patients, including faulty sink, shower and toilet design, clean items stored near sluices, and frequent blockages and leaks from waste pipes1. Blockages can be caused by paper towels, patient wipes, or improper use of bedpan macerators. Furthermore, it has been demonstrated that bacteria in standard sink water traps in seven days form a bio-film that extends up to the sink valve. When the tap is flushed afterwards, bacteria sprout up to a meter around the sink, after which the bacteria can infect patients2. If the bacteria are multi-resistant, they can cause very serious epidemics.
2. Shireen Kotay, Weidong Chai, William Guilford, Katie Barry and Amy J. Mathers. Spread from the Sink to the Patient: in situ Study Using Green Fluorescent Protein (GFP) Expressing- Escherichia coli to Model Bacterial Dispersion from Hand Washing Sink Trap Reservoirs. Appl Environ Microbiol. 2017 Mar 31;83(8).
4. Spread of multi-resistant bacteria from patients carrying them.
Many patients in hospitals, especially those receiving longer care, carry multi-resistant bacteria1. As a result, large amounts of multi-resistant bacteria are flushed down in hospital toilets every day. In the hospital sewage pipes these bacteria can spread and multiply and return to the hospital ward as describe above, infecting other patients. Furthermore, the multi-resistant bacteria can leave the hospital in the waste water and spread its resistant genes to other bacteria in the municipal treatment plant and infect even more people.
1. Hogardt M, Proba P, Mischler D, Cuny C, Kempf VA, Heudorf U. Current prevalence of multidrug-resistant organisms in long-term care facilities in the Rhine-Main district, Germany, 2013. Euro Surveill. 2015;20(26):pii=21171.
The EcoFilter technology consists of the use of evaporators to remove water from liquids containing drug residues, as described in PharmaLundensis Patent application 1. The basis for this separation is that water boils away at 100 degrees while drug needs 600-800 degrees or more to evaporate. By removing nearly all water from the waste water with dissolved drugs, the drug residues are isolated and can easily be sent for destruction. Compare with a teaspoon of salt poured into a pan of boiling water. First, the salt dissolves and disappears, but if you boil away all the water, the salt will deposit on the walls of the pan. It will then be easy to collect the salt deposits for further treatment. This is a robust and well-proven technology that we use in a new way.
However, the system generates large amounts of waste material and in Patent application 2 we describe how the amount of waste material can be reduced, making the process much more economical.
There are many other practical issues that also need to be solved to establish a functioning system in a hospital, which is protected in EcoFilter Patent Applications 3 + 4, which have not yet been published.
EcoFilter® Model 101 Prototype.
Positive results in clinical trials with EcoFilter prototype
Studies with a prototype to clarify the capacity of EcoFilter® to remove urinary antibiotics from patients treated with very high doses of broad spectrum antibiotics have been conducted in Lund in 2015-2017. The tests showed:
A. That untreated urine from these patients contained extremely high amounts of antibiotics with a very pronounced antibacterial effect. Thus, the antibiotics had not been broken down or metabolized to a significant extent as it passed through the body.
B. That urine treated with EcoFilter® completely lacked antibacterial effect – all antibiotics had been eliminated.
Thus, EcoFilter® fully meets all required cleaning requirements.
In these tests, the antibacterial effect was evaluated by a biological bioassay where the germicidal effect of urine on bacteria growing on culture plates was determined. The following broad spectrum antibiotics were included in the test: Bensylpenicillin, Cefotaxim, Cefuroxim, Cloxacillin, Erytromycin, Metronicazol, Rifampicin, Trimetoprim-sulfa and Piperacillin-tazobaktam.
Similar technical solutions (competition)
The methods to eliminate drug residues from hospital effluents are just developing, and there is probably no company which at present can offer a fully functional system for removal pharmaceutical drugs and multi-resistant bacteria from hospital waste water systems. However, there are several groups that work with this problem using various methods.
Akademiska sjukhuset in Uppsala, Sweden has a pilot project with ozone.
In Linköping a treatment plant for removal of drug residues from municipal waste water is being built. For the purpose, ozone is used. It is expected to remove 90 % of drug residues.
Herlev Hospital in Denmark uses several techniques to remove drugs from the wastewater (membrane bioreactor, ozone, activated carbon, and Ultraviolet (UV) rays). This results in a high level of purification, but the process is complicated and expensive.
As described above, there are four problems with today´s hospital waste water system. The above projects focus on the problem of reducing the level of drug residues of the waste water leaving the hospital or municipal waste water plant. However, none of the systems can reduce the number of antibtiotic resistant bacteria in the hospitals own sewage pipes. These will still be FULL of multi-resistant bacteria because the removal of antibiotics will take place OUTSIDE of the hospital. As a consequence, multi-resistant bacteria in the hospital sewage pipes will still be able to cause serious epidemics in hospital wards, because the pipes will still be full of multi-resistant bacteria. Furthermore, multi-resistant bacteria from patients carrying them will still end up in the hospital sewage system and thus can infect patients at the hospital. Clearly, the above systems can not solve all the problems with the release of pharmaceuticals in hospital waste water systems.
IN SUMMARY, the EcoFilter system is the only system that we are aware of that can completely eliminate all antibiotic-resistant bacteria in the hospital sewage pipes, as well as remove all drug residues in hospital waste water.