Emissions from Medical Care Units
After administration, pharmaceuticals are excreted and released into the aquatic environment via wastewater effluent. Unused drugs are sometimes disposed of down drains, and, unless they are biodegraded or eliminated during sewage treatment, traces may en
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Emissions from Medical Care Units K. Kiimmerer
3.1
Introduction After administration, pharmaceuticals are excreted and released into the aquatic environment via wastewater effluent. Unused drugs are sometimes disposed of down drains, and, unless they are biodegraded or eliminated during sewage treatment, traces may enter the aquatic environment and eventually reach drinking water. It is also hypothesised that antibiotics and disinfectants disturb the wastewater treatment process and the microbial ecology in surface waters. Furthermore, resistant bacteria may be selected in the aeration tanks of STPs by the antibiotic substances present. A variety of different substances such as pharmaceuticals, diagnostics and disinfectants are used for medical purposes in hospital and in general practice. This chapter discusses the release of some typical pharmaceuticals (cytotoxics, antibiotics, anaesthetics, diagnostics and disinfectants) by hospitals as one of the main pathways for their introduction into the aquatic environment. For this purpose, we present the data obtained from German hospitals of different size and medical service spectrum and from a number of European hospitals. 3.2
Cytostatic Agents Cytostatic agents (Fig. 3-1) are used in cancer therapy. In Germany, the two most widely used compounds are ifosfamide and cyclophosphamide. It has been calculated that the total volume of these drugs used in Germany in 1996 was 400 kg and 250 kg, respectively (Kiimmerer and AI-Ahmad 1998). The volume of cytostatics used lies far below the quantitative relevance of other drugs such as antibiotics (approximately 400 t per year in Germany for medical purposes) or analgesics. In Germany, the anticipated annual average concentrations of cytostatics in wastewater are a few ng rl. This is in the same range as those actually measured (Steger-Hartmann et al. 1996) in wastewater, and levels are presumably under 1 ng rl in surface water. Carcinogenicity, mutagenicity and fetotoxic properties have been well demonstrated (Skov et al. 1990). Seen under the aspect of potential emission into the environment, cytotoxics are an important group of drugs in terms of their risk potential for humans and the environment. It has been shown that degradability is largely independent of the mode of action and the chemical structure of the cytostatic agents. Most of the active substances investigated have proved to have low biodegradability (e.g. Kiimmerer et al.1996; AI-Ahmad et al.1997; Kiimmerer and AI-Ahmad 1997; Steger-Hartmann et al.1997; AI-Ahmad and
K. Kümmerer (ed.), Pharmaceuticals in the Environment © Springer-Verlag Berlin Heidelberg 2004
K. Kiimmerer
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a
c
b OH HO~
0
L-~:§ HN
/0
0
OH
:~NH;
o HO
NH
~~OH
OH
OH
d
e
f
g
Fig. 3.1. Formula of some widely used cytostatics; a 5-fluorouracil; b cyclophosphamide; c ifosfamide; d epirubicin; e mitoxantron; f cis-platinum; g carboplatinum
Kiimmerer 2001). Unless they are eliminated by adsorption onto sewage sludge, the active substances pass through municipal sewage treatmen
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