Tag: Emission limits

Recently, Le Page et al. published a paper in Environmental International (1), partially building on the predicted no-effect concentrations for resistance selection for 111 antibiotics that me and Joakim Larsson published around two years ago (2). In their paper, the authors stress that discharge limits for antibiotics need to consider their potency to affect both environmental and human health, which we believe is a very reasonable standpoint, and to which we agree. However, we do not agree on the authors’ claim that cyanobacteria would often be more sensitive to antibiotics than the most sensitive human-associated bacteria (1). Importantly, we also think that it is a bit unclear from the paper which protection goals are considered. Are the authors mainly concerned with protecting microbial diversity in ecosystems, protecting ecosystem functions and services, or protecting from risks for resistance selection? This is important because it influence why one would want to mitigate, and therefore who would perform which actions. To elaborate a little on our standpoints, we wrote a short correspondence piece to Environment International, which is now published (3). (It has been online for a few days, but without a few last-minute changes we did to the proof, and hence I’m only posting about it now when the final version is online.) There is indeed an urgent need for discharge limits for antibiotics, particularly for industrial sources (4) and such limits would have tremendous value in regulation efforts, and in development of environmental criteria within public procurement and generic exchange programs (5). Importantly, while we are all for taking ecotoxicological data into account when doing risk assessment, we think that there should be solid scientific ground for mitigations and that regulations need to consider the benefits versus the costs, which is what we want to convey in our response to Le Page et al.

References

1. Le Page G, Gunnarsson L, Snape J, Tyler CR: Integrating human and environmental health in antibiotic risk assessment: a critical analysis of protection goals, species sensitivity and antimicrobial resistance. Environment International, in press (2017). doi: 10.1016/j.envint.2017.09.013
2. Bengtsson-Palme J, Larsson DGJ: Concentrations of antibiotics predicted to select for resistant bacteria: Proposed limits for environmental regulation. Environment International, 86, 140–149 (2016). doi: 10.1016/j.envint.2015.10.015
3. Bengtsson-Palme J, Larsson DGJ: Protection goals must guide risk assessment for antibiotics. Environment International, in press (2017). doi: 10.1016/j.envint.2017.10.019
4. Bengtsson-Palme J, Larsson DGJ: Time to limit antibiotic pollution. The Medicine Maker, 0416, 302, 17–18 (2016). [Paper link]
5. Bengtsson-Palme J, Gunnarsson L, Larsson DGJ: Can branding and price of pharmaceuticals guide informed choices towards improved pollution control during manufacturing? Journal of Cleaner Production, 171, 137–146 (2018). doi: 10.1016/j.jclepro.2017.09.247

Yesterday, Swedish television channel TV4 highlighted a recent publication by myself, Lina Gunnarsson and Joakim Larsson, in which we show that the price of pharmaceuticals is linked to the environmental standards of production countries. Surprisingly, however, this link seems to be mostly driven by whether the product is generic or original (branded), which in turns affect the prices.

In the study (1), published in Journal of Cleaner Production, we have used an exclusive set of Swedish sales data for pharmaceuticals combined with data on the origin of the active ingredients, obtained under an agreement to not identify individual manufacturers or products. We used this data to determine if price pressure and generic substitution could be linked to the general environmental performance and the corruption levels of the production countries, as measured by the Environmental Performance Index (2) and the Corruption Perception Index (3). In line with what we believed, India was the largest producer of generics, while Europe and the USA dominated the market for branded products (1). Importantly, we found that the price and environmental performance index of the production countries were linked, but that this relationship was largely explained by whether the product was original or generic.

To some extent, this relationship would allow buyers to select products that likely originate from countries that, in general terms, have better pollution control, which was also highlighted in the news clip that TV4 produced. However, what was lacking from that clip was the fact that this approach lacks resolution, because it does not say anything about the environmental footprint of individual products. We therefore conclude that to better allow consumers, hospitals and pharmacies to influence the environmental impact of their product choices, there is need for regulation and, importantly, transparency in the production chain, as has also been pointed out earlier (4,5). To this end, emissions from manufacturing need to be measured, allowing for control and follow-up on industry commitments towards sustainable manufacturing of pharmaceuticals (6). Since the discharges from pharmaceutical manufacturing not only leads to consequences to the local environment (7,8), but also in the case of antibiotics has potentially global consequences in terms of increasing risks for resistance development (9), limiting discharges is an urgent need to avoid a looming antibiotic resistance crisis (10).

The paper was also highlighted by the Centre for Antibiotic Resistance Research, and can be read here or here.

References

1. Bengtsson-Palme J, Gunnarsson L, Larsson DGJ: Can branding and price of pharmaceuticals guide informed choices towards improved pollution control during manufacturing? Journal of Cleaner Production, 171, 137–146 (2018). doi: 10.1016/j.jclepro.2017.09.247
2. Hsu A, Alexandre N, Cohen S, Jao P, Khusainova E: 2016 Environmental Performance Index. Yale University, New Haven, CT, USA (2016). http://epi.yale.edu/reports/2016-report
3. Transparency International: Corruption Perceptions Index 2014. Transparency International, Berlin, Germany (2014). http://www.transparency.org/cpi2014/in_detail
4. Larsson DGJ, Fick J: Transparency throughout the production chain–a way to reduce pollution from the manufacturing of pharmaceuticals? Regulatory Toxicology and Pharmacology, 53, 161–163 (2009). doi:10.1016/j.yrtph.2009.01.008
5. Ågerstrand M, Berg C, Björlenius B, Breitholtz M, Brunström B, Fick J, Gunnarsson L, Larsson DGJ, Sumpter JP, Tysklind M, Rudén C: Improving environmental risk assessment of human pharmaceuticals. Environmental Science & Technology, 49, 5336–5345 (2015). doi:10.1021/acs.est.5b00302
6. Industry Roadmap for Progress on Combating Antimicrobial Resistance: Industry Roadmap for Progress on Combating Antimicrobial Resistance – September 2016. (2016). http://www.ifpma.org/wp-content/uploads/2016/09/Roadmap-for-Progress-on-AMR-FINAL.pdf
7. Larsson DGJ, de Pedro C, Paxeus N: Effluent from drug manufactures contains extremely high levels of pharmaceuticals. Journal of Hazardous Materials, 148, 751–755 (2007). doi:10.1016/j.jhazmat.2007.07.008
8. aus der Beek T, Weber FA, Bergmann A, Hickmann S, Ebert I, Hein A, Küster A: Pharmaceuticals in the environment–Global occurrences and perspectives. Environmental Toxicology and Chemistry, 35, 823–835 (2016). doi:10.1002/etc.3339
9. Bengtsson-Palme J, Larsson DGJ: Concentrations of antibiotics predicted to select for resistant bacteria: Proposed limits for environmental regulation. Environment International, 86, 140–149 (2016). doi: 10.1016/j.envint.2015.10.015
10. Bengtsson-Palme J, Larsson DGJ: Time to limit antibiotic pollution. The Medicine Maker, 0416, 302, 17–18 (2016). [Paper link]

So, on Thursday (May 26th) I will defend my thesis, titled “Antibiotic resistance in the environment: a contribution from metagenomic studies”. I will not dwell into this by writing a novel text, but will instead shamelessly reproduce the press release, which should give a reasonable overview of what I have been doing:

More and more people are infected with antibiotic resistant bacteria. But how do bacteria become resistant? A doctoral thesis from the Centre for Antibiotic Resistance Research at University of Gothenburg has investigated the role of the environment in the development of antibiotic resistance.

“An important question we asked was how low concentrations of antibiotics that can favour the growth of resistant bacteria in the environment”, says Johan Bengtsson-Palme, author of the thesis.

“Based on our analyses, we propose emission limits for 111 antibiotics that should not be exceeded in order to avoid that environmental bacteria become more resistant.”

A starting point to regulate antibiotic pollution
A recent report, commissioned by the British Prime Minister David Cameron, proposes that the emission limits suggested in Johan’s thesis should be used as a starting point to regulate antibiotic pollution from, for example, pharmaceutical production – globally.

“Many people are surprised that such regulations are not already in place, but today it is actually not a crime to discharge wastewater contaminated with large amounts of antibiotics, not even in Europe”, says Johan Bengtsson-Palme.

Resistance genes
In one of the studies in the thesis, the researchers show that resistance genes against a vast range of antibiotics are enriched in an Indian lake polluted by dumping of wastewater from pharmaceutical production.

“It’s scary. Not only do the bacteria carry a multitude of resistance genes. They are also unusually well adapted to share those genes with other bacteria. If a disease-causing bacterium ends up in the lake, it may quickly pick up the genes it needs to become resistant. Since the lake is located close to residential areas, such spread of resistant bacteria to humans is not hard to imagine”, says Johan Bengtsson-Palme.

Spreading by travelers
The thesis also shows that resistant bacteria spread in the intestines of travelers who have visited India or Central Africa, even if the travelers themselves have not become sick.

“That resistant bacteria spread so quickly across the planet highlights that we must adopt a global perspective on the resistance problem”, says Johan Bengtsson-Palme. “Furthermore, it is not enough to reduce the use of antibiotics in healthcare. We must also reduce the use of antibiotics for animals, and try to limit the releases of antibiotics into the environment to try to get control over the growing antibiotic resistance problem before it is too late”.

The thesis Antibiotic resistance in the environment: a contribution from metagenomic studies will be defended on a dissertation on May 26th.

After a long wait (1) Sara Lundström’s paper establishing minimal selective concentrations (MSCs) for the antibiotic tetracycline in complex microbial communities (2), of which I am a co-author, has gone online. Personally, I think this paper is among the finest work I have been involved in; a lot of good science have gone into this publication. Risk assessment and management of antibiotics pollution is in great need of scientific data to underpin mitigation efforts (3). This paper describes a method to determine the minimal selective concentrations of antibiotics, and investigates different endpoints for measuring those MSCs. The method involves a testing system highly relevant for aquatic communities, in which bacteria are allowed to form biofilms in aquaria under controlled antibiotic exposure. Using the system, we find that 1 μg/L tetracycline selects for the resistance genes tetA and tetG, while 10 μg/L tetracycline is required to detect changes of phenotypic resistance. In short, the different endpoints studied (and their corresponding MSCs) were:

• CFU counts on R2A plates with 20 μg/mL tetracycline – MSC = 10 μg/L
• MIC range – MSC ~ 10-100 μg/L
• PICT, leucine uptake after short-term TC challenge – MSC ~ 100 μg/L
• Increased resistance gene abundances, metagenomics – MSC range: 0.1-10 μg/L
• Increased resistance gene abundances, qPCR (tetA and tetG) – MSC ≤ 1 μg/L
• Changes to taxonomic diversity – no significant changes detected
• Changes to taxonomic community composition – MSC ~ 1-10 μg/L

This study confirms that the estimated PNECs we reported recently (4) correspond well to experimentally determined MSCs, at least for tetracycline. Importantly, the selective concentrations we report for tetracycline overlap with those that have been reported in sewage treatment plants (5). We also see that tetracycline not only selects for tetracycline resistance genes, but also resistance genes against other classes of antibiotics, including sulfonamides, beta-lactams and aminoglycosides. Finally, the approach we describe can be used for improved in risk assessment for (also other) antibiotics, and to refine the emission limits we suggested in a recent paper based on theoretical calculations (4).

References and notes

1. Okay, seriously: how can a journal’s production team return the proofs for a paper within 24 hours of acceptance, and then wait literally five weeks before putting the final proofs online? Nothing against STOTEN, but I honestly wonder what was going on beyond the scenes here.
2. Lundström SV, Östman M, Bengtsson-Palme J, Rutgersson C, Thoudal M, Sircar T, Blanck H, Eriksson KM, Tysklind M, Flach C-F, Larsson DGJ: Minimal selective concentrations of tetracycline in complex aquatic bacterial biofilms. Science of the Total Environment, 553, 587–595 (2016). doi: 10.1016/j.scitotenv.2016.02.103 [Paper link]
3. Ågerstrand M, Berg C, Björlenius B, Breitholtz M, Brunstrom B, Fick J, Gunnarsson L, Larsson DGJ, Sumpter JP, Tysklind M, Rudén C: Improving environmental risk assessment of human pharmaceuticals. Environmental Science and Technology (2015). doi:10.1021/acs.est.5b00302
4. Bengtsson-Palme J, Larsson DGJ: Concentrations of antibiotics predicted to select for resistant bacteria: Proposed limits for environmental regulation. Environment International, 86, 140-149 (2016). doi: 10.1016/j.envint.2015.10.015
5. Michael I, Rizzo L, McArdell CS, Manaia CM, Merlin C, Schwartz T, Dagot C, Fatta-Kassinos D: Urban wastewater treatment plants as hotspots for the release of antibiotics in the environment: a review. Water Research, 47, 957–995 (2013). doi:10.1016/j.watres.2012.11.027

Yesterday was an intensive day for typesetters apparently, since they put two of my papers online on the same day. This second paper was published in Environment International, and focuses on predicting minimal selective concentrations for all antibiotics present in the EUCAST database (1).

Today (well, up until yesterday at least), we have virtually no knowledge of which environmental concentrations that can exert a selection pressure for antibiotic resistant bacteria. However, experimentally determining minimal selective concentrations (MSCs) in complex ecosystems would involve immense efforts if done for all antibiotics. Therefore, efforts to theoretically determine MSCs for different antibiotics have been suggested (2,3). In this paper we therefore estimate upper boundaries for selective concentrations for all antibiotics in the EUCAST database, based on the assumption that selective concentrations a priori must be lower than those completely inhibiting growth. Data on Minimal Inhibitory Concentrations (MICs) were obtained for 122 antibiotics and antibiotics combinations, the lowest observed MICs were identified for each of those across all tested species, and to compensate for limited species coverage, we adjusted the lowest MICs for the number of tested species. We finally assessed Predicted No Effect Concentrations (PNECs) for resistance selection using an assessment factor of 10 to account for the differences between MICs and MSCs. Since we found that the link between taxonomic similarity between species and lowest MIC was weak, we have not compensated for the taxonomic diversity that each antibiotic was tested against – only for limited number of species tested. In most cases, our PNECs for selection of resistance were below available PNECs for ecotoxicological effects retrieved from FASS. Also, concentrations predicted to be selective have, for some antibiotics, been detected in regular sewage treatment plants (4), and are greatly exceeded in environments polluted by pharmaceutical pollution (5-7), often with drastic consequences in terms of resistance gene enrichments (8-10). This is a central issue since in principle a transfer event of a novel resistance determinant from an environmental bacteria to an (opportunistic) human pathogen only need to occur once to become a clinical problem (11). Once established, the gene could then spread through human activities, such as trade and travel (7,13). Importantly, this paper:

• Provides upper boundaries for selective concentrations (MSCs) for 111 antibiotics
• Predicts no effect concentrations (PNECs) for resistance selection
• Can guide implementation of compound-specific emission limits based on the provided concentrations

The paper is available under open access here. We hope, and believe, that the data will be of great use in environmental risk assessments, in efforts by industries, regulatory agencies or purchasers of medicines to define acceptable environmental emissions of antibiotics, in the implementation of environmental monitoring programs, for directing mitigations, and for prioritizing future studies on environmental antibiotic resistance.

References:

1. Bengtsson-Palme J, Larsson DGJ: Concentrations of antibiotics predicted to select for resistant bacteria: Proposed limits for environmental regulation. Environment International, 86, 140-149 (2016). doi: 10.1016/j.envint.2015.10.015 [Paper link]
2. Ågerstrand M, Berg C, Björlenius B, Breitholtz M, Brunstrom B, Fick J, Gunnarsson L, Larsson DGJ, Sumpter JP, Tysklind M, Rudén C: Improving environmental risk assessment of human pharmaceuticals. Environmental Science and Technology (2015). doi:10.1021/acs.est.5b00302
3. Tello A, Austin B, Telfer TC: Selective pressure of antibiotic pollution on bacteria of importance to public health. Environmental Health Perspectives, 120, 1100–1106 (2012). doi:10.1289/ehp.1104650
4. Michael I, Rizzo L, McArdell CS, Manaia CM, Merlin C, Schwartz T, Dagot C, Fatta-Kassinos D: Urban wastewater treatment plants as hotspots for the release of antibiotics in the environment: a review. Water Research, 47, 957–995 (2013). doi:10.1016/j.watres.2012.11.027
5. Larsson DGJ, de Pedro C, Paxeus N: Effluent from drug manufactures contains extremely high levels of pharmaceuticals. Journal of Hazardous Materials, 148, 751–755 (2007). doi:10.1016/j.jhazmat.2007.07.008
6. Fick J, Söderström H, Lindberg RH, Phan C, Tysklind M, Larsson DGJ: Contamination of surface, ground, and drinking water from pharmaceutical production. Environmental Toxicology and Chemistry, 28, 2522–2527 (2009). doi:10.1897/09-073.1
7. Larsson DGJ: Pollution from drug manufacturing: review and perspectives. Philosophical Transactions of the Royal Society London, Series B Biological Sciences, 369 (2014). doi:10.1098/rstb.2013.0571
8. Bengtsson-Palme J, Boulund F, Fick J, Kristiansson E, Larsson DGJ: Shotgun metagenomics reveals a wide array of antibiotic resistance genes and mobile elements in a polluted lake in India. Frontiers in Microbiology, Volume 5, Issue 648 (2014). doi: 10.3389/fmicb.2014.00648 [Paper link]
9. Kristiansson E, Fick J, Janzon A, Grabic R, Rutgersson C, Weijdegård B, Söderström H, Larsson DGJ: Pyrosequencing of antibiotic-contaminated river sediments reveals high levels of resistance and gene transfer elements. PLoS ONE, Volume 6, e17038 (2011). doi:10.1371/journal.pone.0017038.
10. Marathe NP, Regina VR, Walujkar SA, Charan SS, Moore ERB, Larsson DGJ, Shouche YS: A Treatment Plant Receiving Waste Water from Multiple Bulk Drug Manufacturers Is a Reservoir for Highly Multi-Drug Resistant Integron-Bearing Bacteria. PLoS ONE, Volume 8, e77310 (2013). doi:10.1371/journal.pone.0077310
11. Bengtsson-Palme J, Larsson DGJ: Antibiotic resistance genes in the environment: prioritizing risks. Nature Reviews Microbiology, 13, 369 (2015). doi: 10.1038/nrmicro3399-c1 [Paper link]
12. Bengtsson-Palme J, Angelin M, Huss M, Kjellqvist S, Kristiansson E, Palmgren H, Larsson DGJ, Johansson A: The human gut microbiome as a transporter of antibiotic resistance genes between continents. Antimicrobial Agents and Chemotherapy, 59, 10, 6551-6560 (2015). doi: 10.1128/AAC.00933-15 [Paper link]