Pharmaceuticals in wastewater treatment plants: a systematic review on the substances of greatest concern responsible for the development of antimicrobial resistance

Gabriele Frascaroli*, Deborah Reid, Colin Hunter, Joanne Roberts, Karin Helwig, Janice Spencer, Ania Escudero

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

33 Citations (Scopus)
258 Downloads (Pure)


In recent years, there is a growing concern about the alarming spread of antimicrobial resistance (AMR) in different environments. Increasingly, many species of bacteria, fungi and viruses are becoming immune to the most commonly used pharmaceuticals. One of the causes of the development of the resistance is the persistence of these drugs, excreted by humans, in municipal and hospital wastewater (WW). Consequently, wastewater treatment plants (WWTPs) are a primary source of antimicrobial resistance genes as novel pollutants. This systematic review sought to examine the relevant literature on pharmaceutical residues (PRs) responsible for AMR in municipal and hospital WW in order to propose a classification of the PRs of greatest concern and provide an updated source for AMR management in WWTPs. Among 546 studies collected from four databases, 18 were included in the present review. The internal and external validity of each study was assessed, and the risk of bias was evaluated on a 20-parameter basis. Results were combined in a narrative synthesis discussing influent and effluent PR concentrations at 88 WWTPs, seasonal variations, differences between hospital and municipal WW, environmental risk assessment values of antimicrobial substances and treatment facilities removal efficiencies. Among the 45 PRs responsible for AMR evaluated in this study, the antibiotics ciprofloxacin, clarithromycin, erythromycin, metronidazole, ofloxacin, sulfamethoxazole and trimethoprim constitute a considerable risk in terms of ubiquitous distribution, worrying concentrations, risk quotient values and resistance to removal treatments. Gaps in knowledge, data and information reported in this review will provide a valuable source for managing AMR in WWTPs.

Original languageEnglish
Article number6670
Number of pages26
JournalApplied Sciences
Issue number15
Early online date21 Jul 2021
Publication statusPublished - Aug 2021


  • removal
  • environmental risk assessment
  • classification
  • pharmaceutical residues
  • antimicrobial resistance
  • wastewater
  • wastewater treatment plants
  • occurrence

ASJC Scopus subject areas

  • General Engineering
  • Instrumentation
  • General Materials Science
  • Fluid Flow and Transfer Processes
  • Process Chemistry and Technology
  • Computer Science Applications


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