Managing AMR and wastewater in hospitals

By Sharon Pfleger, Consultant in Pharmaceutical Public Health, NHS Highland

Water is essential for human health and the health services we provide to our population. Looking after our water supply is an essential part of the NHS’s social and environmental responsibility. We need to use the water we have in an environmentally sustainable way and this has been a focus of mine for many years now in NHS Highland. That’s how Caithness General Hospital in Wick became the first hospital in the world to achieve the Alliance for Water Stewardship certification in recognition of its environmentally responsible use of water and its action plan to improve water quality.

Our biggest concerns

When a medicine is taken, between 30-100% of it is excreted by the human body and flushed down the toilet, entering the sewage system. Skin creams and lotions can also be washed off in the shower or bath. Not all medicine traces are removed by waste water treatment plants, which means tiny amounts can enter rivers and oceans. Even these tiny amounts can impact sea life leading to changes in physiology, behaviour and reproduction. For example, pollution of our waters with female hormones can result in male fish becoming feminised, which could ultimately lead to fish population collapse.

However, the biggest threat from environmental pollution with medicines is the development of antimicrobial resistance (AMR). It is one of our biggest areas of public health concern. It’s estimated that by 2050, antimicrobial resistant infections may become the leading cause of death, killing 10 million people every year worldwide. When antibiotics and other medicines are used by humans and excreted into wastewater, it can lead to the conditions being created which results in the development of new AMR genes in bacteria.

“Wake up call”

That’s why looking at the hospital’s wastewater output was so important to NHS Highland. The One Health Breakthrough Partnership was formed, bringing together public health expertise with researchers, water providers and the environment protection agency, to work on this along with our environment and sustainability leads. We tested the hospital’s wastewater for eight commonly used medicines, we shockingly found seven of them, including painkillers, antibiotics, heart medicines and antidepressants. This was a real wake up call for us and so we set about making changes to address the problem, both within the hospital and across NHS Highland.

What are we doing about it?

First, we developed a patient information video on antibiotics called “Antibiotics and You” giving the public key points on when an antibiotic is needed and when it’s not, AMR and the environment, finishing the course and not sharing antibiotics and finally how to safely dispose of them. The video had a significant impact, with people reporting a 56% increase in understanding of the environmental issue of antibiotic pollution because of watching it.

Next, we looked at how to make the medicines Formulary greener. Medicines in the formulary are historically chosen for efficacy, safety, and cost-effectiveness. However, we introduced a new consideration: the environmental impact.  We are getting underway with this work which will enable us to give prescribers information to make the best choice for patients, as well as the safest choice for the environment.

Of course, the biggest impact we can make is not to prescribe medicines in the first place. This is very much the “Realistic Medicine” approach, asking whether a medicine or medical intervention is actually the answer for a patient. We need to ensure that we fully understand what “good” would look like for the patient, what matters to them?  Patients should be actively involved in their treatment options whether it is a procedure, a medicine or a lifestyle change.

Looking to the future

We’ve got a long action plan which includes looking at the use of nanotechnology to take medicine traces out of the hospital wastewater before it enters the sewage system, a crucial step forward in making healthcare more sustainable, as well as a “blue” prescribing strategy using our water resources to improve health, a bit like green prescribing but involving water.

Looking to my future, I want to continue getting the message across that as a population we need to use medicines responsibly and think about our environment to get the best results for our health and our planet’ s health.

I’ve recently joined the Homeward Bound programme for female leaders in STEMM to save our planet one pill at a time.  I was lucky enough to be selected from over 400 applicants from across the world to take forward female leadership in climate and environmental issues.  The programme culminates in a 3-week expedition to Antarctica to see climate change up close and to invigorate us to really strive for change.

I’m the first pharmacist ever to be selected for the programme but if you or any other females working in STEMM (science, technology, engineering, maths and medicine) fancy following in my footsteps applications for Cohort 7 are now open!

See more about Sharon’s work here: One Health Breakthrough PartnershipHomeward Bound global leadership initiative, and the UK team.

Sharon’s page: Saving our planet, one pill at a time! | Chuffed | Non-profit charity and social enterprise fundraisin and the Antibiotics video

Read more about RPS action on sustainability in healthcare


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