Assessment of community-wide antimicrobials usage in Eastern China using wastewater-based epidemiology

Like Xu, Jinxin Zang, Wenjuan Cong, Elizabeth Holton, Lufang Jiang, Samuel K. Sheppard, Yingying Wang, Na Wang, Jason Weeks, Chaowei Fu, Qingwu Jiang, Helen Lambert, Barbara Kasprzyk-Hordern

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11 Citations (SciVal)


Wastewater-based epidemiology (WBE) has potential to identify the epidemiological links between people, animals, and the environment, as part of antimicrobial resistance (AMR) surveillance. In this study, we investigated six wastewater treatment plants (WWTPs) serving six communities located in two regions in Eastern China: Site A in Zhejiang and site B in Jiangsu province to assess the public use of antimicrobial agents (AA). Fifty antimicrobials and 24 of their metabolites were quantified using ultraperformance liquid chromatography coupled with triple quadrupole tandem mass spectrometry (UPLC-MS/MS). Spatiotemporal trends were established for measured concentrations, daily loads, and population-normalised daily loads. Daily AA mass loads varied between 1.6 g/day and 324.6 g/day reflecting the WWTP scales, with macrolides and β-lactams showing the highest overall environmental burden at 223.7 g/day and 173.7 g/day, respectively. Emissions of antibiotic residues from manufacturing have been observed, with the peak daily load 12-fold higher than the overall load from a community serving a population of over 600,000. Community exposure levels of 225.2 ± 156.2 mg/day/1000 inhabitant and 351.9 ± 133.5 mg/day/1000 inhabitant were recorded in site A and B, respectively. Paired parent-metabolites analysis identified a large proportion (64–78%) of un-metabolised metronidazole and clindamycin at site B, indicating improper disposal of unused drugs either in the community or in livestock production. Consumption levels, calculated via WBE, suggested relatively low antimicrobial usage in Eastern China compared to other areas in China. This first application of WBE in Eastern China to assess the community-wide exposure to AAs has potential to inform regional antimicrobial stewardship.

Original languageEnglish
Article number118942
JournalWater Research
Early online date2 Aug 2022
Publication statusPublished - 15 Aug 2022

Bibliographical note

Funding Information:
The authors would like to thank the managers of WWTPs for their support during the sampling period and the information provided on the wastewater characteristics. Also, this study received support from local CDCs (Centre for Disease Control and Prevention). This study was part of the UK-China AMR Initiative and was funded by the Medical Research Council and Newton Fund through a UK-CHINA AMR Partnership Hub Award (MR/S013717/1) and National Natural Science Foundation of China ( 81861138050 ).


  • Antibiotic/antimicrobial
  • Antimicrobial resistance
  • Eastern China
  • Wastewater-based epidemiology

ASJC Scopus subject areas

  • Environmental Engineering
  • Civil and Structural Engineering
  • Ecological Modelling
  • Water Science and Technology
  • Waste Management and Disposal
  • Pollution


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