Selected pharmaceutical analysis in a wastewater treatment plant during COVID-19 infection waves in South Africa

Globally, an extensive range of pharmaceuticals are consumed daily to treat a variety of illnesses and diseases. Since the occurrence of the SARS-CoV-2 virus (COVID-19) outbreak, the use of pharmaceuticals has increased drastically in order to treat and prevent infection. Studies have shown that pharmaceutical usage is largely dependent on seasonal temperatures. This was explored in the present study and was verified by the results obtained. Versatile solid phase extraction (SPE) and liquid chromatography-mass spectrometry (LC-MS) methods were developed and validated for the accurate detection of target pharmaceuticals. Method percentage recoveries ranged from 73.53-100.70%, while the limit of detection (LOD) and limit of quantification (LOQ) ranged from 0.0330-0.886 mg L−1 and 0.0990-2.68 mg L−1, respectively. Resulting concentrations of pharmaceuticals used to treat chronic ailments such as diabetes, hypertension, tuberculosis and HIV/AIDS showed consistent daily usage while pharmaceuticals used for the treatment of COVID-19 and influenza showed distinct seasonal trends. Concentrations obtained for sulfamethoxazole hydroxylamine and sulfamethoxazole ranged from 0.05215-0.3438 mg L−1 and 0.009818-0.3002 mg L−1, respectively, while concentrations quantified for prednisolone and ivermectin ranged from 0.008775-0.4482 mg L−1 and 0.008520-0.979 mg L−1, respectively. Trends also directly correlated with the total number of active COVID-19 cases experienced in South Africa during sampling periods and this was confirmed using a one-way ANOVA test. P-values obtained for sulfamethoxazole hydroxylamine, sulfamethoxazole and ivermectin were below 0.05. © 2023 The Royal Society of Chemistry.

Acute kidney injury associated to sulfamethoxazole urine crystal: The importance of clinical suspicion.

Management of acute kidney injury (AKI) associated with drug-induced crystal nephropathy can be difficult, and timely diagnosis is critical to resolve this condition. We present the case of a 55-year-old woman with history of systemic lupus erythematosus (SLE), who, after treatment with trimethoprim/sulfamethoxazole (TMP/SMX) for suspected Pneumocystis jirovecii pneumonia, developed severe AKI. Automated urinary sediment initially reported hematuria, leukocyturia and "uric acid crystals". She did not have allergic symptoms, clinical manifestations of active SLE nor hyperuricemia. AKI persisted despite volume expansion with crystalloids. Due to SMX exposure, it was suspected that "uric acid crystals" could be in reality "SMX crystals", and were a possible cause of crystal nephropathy. TMP/SMX was withheld and urinary alkalization was performed, with subsequent resolution of AKI. SMX urine crystals were posteriorly confirmed by Fourier transform infrared spectroscopy.

THE SUBSEQUENT IMPACT OF COVID-19 FOR BOTH IMMUNE DYSREGULATION AND OPPORTUNISTIC INFECTIONS

SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: The COVID-19 pandemic remains a burden to healthcare worldwide. Current literature suggests a possible link between COVID-19 survivors and opportunistic infections. We present a case of an immunocompetent male who presented with pneumocystis jirovecii pneumonia (PJP) in the setting of a recent COVID-19 infection. CASE PRESENTATION: A 65-year-old man with 65 pack-year smoking history, COPD, and recent COVID-19 pneumonia requiring hospitalization 1 month prior, presented with 2 days of dyspnea. His physical exam was notable for hypoxia requiring supplemental oxygen and bibasilar crackles. WBC was elevated at 15,500. ABG was significant for hypoxemia. A CT chest demonstrated bilateral peripheral mixed ground glass and consolidative opacities (Figure 1). Upon admission, the patient received ceftriaxone and azithromycin for presumed community acquired pneumonia. However, the patient continued to clinically decompensate with increasing oxygen requirements. As such, a repeat CT was ordered which demonstrated bilateral ground glass opacities, interstitial scarring, and subpleural honeycombing (Figure 2). A bronchoscopy was also performed;bronchoalveolar lavage was positive for PJP by PCR but with negative DFA. The patient was started on trimethoprim/sulfamethoxazole (TMP/SMX) and prednisone. After 3 weeks, the patient clinically improved and was discharged to a skilled nursing facility for rehabilitation. Subsequent CT scan 1 month after initial presentation demonstrated fibrotic changes and bronchial wall thickening (Figure 3). DISCUSSION: In our case, the patient was an immunocompetent male with underlying COPD and recent COVID-19 pneumonia, found to have PJP by PCR. The PCR test for PJP has a higher sensitivity compared to DFA (1), so our patient's incongruent positive PCR and negative DFA test results may represent true PJP or an organizing pneumonia with colonization. A lung biopsy with histology ultimately could have confirmed the diagnosis but was not performed in this case given the patient's clinical improvement with steroids and TMP/SMX (2). Previous studies have demonstrated that COVID-19 can cause immune dysregulation via decreased T cell count and thus can increase the risk for opportunistic infections (3). Furthermore, multiple case reports have shown concurrent COVID-19 and PJP in immunocompetent patients (1). Based on his findings, we believe that our patient was at increased risk for and subsequently developed PJP as a direct consequence of his recent COVID-19 infection. CONCLUSIONS: COVID-19 has been identified as a predisposing factor for subsequent chronic conditions. Studies have demonstrated the capability of COVID-19 infection to weaken the immune system for opportunistic infections as well as remodel the pulmonary architecture. Both conditions can confer high morbidity and mortality for COVID-19 survivors. As such, a close surveillance of this population is warranted. Reference #1: Chong WH, Saha BK, Chopra A. Narrative review of the relationship between COVID-19 and PJP: does it represent coinfection or colonization? Infection (2021) 49:1079–1090. doi:10.1007/s15010-021-01630-9 Reference #2: Culebras M, Loor K, Sansano I, Persiva Ó, Clofent D, Polverino E, Felipe A, Osorio J, Muñoz X, Álvarez A, et al. Histological Findings in Transbronchial Cryobiopsies Obtained From Patients After COVID-19. Chest (2022) 161:647–650. doi:10.1016/j.chest.2021.09.016 Reference #3: Qin C, Zhou L, Hu Z, Zhang S, Yang S, Tao Y, Xie C, Ma K, Shang K, Wang W, et al. Dysregulation of immune response in patients with coronavirus 2019 (COVID-19) in Wuhan, China. Clin Infect Dis (2020) 71:762–768. doi:10.1093/cid/ciaa248 DISCLOSURES: No relevant relationships by Duc Do No relevant relationships by Clara Suh

Characteristics and influencing factors for Stenotrophomonas maltophilia infection in a tertiary general hospital of Sanya city and drug resistance from 2016 to 2020

OBJECTIVE: To investigate the characteristics and influencing factors for Stenotrophomonas maltophilia (SMA) infection in Sanya and analyze the drug resistance so as to provide guidance for prevention and control of infection in medical institutions. METHODS: The hospitalization data were collected from the patients with SMA infection who were hospitalized in three tertiary general hospitals of Sanya from 2016 to 2020. The characteristics of SMA infection and influencing factors for respiratory tract and non-respiratory tract SMA infection were retrospectively analyzed, and the result of drug susceptibility testing was observed. RESULTS: A total of 753 case times of patients had SMA infection, including 606 (80.48%) case times of respiratory tract infection and 147 (19.52%) case times of non-respiratory tract infection. The isolation rate was the highest in respiratory medicine department (16.73%), followed by critical care medicine department (15.67%) and neurosurgery department (12.35%). The percentages of the patients with advanced age, complications with hypertension and pulmonary diseases, tracheotomy were the higher in the respiratory tract infection group than in the non-respiratory tract infection group (P < 0.05);while the percentages of the patients with malignant tumors, bacteremia, surgery, urinary tract intubation, low immunity and use of antibiotics and immunosuppressants were the higher in the non-respiratory tract infection group than in the respiratory tract infection group (P < 0.05). The result of drug susceptibility testing showed that the drug resistance rate of the SMA strains to sulfamethoxazole-trimethoprim was only 2.39%, while the drug resistance rate to ceftazidime was as high as 74.50%. CONCLUSION: The major influencing factors for the respiratory tract SMA infection include pulmonary diseases, hypertension, advanced age and tracheotomy;the influencing factors for the non-respiratory tract SMA infection include malignant tumors, low immunity, long-term excessive use of immunosuppressants and broad-spectrum antibiotics, bacteremia, surgery and urinary tract intubation. The SMA strains isolated from the city are highly sensitive to sulfamethoxazole-trimethoprim but are highly resistant to ceftazidime and chloramphenicol. It is necessary for the hospital to reasonably use antibiotics based on the result of drug susceptibility testing.

SYSTEMATIC LITERATURE REVIEW on the SCREENING and PROPHYLAXIS of CHRONIC and OPPORTUNISTIC INFECTIONS

Background: Opportunistic and chronic infections can arise in the context of treatment used for Autoimmune Rheumatic Diseases (ARDs). Although it is recognized that screening procedures and prophylactic measures must be followed, clinical practice is largely heterogeneous, with relevant recommendations not currently developed or disparately located across the literature. Objectives: To conduct a systematic literature review (SLR) focusing on the screening and prophylaxis of opportunistic and chronic infections in ARDs. This is preparatory work done by members of the respective EULAR task force (TF). Methods: Following the EULAR standardised operating procedures, we conducted an SLR with the following 5 search domains;1) Infection: infectious agents identifed by a scoping review and expert opinion (TF members), 2) Rheumatic Diseases: all ARDs, 3) Immunosuppression: all immunosuppressives/immunomodulators used in rheumatology, 4) Screening: general and specifc (e.g mantoux test) terms, 5) Prophylaxis: general and specifc (e.g trimethop-rim) terms. Articles were retrieved having the terms from domains 1 AND 2 AND 3, plus terms from domains 4 OR 5. Databases searched: Pubmed, Embase, Cochrane. Exclusion criteria: post-operative infections, pediatric ARDs, not ARDs (e.g septic arthritis), not concerning screening or prophylaxis, Covid-19 studies, articles concerning vaccinations and non-Εnglish literature. Quality of studies included was assessed as follows: Newcastle Ottawa scale for non-randomized controlled trials (RCTs), RoB-Cochrane tool for RCTs, AMSTAR2 for SLRs. Results: 5641 studies were initially retrieved (Figure 1). After title and screening and removal of duplicates, 568 full-text articles were assessed for eligibility. Finally, 293 articles were included in the SLR. Most studies were of medium quality. Reasons for exclusion are shown in Figure 1. Results categorized as per type of microbe, are as follows: For Tuberculosis;evidence suggests that tuberculin skin test (TST) is affected by treatment with glucocorticoids and conventional synthetic DMARDs (csDMARDs) and its performance is inferior to interferon gamma release assay (IGRA). Agreement between TST and IGRA is moderate to low. Conversion of TST/IGRA occurs in about 10-15% of patients treated with biologic DMARDs (bDMARDs). Various prophylactic schemes have been used for latent TB, including isoniazide for 9 months, rifampicin for 4 months, isoniazide/rifampicin for 3-4 months. For hepatitis B (HBV): there is evidence that risk of reactivation is increased in patients positive for hepatitis B surface antigen. These patients should be referred for HBV treatment. Patients who are positive for anti-HBcore antibodies, are at low risk for reactivation when treated with glucocorticoids, cDMARDs and bDMARDs but should be monitored periodically with liver function tests and HBV-viral load. Patients treated with rituximab display higher risk for HBV reactivation especially when anti-HBs titers are low. Risk for reactivation in hepatitis C RNA positive patients, treated with bDMARDs is low. However, all patients should be referred for antiviral treatment and monitored periodically. For pneumocystis jirovecii: prophylaxis with trimeth-oprim/sulfamethoxazole (alternatively with atovaquone or pentamidine) should be considered in patients treated with prednisolone: 15-30mg/day for more than 4 weeks. Few data exist for screening and prophylaxis from viruses like E B V, CMV and Varicella Zoster Virus. Expert opinion supports the screening of rare bugs like histoplasma and trypanosoma in patients considered to be at high risk (e.g living in endemic areas). Conclusion: The risk of chronic and opportunistic infections should be considered in all patients prior to treatment with immunosuppressives/immunomod-ulators. Different screening and prophylaxis approaches are described in the literature, partly determined by individual patient and disease characteristics. Collaboration between different disciplines is important.

Pharmaceuticals as Emerging Pollutants in the Reclaimed Wastewater Used in Irrigation and Their Effects on Plants, Soils, and Groundwater

Pharmaceuticals and personal care products (PPCPs) were investigated in five wastewater treatment plants (WWTPs), groundwater, irrigated soils, and plants in Amman and Al-Balqa governorates in Jordan. PPCPs were extracted from water samples by solid-phase extraction (SPE) and analyzed by high-performance liquid chromatography coupled with tandem mass spectrometry (HPLC–MS/MS). Carbamazepine, ciprofloxacin, ceftiofur, diclofenac, erythromycin, lincomycin, ofloxacin, pyrimthamine, spiramycin, sulfamethoxazole, sulfapyridine, testosterone, trimethoprim, and thiamphenicol were detected in all raw wastewaters in μg/L, whereas 45 PPCPs were below the detection limits (<0.02 μg/L) in all samples. Na`ur and Abu Nuseir WWTPs showed high PPCPs removal efficiencies in comparison with AL-Baqa`a, Salt, and Fuhais-Mahis WWTPs. Boqorreya spring showed signs of contamination by Salt WWTP effluents as a result of mixing. Irrigation with effluents showed higher carbamazepine concentrations in soils at the top soil layers (0 to 20 cm) in all farms than its concentrations at the root zone (20 to 40 cm) by using drip irrigation system with various plants. In plants, carbamazepine concentration was only detected in high concentration level in mint leaves. In the same farm, diclofenac concentration was detected only in olives and not in twigs and leaves, indicating a high rate of plant uptake especially during the olive’s growth period. Furthermore, plant fruits, leaves, and stems left on the farm after harvesting are generally consumed by cattle, which means entering the food chain of humans.

Stenotrophomonas maltophilia Bacteremia Associated With Severe COVID-19: Successful Treatment With Appropriate Antimicrobial Therapy.

Stenotrophomonas maltophilia, an opportunistic pathogen, can cause bacteremia in immunocompromised and debilitated patients. A 50-year-old man with severe coronavirus disease 2019 (COVID-19) was admitted to our hospital's intensive care unit where he underwent extracorporeal membrane oxygenation and ventilatory support. On day 25, he developed S. maltophilia bacteremia originating from an indwelling central venous catheter. After confirming susceptibility, trimethoprim-sulfamethoxazole (80 mg/400 mg) was administered thrice daily. Following improvement, he was weaned from ventilation, recovered sufficiently, and was discharged on day 53. To the best of our knowledge, this is the first report of a patient recovering after antimicrobial treatment for S. maltophilia bacteremia associated with severe COVID-19.

Biochar-Supported TiO2-Based Nanocomposites for the Photocatalytic Degradation of Sulfamethoxazole in Water-A Review.

Sulfamethoxazole (SMX) is a frequently used antibiotic for the treatment of urinary tract, respiratory, and intestinal infections and as a supplement in livestock or fishery farming to boost production. The release of SMX into the environment can lead to the development of antibiotic resistance among the microbial community, which can lead to frequent clinical infections. SMX removal from water is usually done through advanced treatment processes, such as adsorption, photocatalytic oxidation, and biodegradation. Among them, the advanced oxidation process using TiO2 and its composites is being widely used. TiO2 is a widely used photocatalyst; however, it has certain limitations, such as low visible light response and quick recombination of e-/h+ pairs. Integrating the biochar with TiO2 nanoparticles can overcome such limitations. The biochar-supported TiO2 composites showed a significant increase in the photocatalytic activities in the UV-visible range, which resulted in a substantial increase in the degradation of SMX in water. The present review has critically reviewed the methods of biochar TiO2 composite synthesis, the effect of biochar integration with the TiO2 on its physicochemical properties, and the chemical pathways through which the biochar/TiO2 composite degrades the SMX in water or aqueous solution. The degradation of SMX using photocatalysis can be considered a useful model, and the research studies presented in this review will allow extending this area of research on other types of similar pharmaceuticals or pollutants in general in the future.