Antibiotics (ABs) in the aquatic environment is a major problem due to the emergence of antibiotic resistance. The long-term ecological impact on the aquatic environment is unknown. Many sources allow entry of ABs into the environment, including Wastewater Treatment Plants (WWTPs), agricultural run-off, hospital effluent and landfill leachate. Concentrations of ABs in the aquatic environment vary significantly, studies have shown fluoroquinolones, tetracycline, macrolides, sulphonamides and penicillins to reach 2900, 1500, 9700, 21400 and 1600 ngL -1 in wastewater effluent samples, however, concentrations are highly variable between different countries and depend on several factors including seasonally variation, prescription, and WWTP operating procedures. Likewise, the reported concentrations that cause environmental effects varies greatly between ABs, even within the same This article is protected by copyright. All rights reserved. Accepted Articleclass, however, this predicted concentration for the ABs considered was frequently <1000 ngL -1 indicating that when discharged into the environment along with treated effluent, these have a potential detrimental effect on the environment. Antibiotics are generally quite hydrophilic in nature; however, they can ionise in the aquatic environment to form charged structures, such as cations, zwitterions, and anions.Certain classes, particularly fluoroquinolones and tetracyclines, can adsorb onto solid matrices, including soils, sediment, and sludge, making it difficult to fully understand their chemical fate in the aquatic environment. The adsorption coefficient (K d ) varies between different classes of ABs, where tetracyclines and fluoroquinolones show the highest K d values. Adsorption coefficients values for fluoroquinolones, tetracyclines, macrolides and sulphonamides have been reported as 54600, 7600, 130 and 1.37 Lkg -1 . Factors such as pH of the environment, solid matrix (sediment/soil sludge) and ionic strength can influence the K d , therefore, several values exist in literature for the same compound.

The present study reviews options for reducing harm from pharmaceuticals that are known to cause adverse impacts by their presence in the environment. It reviews recent global and European Union policy development, which could go further in recognizing and addressing the issue in a global context. It considers green chemistry, which can help clean up production processes but holds only long‐term promise for creating “green” alternatives. It explores the potential of health promotion and disease prevention, which can contribute significantly to a reduction of the disease burden and thus the need for medicines, both for infectious and for noncommunicable disease. Eco‐directed sustainable prescribing practices are reviewed, which have been adopted successfully to reduce the use of harmful pharmaceuticals. We note recent developments in medicines optimization and precision medicine, which hold promise for improving patient outcomes, saving costs, and reducing pharmaceutical use, through individually tailored prescribing whereby the patient codecides their therapy. Waste prevention through reuse or redistribution is beginning to find public support and “take‐back” waste disposal schemes set up via extended producer responsibility systems have achieved high returns. Finally, the paper summarizes preferred advanced wastewater technologies, including innovative low‐cost, low‐energy options. In summary, although end‐of‐pipe options have a role to play, particularly for highly concentrated wastewaters, solutions further up the medicinal chain and disease prevention interventions, informed by a broad view of health and health care, are needed to pursue a much greater potential reduction of pharmaceuticals in the environment than can be achieved by end‐of‐pipe solutions alone. Environ Toxicol Chem 2023;00:1–11. © 2023 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.