Pharmaceutical class Compound •Reason for inclusion  Notes Analgesics and anti-inflammatories Naproxen •Identified by 4 partners •MEC of 9300ng/l (Zorita et al., 2009) •found in waste water and surface water (CH, NL) •up to 30% hospital contribution Analgesics, or pain killers, are widely used and have been measured in high concentrations in sewage influent and effluent, as well as in surface waters (Derksen et al, 2001). For some analgesics (e.g. Paracetamol and Ibuprofen) the hospital contribution is relatively small as these compounds can be bought over the counter, so that they were not monitored even though they pose an environmental risk.   Diclofenac •selected by 5 partners •high consumption (CH, NL) •highest acute toxicity of non-steroidal anti-inflammatory drug (NSAID) (Fent et al., 2006) •proposed as Priority Substance Anticonvulsants/tranquilisers Carba-mazepine •selected by 4 partners •on 5 priority lists •persistent in standard waste water treatment (e.g. Ferrari et al., 2003) Carbamazepine is not a typical hospital drug, but has been previously encountered in waste water and identified as a priority by several organisations. Betablockers/Anti-hypertensives Atenolol •Selected by 3 partners •Found in wastewater (CH) •on 3 priority lists Betablockers are not typical hospital drugs, but may be used in above average amounts in care homes; atenolol was selected as a representative Lipid Regulators Bezafibrate •Selection by 4 partners •Found in wastewater (CH) •on 5 priority lists   Chronic exposure to these compounds did show inhibition of growth population on rotifers and crustaceans at lower concentrations, whereas acute toxicity was in the order of dozens of mg/L. Genotoxic and mutagenic effects were especially found for gemfibrocil and its by-products (Isidori et al., 2007). Anaesthetics Lidocaine •Selected by 3 partners •Found in wastewater (CH) •Widely used anaesthetic •Expected high hospital contribution Lidocaine is a widely used anaesthetic and expected to have a high hospital contribution. Antibacterials Amoxicillin † •selected by 4 partners •high concentrations expected •most used antibacterial (NL) Antibacterials are a diverse group of chemicals that can be divided into subgroups such as β-lactams (including penicillins), quinolones, tetracyclines, macrolides, sulphonamides and others. In most countries, β-lactams account for approximately 50-70% of antibacterials. Some sorption to sludge occurs, but biodegradation is poor for most antibacterials (Kümmerer, 2009a).  The concentrations reported for β-lactams are low compared to those expected given the extensive use; this could be due to analytical difficulties (Kümmerer, 2004)  because β-lactams are not very stable and readily hydrolyse  (Hirsch et al., 1999; Längin et al., 2009). According to literature, the hospital contribution to total environmental load varies between only a few percent and over 80% (Ternes and Joss, 2006).   Ciprofloxacin •selected by 4 partners •most used fluoroquinolone (NL, CH) •high concentrations expected in hospital •low PNEC   Clarithro-mycin •selected by 4 partners •most frequently used macrolide (NL) •found in wastewater (CH) •low PNEC   Erythromycin •selected by 5 partners •on 5 priority lists   Sulfameth-oxazole ‡ •selected by 5 partners •high concentrations expected (NL) •top sulfanomide (NL) •4 priority lists (DE) •found in wastewater (CH) Contrast media Diatrizoate •selected by 5 partners •on 4 priority lists Most contrast media are water soluble and are typically complex iodinated compounds.  All tend to be excreted almost 100% and be persistent, and were included as hospital specific substances even though they are designed to be biologically inert.   Iopamidol •selected by 4 partners •on 3 priority lists   Iopromide •selected by 4 partners •on 3 priority lists Cytostatics Cyclophos-phamide •selected by 4 partners •highly persistent in waste water (Buerge et al., 2006) •3 priority lists Cytostatics, or anti-neoplastics, are anti-cancer drugs and may have carcinogenic, mutagenic, fetotoxic and teratogenic effects (Kümmerer et al., 1997) even though only at high concentrations (Ferk et al., 2009). They are generally persistent and the widely used antineoplast Ifosfamide was was found not to be eliminated by conventional treatment (Kümmerer et al., 1997).   Ifosfamide •selected by 4 partners •highly persistent in waste water (Buerge et al., 2006) •3 priority lists Other treatment groups/PPCPs considered but not included in monitoring programme •Other substances such as psycho-active (Care Commission and Mental Welfare Commission, 2009), anti-viral and anti-diabetic drugs were suggested for monitoring but are primarily used in the community and was therefore less relevant to the project. Other compounds suggested by the partners included preservatives, diuretics, anti-fungals, disinfectants, antacids and anti-worming agents. †It was agreed that Amoxicillin would be of interest, but there were concerns over the analyte stability. It was nonetheless planned to be monitored by 5 out of 6 partners and has therefore been left in the data tables accompanying this paper ‡Including the metabolite N - acetyl - sulfamethoxazole. Excretion of sulfamethoxazole is mainly in the form of the metabolite but there is a degree of conversion back to the parent compound during wastewater treatment, so that parent compound and metabolite need to be included in mass balances (Göbel et al., 2005)

Table 3: Compounds selected for monitoring.