Many PhACs and byproducts exist in rivers, lakes, and groundwater [26]. Due to their widespread use, persistence, and bioaccumulation potential, several classes of PhACs have been identified as hazards to human and environmental health. They primarily infiltrate waterways through wastewater treatment plants, improper drug disposal, and human and animal waste (Figure 1).

PhACs can alter aquatic systems’ nutrient cycling, energy transmission, and microbial community composition, resulting in altered reproduction and development, as well as changing the behavior and survivability of almost all aquatic vertebrates and invertebrates [50,76]. Moreover, low antibiotic concentrations are associated with the survival and spread of antibiotic-resistant bacteria (ARBs) and antibiotic resistance genes (ARGs), which endanger human and animal health. Indeed, chronic exposure to trace amounts of PhACs in potable water or the consumption of contaminated aquatic organisms may result in medication resistance. To reduce PhACs’ contamination of water bodies and soil, upgrading treatment facilities or implementing new treatment methods is imperative. Depending on persistence, bioaccumulation, and exposure, pharmaceutical pollution varies by region and water body. Nevertheless, it is important to note that while conventional pollution typically has a more detrimental impact on hosts or pathogens when present in higher quantities, emerging pollutants such as pharmaceuticals can often exert their effects even at lower doses, usually after long-term exposure [6,77,78]. This phenomenon can be attributed to the specific manner in which these chemicals target conserved pathways [79]. The sensitization of the public, proper use and disposal, waste management, and purification have been proposed as essential measures to reduce pharmaceutical pollution and its potential adverse health and environmental effects [80]. Table 1 summarizes the main sources and the corresponding effects of these PhACs.

Antibiotics are frequently employed in human as well as animal medicine for the purpose of treating bacterial infections. Penicillins, cephalosporins, lincosamides, macrolides, tetracyclines, sulfonamides, and quinolones are among the most frequently utilized classes of antibiotics in human medicine [89]. After ingestion, humans and animals frequently excrete antibiotics. Antibiotics and their constituents can also be released from untreated or inadequately treated effluents if conventional wastewater treatment methods are ineffective at removing them [35,36]. The excessive utilization of agricultural practices, such as farming and raising livestock, may be another source that contributes to the release of antibiotics into the surrounding environment.

Due to their vast utilization, the discharge of antibiotic-containing effluent into rivers, lakes, or other water bodies contributes significantly to pharmaceutical pollution [81,84,87,88,91,116]. Despite utilizing advanced treatment methods like activated carbon adsorption, ozone treatment, or other advanced methods, completely eradicating antibiotic residues from enriched wastes may not be achievable. Furthermore, the persistence of antibiotics in the environment can be attributed to their resistance to degradation [86]. Hence, antibiotics in the environment can potentially contribute to developing and spreading antibiotic resistance in microorganisms, posing significant challenges in treating infections. It can also exert selective pressure by disturbing the equilibrium of microbial communities in water bodies, thereby affecting nutrient cycling and the overall ecosystem functioning. This disturbance contributes to the emergence and dissemination of antibiotic-resistant bacteria (ARBs) and antibiotic resistance genes (ARGs) [82,83].

Endocrine-disrupting chemicals (EDCs) are naturally occurring or artificially produced compounds that interfere with the normal functioning of hormones in the body. Hormones such as estrogen are integral endocrine system components [117]. According to the United States Environmental Protection Agency (EPA), an EDC is an exogenous substance that possesses the capacity to interfere with the synthesis, secretion, transport, metabolism, receptor binding, or clearance of endogenous hormones, thereby inducing modifications in the endocrine and homeostatic systems [118,119]. EDCs are commonly found in a variety of everyday products, such as human and animal medications (e.g., diethylstilbestrol), cosmetics (e.g., triclosan), food and beverage packaging (e.g., perfluorochemicals, bisphenol A, phthalates), toys (e.g., lead and cadmium), industrial solvents or oils and their by-products (e.g., dioxins and polychlorinated biphenyls), and pesticides (e.g., dichlorodiphenyltrichloroethane and chlorpyrifos) [120,121,122]. EDCs can be classified into four distinct groups based on their source: industrial (e.g., dioxins, polychlorinated biphenyls, and alkylphenols), agricultural (including pesticides, insecticides, herbicides, phytoestrogens, and fungicides), residential (such as phthalates, polybrominated biphenyls, and bisphenol A), and pharmaceutical (including birth control pills, hormone replacement therapy, and parabens) [118,123,124].

Pharmaceutical EDCs can enter the environment through excretion and improper disposal [92,96,98]. Since hormones regulate human and animal physiological processes, their release into the environment through agricultural and livestock manure runoff can contribute to environmental pollution and ultimately disrupt the endocrine systems of aquatic organisms, resulting in reproductive and developmental abnormalities, altered sex ratios, and stunted growth and development [93,94,95,97,99,100]. Estrogenic hormones, such as estradiol and ethinyl estradiol (i.e., a synthetic estrogen present in contraceptive medications), are of special concern. The presence of these hormones has been linked to the occurrence of feminization effects in fish populations. Exposure to these hormones can induce the development of intersex traits, characterized by both male and female characteristics within a single individual, as well as the disturbance of normal reproductive processes. Fish feminization can have significant implications for population dynamics and reproductive success. It can sometimes lead to population declines or the extinction of endangered species [125,126].

Although the direct impact of hormone-contaminated water on human health is not yet fully understood, scientists continue to investigate the potential risks since it is believed that chronic exposure to low levels of hormone contaminants in potable water or consuming contaminated aquatic organisms may subtly affect human endocrine systems [127].

Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly employed to manage pain and inflammation. The detection of analgesics and NSAIDs in both ground and surface water, such as lakes and rivers, has become prevalent due to their extensive utilization. Minute amounts of NSAIDs have been identified in various environmental matrices such as soil, wastewater, surface water, groundwater, sediments, snow, and drinking water [39,104]. Despite negligible detectable environmental concentrations, NSAIDs have long-lasting ecotoxic impacts on the biotic components of ecosystems [103,104]. According to Feng et al. [128], daily NSAID consumption exceeds 30 million doses and is rising swiftly. Due to their stability and resistance to degradation, these compounds can persist in the environment and accumulate over time. NSAIDs can enter the environment through various routes, but human excretion is the most common. The inappropriate disposal of unused medications further contributes to NSAID pollution [129]. Additionally, pharmaceutical manufacturing and healthcare facility effluent discharges can release NSAIDs into the environment. NSAIDs can influence organisms’ behavior, reproduction, growth, and development. For instance, NSAIDs such as ibuprofen and diclofenac have been associated with impaired reproduction and aberrant development in fish. In addition, repeated exposure to NSAIDs may cause bioaccumulation in aquatic organisms. Bioaccumulation can occur through the food chain, leading to elevated levels of NSAIDs in predators that consume contaminated prey. NSAIDs can influence the microbial communities of aquatic ecosystems by inhibiting the development and activity of beneficial bacteria, resulting in population imbalances among microorganisms and disruption of essential ecological processes [101,102].

Psychotropic medications and AEDs are commonly employed in managing mental health disorders, such as anxiety and depression, addiction, seizures and convulsions, and chronic pain management. Researchers have discovered traces of psychotropics and AEDs in aquatic environments, implying their widespread presence. Psychotropic and AED drugs infiltrate the environment primarily through human excretion following their use as medications. The active compounds of psychotropic medications are metabolized within the body, and the residues are excreted through urine and feces. Also, these drugs can infiltrate wastewater systems via sewage or septic tanks [43,44,108]. Studies have demonstrated that exposure to psychotropic medications can induce alterations in the behavior, reproductive patterns, and physiological functions of fish, invertebrates, and other aquatic organisms [106,107], contributing to further disrupting the natural ecological processes and aquatic ecosystem populations.

β-blockers are a class of pharmaceutical drugs (competitive antagonists) that inhibit the activity of adrenergic β-receptors in the sympathetic nervous system. The broad range of pathologies for which β-blockers are prescribed has resulted in an annual consumption increase of more than treble [130,131]. Although β-blockers have significant therapeutic value, they can potentially contribute to pharmaceutical pollution and have environmental effects. The increased consumption of β-blockers has led to increased tracing in the environment, and their presence has been detected in several bodies of water [132,133]. The administration of β-blockers has the potential to exert adverse effects on fish, as evidenced by their ability to induce alterations in pulse rate and other cardiovascular-related physiological processes. They have been found to have various impacts on aquatic organisms, such as causing disruption in testosterone levels, reducing fertility and reproduction rates, and inducing abnormal behavior [109,110,111]. β-blockers can alter the activities and functions of microorganisms involved in decomposing organic matter during treatment within wastewater treatment facilities [112].

Chemotherapy and anticancer medications may pose risks as pharmaceutical pollutants when discharged into the environment [115]. Human excretion is the primary source after administering these medications to cancer patients. However, the incorrect disposal of unused medicines can contribute to chemotherapy drug pollution. Typically, conventional wastewater purification processes are ineffective at removing chemotherapy drugs. Thus, these drugs can enter the environment through treated effluents [114,134]. Certain chemotherapy drugs are designed to be exceedingly robust and resistant to degradation to exert their therapeutic effects on the human body. This stability will also allow them to endure for extended periods in the environment and, consequently, may accumulate over time, resulting in long-term exposure in particular regions [114,135]. Chemotherapeutic medications may adversely affect aquatic organisms and other non-target species [113]. They can affect the growth, development, and reproduction of organisms exposed to them by interfering with normal cell division and DNA replication. Several investigations have demonstrated toxic effects at environmental concentrations on fish, invertebrates, and other aquatic organisms [114]. Additionally, chemotherapy drugs can disrupt the growth and activity of soil and water microbial communities in the environment, leading to population imbalances and disturbances in ecological processes.