Wastewater's Role in the Fight Against Antimicrobial Resistance
Innovative approaches like wastewater-based epidemiology are emerging as powerful tools in the fight against AMR.
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Antimicrobial resistance (AMR) is one of the most urgent and growing threats to global health. As bacteria evolve to resist antibiotics, common infections – such as pneumonia, urinary tract infections and diarrhea – are becoming harder to treat.
The consequences of AMR are dire, with deaths directly attributable to AMR projected to rise from 1.14 million in 2021 to 1.91 million by 2050. The broader death toll associated with AMR could increase by nearly 75%, from 4.71 million in 2021 to an estimated 8.22 million by 2050.
Tackling this threat requires innovative solutions, and wastewater-based epidemiology (WBE) is emerging as a promising tool to detect and monitor the spread of AMR in communities worldwide. A new study, published in BioEssays, highlights the potential WBE holds as a powerful tool for detecting early signals of AMR at the community level.
Wastewater: A window into public health
Wastewater is often a hidden source of valuable health information. For years, researchers have used wastewater samples to track issues like drug use and outbreaks of diseases such as polio.
In recent years, it has proven effective in monitoring the spread of COVID-19, providing real-time data on infection rates and emerging variants. This concept can be extended to AMR surveillance, as Dr. Jose Balcazar from the Catalan Institute for Water Research (ICRA-CERCA) emphasizes in his recent study.
“Wastewater can provide valuable insights into population-level health by capturing antibiotic resistance determinants from both symptomatic and asymptomatic individuals, including those without access to healthcare,” Balcazar detailed.
This method offers the advantage of capturing health data from entire populations and provides a more inclusive view of public health than traditional clinical surveillance methods.
The promise and challenges of WBE
The major strength of WBE lies in its ability to detect emerging resistance patterns early, often before they are identified through clinical surveillance.
“Unlike clinical surveillance, which depends on individuals seeking medical attention, WBE provides a broader, community-level perspective that also captures data from individuals who do not access healthcare services,” Balcazar explained. This proactive approach enables researchers to monitor entire populations in a cost-effective, non-invasive manner.
Additionally, WBE is particularly valuable in low-resource settings, such as rural areas and informal settlements, where centralized healthcare infrastructure may be lacking.
“WBE is also non-invasive, anonymous and cost-effective, as it reduces the need for individual testing while still generating valuable epidemiological data. Its ability to support longitudinal monitoring allows for continuous tracking of AMR trends, which is essential for evaluating public health interventions and informing antibiotic use policies,” Balcazar added.
However, significant challenges remain. Standardized protocols for sampling, processing and analyzing wastewater are still lacking, and interpreting WBE data can be complex.
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“A major concern is the challenge in linking detected antibiotic resistance genes (ARGs) or antibiotic-resistant bacteria in wastewater to specific sources, such as hospitals, households or agricultural runoff,” Balcazar said.
Furthermore, variability in the persistence of ARGs within wastewater systems complicates efforts to interpret the data consistently across different locations and periods.
He added: “To fully realize the potential of WBE as a complementary strategy for AMR surveillance, existing technical, logistical, ethical and regulatory barriers must be addressed.”
A global effort to maximize WBE’s potential
“Altogether, WBE represents a valuable complement to AMR surveillance by offering community-level insights and enabling earlier detection of resistance trends,” Balcazar detailed. However, to fully unlock the potential of WBE for AMR surveillance, international coordination and investment are required. Balcazar advocates for the development of standardized testing protocols and quality assurance measures to ensure consistent results across global efforts.
Collaboration between environmental, health and policy institutions will be crucial to integrate wastewater data into broader public health systems and antibiotic stewardship strategies. In addition, there is a need for sustained investment in infrastructure, laboratory capacity and training, particularly in low- and middle-income countries, where resources for surveillance are often limited.
“With the right support and coordination, wastewater could become an essential early-warning system, helping save lives before infections become untreatable,” Balcazar concluded.
Reference: Balcázar JL. Wastewater-based epidemiology as a complementary tool for antimicrobial resistance surveillance: Overcoming barriers to integration. BioEssays. 2025. doi: 10.1002/bies.70034
