Guarding against AMR: Unlocking the potential of wastewater surveillance in public health
This article is authored by Dr Narendra Saini, chairman, AMR Committee, Indian Medical Association (IMA), New Delhi.
Antimicrobial Resistance (AMR) has escalated as a global health crisis and poses a great risk to the public health systems around the world, including India. Resistant infections can complicate treatments, lengthen hospital stays, and increase mortality rates. A recent study published in The Lancet highlights the alarming impact of antimicrobial resistance (AMR) on global health, estimating that over 39 million deaths could occur from antibiotic-resistant infections between now and 2050.

In India, the health systems are particularly vulnerable given the widespread use and misuse of antibiotic drugs and under-resourced infrastructure in certain areas. To combat this silent pandemic, Wastewater Surveillance (WWS) offers unique capabilities in detection and surveillance. WWS can help detect resistance patterns in a community early and enable appropriate measures for public health response. It emerged as a powerful tool in global poliovirus eradication efforts, and more recently in the Covid-19 pandemic detecting silent pandemics and emerging variant strains. By monitoring wastewater, public health actors, and hospitals can identify AMR hotspots and concentration levels, allowing for targeted measures and interventions. In countries like India, where resistance rates are high, WWS could play a crucial role in preserving the efficacy of current treatments in hospitals and strengthening public health systems.
WWS has been leveraged to monitor poliovirus for decades and gained prominence during the advent of the Covid-19 pandemic as a resource-efficient tool for monitoring the spread and evolution of SARS-CoV-2. WWS, as a tool, provides an opportunity to also understand and address the environmental transmission of various antibiotic-resistant pathogens in the environment imparting reflections of the resistance patterns in the human and animal population, especially in hospital settings.
Hospitals are seen as hotspots for the development and spread of antibiotic-resistance genes (ARGs) due to the high and constant use of antibiotics. It is imperative that antibiotic resistance levels be constantly monitored to help inform and alert hospitals to the emergence of potential outbreaks and help prioritise necessary interventions that need to be undertaken. WWS has proven to be an efficient and cost-effective approach to monitor antibiotic resistance across hospital settings to help provide insights into prevalent ARGs in the ecosystem.
WWS can help develop other tools to monitor resistance patterns such as antibiograms. Antibiograms provide a profile of antimicrobial susceptibility testing results of specific microorganisms to a battery of antimicrobial drugs. They are extremely beneficial to monitor the trends in pathogens and their resistance to different drugs, providing invaluable data to both clinical medicine and surveillance. These antibiograms can be developed by analysing the existing ARGs in wastewater helping hospital providers understand the pathogens that are currently resistant and adapt antibiotic prescription policies accordingly. As they provide a localised summary of the antimicrobial susceptibilities for prevalent bacterial pathogens in the hospital environment, it enables public health actors to make informed decisions about empiric treatments.
In addition to aiding the development of antibiograms, WWS can also play a fundamental role in Antibiotic Stewardship Programs (ASPs). ASPs are critical frameworks deployed to combat the rising threat of AMR to help ensure the correct and necessary dosage and types of antibiotics are prescribed and keep the misuse of these drugs in check. Traditionally, ASPs have relied on clinical data to inform and guide protocols but consequentially provide limited perspectives since resistance patterns are observed within a limited health care setting. Integration of WWS into ASPs can help ensure that a community-wide dimension can enhance their effectiveness. The data capabilities of WWS can transition ASPs from reactive frameworks to proactive frameworks, assisting in identifying emerging threats before they escalate.
WWS is pivotal to our national AMR strategies as it enables policymakers and health actors to direct targeted interventions. The formal recognition of WWS in the National Action Plan on Antimicrobial Resistance (NAP-AMR) would ensure it receives the resources and standardisation needed for effective implementation nationwide. This effort requires collaboration across medical, scientific, and governmental sectors to create a unified approach to AMR surveillance. By adopting WWS, we can build a proactive, data-driven defence against AMR, protecting public health and reinforcing our national resilience against one of the most pressing challenges of our time.
This article is authored by Dr Narendra Saini, chairman, AMR Committee, Indian Medical Association (IMA), New Delhi.
