Wastewater surveillance of antibiotic resistant bacteria for public health action: Potential and Challenges

Antibiotic resistance is an urgent public health threat: an estimated 2 out of every 5 infection deaths are associated with antibiotic resistant bacteria. Current actions to reduce this threat include requiring prescriptions for antibiotic use, antibiotic stewardship programs, educational programs targeting patients and healthcare providers, and limiting antibiotic use in agriculture, aquaculture, and animal husbandry. Early warning of the emergence and spread of antibiotic resistant bacteria would aid these efforts. The SARS-CoV-2 pandemic demonstrated the value of wastewater surveillance as an early warning system for viral spread and detection of the emergence of new viral strains. In this commentary we explore whether monitoring wastewater for antibiotic resistant genes and/or bacteria resistant to antibiotics might provide similarly useful information for public health action. Using carbapenem resistance as an example, we highlight technical challenges associated with using wastewater to quantify temporal/spatial trends in antibiotic resistant bacteria (ARBs) and antibiotic resistant genes (ARGs) and compare with clinical information. We also comment on using wastewater to track foodborne outbreaks. We conclude with our assessment that beyond source tracking the value added of screening wastewater for ARBs and ARGs for direct public health action is relatively low with current technologies compared to surveillance methods already in place.