Antimicrobial resistance (AMR) has become a global health crisis and poses a significant risk to public health systems around the world, including India. Resistant infections can complicate treatments, extend 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 more than 39 million deaths could occur from antibiotic-resistant infections by 2050.

In India, health systems are particularly vulnerable given the widespread and misuse of antibiotics and the lack of infrastructure in some regions. To combat this silent pandemic, wastewater monitoring (WWS) offers unique detection and monitoring capabilities. WWS can help quickly detect resistance patterns in a community and enable appropriate measures for public health response. It has emerged as a powerful tool in global efforts to eradicate poliovirus 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 hotspots and concentration levels of AMR, enabling targeted measures and interventions. In countries like India, where resistance rates are high, WWS could play a crucial role in preserving the effectiveness of current treatments in hospitals and strengthening public health systems.

WWS has been used to monitor poliovirus for decades and rose to 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, also provides the opportunity to understand and address the environmental transmission of various antibiotic-resistant pathogens in the environment, providing insight into resistance patterns in the human and animal population, particularly in a hospital environment.

Hospitals are considered hotspots for the development and spread of antibiotic resistance genes (ARGs) due to the high and consistent use of antibiotics. It is imperative that antibiotic resistance levels are constantly monitored to help inform and alert hospitals of the emergence of potential outbreaks and prioritize necessary interventions to be undertaken. WWS has proven to be an effective and cost-effective approach to monitoring antibiotic resistance in hospital settings to help provide information on 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 microorganisms specific to a battery of antimicrobial drugs. They are extremely useful for monitoring pathogen trends and their resistance to different drugs, providing invaluable data for both clinical medicine and surveillance. These antibiograms can be developed by analyzing existing ARGs in wastewater, helping hospital providers understand currently resistant pathogens and adapt antibiotic prescribing policies accordingly. Because they provide a localized summary of antimicrobial susceptibilities of bacterial pathogens prevalent in hospital settings, they enable public health stakeholders to make informed decisions about empirical treatments.

In addition to assisting in the development of antibiograms, WWS can also play a fundamental role in antibiotic stewardship programs (ASP). ASPs are essential frameworks deployed to combat the growing menace of AMR to ensure that the correct and necessary dosage and types of antibiotics are prescribed and to control the misuse of these drugs. Traditionally, ASPs rely on clinical data to inform and guide protocols, but therefore provide limited insights since resistance patterns are observed in a limited healthcare setting. Integrating WWS into ASPs can help ensure that a community-wide dimension can improve their effectiveness. WWS’s data capabilities can move ASPs from reactive to proactive frameworks, helping to identify emerging threats before they escalate.

WWS plays a central role in our national AMR strategies, as it enables policy makers and health stakeholders to lead targeted interventions. Formal recognition of WWS in the National Action Plan on Antimicrobial Resistance (NAP-AMR) would ensure that it receives the resources and standardization necessary for effective implementation nationwide. This effort requires collaboration across the medical, scientific, and government sectors to create a unified approach to AMR surveillance. By adopting WWS, we can build a proactive, data-driven defense against AMR, protecting public health and strengthening our national resilience to one of the most pressing challenges of our time.

This article is written by Dr. Narendra Saini, Chairman, AMR Committee, Indian Medical Association (IMA), New Delhi.