Could wastewater-based surveillance be key to combating antimicrobial resistance?

Antimicrobial resistance (AMR) is one of the most urgent health threats of the 21st century. Surveillance is needed to enable timely interventions, close knowledge gaps, and anticipate long-term trends. Current frameworks rely heavily on clinical data, which often fail to capture population-level dynamics. Wastewater-based surveillance (WBS) offers a complementary approach by detecting antibiotic resistance genes (ARGs) in sewage. In AMR surveillance, early warning includes the detection of novel or clinically relevant ARGs, including those carried by mobile genetic elements (MGEs) before they affect clinical outcomes. WBS can also reveal resistome composition, dissemination routes, and ecological drivers of AMR. This is especially relevant in settings with poor sanitation, high exposure, and limited clinical reporting. Unlocking its potential will require harmonized protocols, sustained investment, and strong ethical measures. Within a One Health framework, WBS can strengthen equitable and evidence-based strategies against AMR.