Antibiotic Resistance in South African Wastewater Treatment Plants: A Narrative Review of WHO-Listed Critical Priority Enteric Bacteria

The spread of antibiotic resistance is contributing to 4.95 million cases of mortality per year, and it is categorised as one of the top three threats to public health in modern society, threatening the ability to treat common infections. Wastewater treatment plants influence the dissemination and acquisition of antibiotic resistance to enteric bacteria due to the abundance of nutrients present in them. This narrative review synthesises published evidence on antibiotic resistance patterns in South African Wastewater treatment plants, with specific emphasis on WHO-listed critical priority enteric pathogens. This review is the first to provide a temporal analysis (2009–2024) of antibiotic resistance trends in South African Wastewater treatment plants before and after the WHO’s 2017 Bacterial Priority Pathogen List (BPPL), revealing a 20–50% increase in resistance to critical antibiotics, such as vancomycin and carbapenems, across Escherichia coli, Klebsiella pneumoniae, Enterococcus spp., Salmonella spp., and Campylobacter spp. Inconsistent monitoring methods, provincial disparities, and limited molecular investigations hinder a comprehensive national assessment. This review fills a critical geographic gap by focusing on South Africa, a low-middle-income country with unique socio-economic and environmental challenges and integrates local data with WHO’s global health priorities. By synthesising 24 studies and employing statistical analysis, it identifies region-specific resistance patterns and proposes a novel framework for enhanced monitoring using metagenomics and predictive modelling, advancing beyond existing African wastewater resistome studies.