Wastewater-based surveillance of ESKAPE pathogens in resource-limited countries (RLCs): an essential tool for monitoring antibiotic resistance

Antibiotic-resistant bacteria (ARB) among ESKAPE pathogens represent one of the most serious public health threats. Wastewater-based surveillance (WBS) has emerged as a cost-effective and noninvasive approach for the early detection of antibiotic resistance genes (ARGs). It holds particular promise in resource-limited countries (RLCs), where traditional clinical surveillance often faces infrastructural and financial constraints. This review examines sampling strategies, pathogen detection technologies and relevant case studies, while identifying barriers such as fragmented sanitation systems, insufficient laboratory resources and the lack of standardised protocols for monitoring ESKAPE pathogens, recognised as critical threats in the WHO Bacterial Priority Pathogens List (BPPL), in RLCs. WBS complements existing surveillance systems, providing early warning of trends and informing timely public health interventions. Furthermore, this review proposes a roadmap for integrating WBS into public health frameworks in RLCs. To maximise its potential, scalable and cost-effective sampling and analysis methods tailored to local infrastructure must be developed, alongside clear ethical and regulatory frameworks to address privacy and data-use concerns. In conclusion, the WBS represents a transformative opportunity for public health monitoring in RLCs. Despite logistical and infrastructural hurdles, its capacity to deliver population-level insights into disease dynamics makes it an invaluable component of a modern surveillance system.