Work

One health perspectives on pharmaceutical and clinical effluents driving multidrug resistance in aquatic ecosystems: a comprehensive review

Year: 2026

Type: review

Abstract: Antimicrobial resistance (AMR) has emerged as one of the most pressing global health challenges, yet the contribution of environmental reservoirs to the spread of multidrug resistance (MDR) remains insufficiently integrated into mainstream discussions. This systematic review synthesizes evidence from 167 peer-reviewed studies published between 2000 and 2026 to examine how pharmaceutical manufacturing effluents and clinical waste drive the dissemination of antibiotic resistance genes (ARGs) and multidrug-resistant bacteria in aquatic ecosystems. The literature was systematically identified and selected from major scientific databases using predefined inclusion and exclusion criteria. The reviewed evidence consistently shows that aquatic environments receiving inadequately treated pharmaceutical and healthcare waste which creates environmental hotspots characterized by elevated antibiotic residues, mobile genetic elements, and resistant microbial communities. Sub-inhibitory antibiotic concentrations, biofilm-mediated horizontal gene transfer and quorum-sensing dynamics collectively accelerate resistance gene dissemination beyond what direct selective killing alone would predict. Heavy metals, including copper, zinc, mercury, cadmium, and arsenic, further reinforce resistance through co-selection mechanisms, sustaining clinically important determinants such as blaNDM-1 , blaKPC , and mcr-1 even in environments with limited antibiotic exposure. The review also highlights the role of non-pathogenic environmental bacteria as genetic reservoirs that facilitate the movement of resistance traits into pathogenic microorganisms. Metagenomic evidence confirms bidirectional exchange of resistance determinants between environmental and clinical bacterial populations, firmly situating the environmental resistome within a One Health framework. Despite growing evidence, important knowledge gaps remain regarding environmental-to-clinical transmission pathways, long-term ecological impacts, and the effectiveness of current mitigation strategies under diverse environmental conditions. Future research should prioritize longitudinal surveillance, multi-omics and systems biology approaches, metagenomic resistome profiling, and machine-learning-based predictive frameworks to better understand resistance dynamics across interconnected ecosystems. The findings support the integration of ARG monitoring into environmental management programs and underscore the need for advanced wastewater treatment technologies, harmonized discharge regulations, and coordinated One Health policies to curb the environmental amplification of antimicrobial resistance. These insights also contribute directly to achieving multiple Sustainable Development Goals, particularly SDG 1, 2, 3, 6, 9, 12, and 17 by fostering sustainable and integrated approaches to AMR mitigation.

Source: Frontiers in Systems Biology

DOI: 10.3389/fsysb.2026.1890380

Authors: Anshnu Tyagi, Minakshi Rajput, Sudhanshu Mishra

Institutions: National Forensic Sciences University, Swedish National Board of Forensic Medicine, National Forensic Institute, Dehradun Institute of Technology University

Language: English

Topic: Pharmaceutical and Antibiotic Environmental Impacts

Subfield: Pollution

Field: Environmental Science

Domain: Physical Sciences

SDG: Good health and well-being

Open Access status: gold

Estimated APC paid: $2,353