Metagenomics unveils the role of hospitals and wastewater treatment plants on the environmental burden of antibiotic resistance genes and opportunistic pathogens.

Antimicrobial resistance (AMR) is a global health challenge, with hospitals and wastewater treatment plants (WWTPs) serving as significant pathways for the dissemination of antibiotic resistance genes (ARGs). This study investigates the potential of wastewater-based epidemiology (WBE) as an early warning system for assessing the burden of AMR at the population level. In this comprehensive year-long study, effluent was collected weekly from three large hospitals, and treated and untreated wastewater were collected monthly from three associated community WWTPs. Metagenomic analysis revealed a significantly higher relative abundance and diversity of ARGs in hospital wastewater than in WWTPs. Notably, ARGs conferring resistance to clinically significant antibiotics such as β-lactams, aminoglycosides, sulfonamides, and tetracyclines were more prevalent in hospital effluents. Conversely, resistance genes associated with rifampicin and MLS (macrolides-lincosamide-streptogramin) were more commonly detected in the WWTPs, particularly in the treated effluent. Network analysis identified the potential bacterial hosts, which are the key carriers of these ARGs. The study further highlighted the variability in ARG removal efficiencies across the WWTPs, with none achieving complete elimination of ARGs or a significant reduction in bacterial diversity. Additionally, ARG profiles remained relatively consistent in hospital and community wastewater throughout the study, indicating a persistent release of a baseload of ARGs and pathogenic bacteria into surface waters, potentially polluting aquatic environments and entering the food chain. The study underscores the need for routine WBE surveillance, enhanced wastewater treatment strategies, and hospital-level source control measures to mitigate AMR dissemination into the environment.