Hospital Wastewater-based Antimicrobial Resistance Surveillance: A Scoping Review

Introduction : Wastewater-based surveillance may offer a population-level approach to infer infectious disease dynamics. Hospitals may be a hotspot for pathogen circulation and antimicrobial resistance (AMR). We performed a scoping review assessing the potential of hospital wastewater to monitor hospital AMR. Methods : We explored four databases from inception to November 19, 2025, for studies using hospital wastewater to monitor antimicrobial resistance. The primary outcome was the detection of AMR in hospital wastewater and the concordance with traditional hospital AMR surveillance. Secondary outcomes included wastewater sampling, laboratory techniques employed for analysis, and reporting geographic distribution. Results : From 5,013 records screened, 30 studies met inclusion criteria. Wastewater sampling included grab or composite samples from hospital outlets. Phenotypic methods—i.e. culture-based—were used in 83% of studies, while PCR (70%), WGS (30%), metagenomics (27%), and PFGE (7%) represented the main genotypic approaches. Targets of interest were predominantly Gram-negative pathogens and key resistance mechanisms, particularly carbapenem and other beta lactam resistance. Although all studies compared wastewater-based and traditional hospital AMR surveillance; sampling strategies, laboratory techniques and alignment of collection periods were heterogeneous. Studies spanned 20 countries, only 7% were from lower-middle-income countries, and none from low-income countries. Conclusion : The potential of wastewater-based surveillance to complement traditional hospital AMR surveillance remains uncertain. Standardized frameworks are needed for cross-study comparisons, and more time-series studies incorporating patient-level data, especially from low- and middle-income countries, are required.