Antimicrobial resistance (AMR) is an increasing major public health problem in the United States. Therefore, monitoring the status of AMR is vital to protecting population health. While there are established surveillance systems in clinical and veterinary settings, there is a lack of well-developed surveillance in the environment. Wastewater-based epidemiology, with focus on wastewater treatment plants (WWTPs), has been proposed as a solution to this gap in observation. This kind of surveillance has many advantages, such as being able to receive results in real-time, and is needed in addition to clinical and veterinary surveillance for AMR. However, this system is not fully developed and is lacking in standardized gene targets and analysis methodology. This review aims to provide a broad and current perspective of how antibacterial resistance can be monitored in wastewater in the United States. It will assess the current literature on method standardization which will allow for the ease of research comparison and risk assessment. It will outline potential gene targets for gram-negative bacterial species, specifically E. coli and Shigella spp., describe the advantages and disadvantages of the main analysis technologies (culture-based, amplification-based [e.g., qPCR], and metagenomics), and assess remaining knowledge gaps for the use of wastewater surveillance to monitor AMR. Wastewater-based epidemiology has the potential to be a low cost, passive surveillance method to help estimate the AMR status in a community and be used in conjunction with clinical and veterinary surveillance systems to aid public health officials inform policy and mitigation practices to slowing the spread of AMR.
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