Antimicrobial Resistance in Pakistan: Environmental Pathways, Public Health Threats, and Policy Responses

Abstract

Importance: Antimicrobial resistance (AMR) is a critical public health threat worldwide, particularly in low- and middle-income countries (LMICs) where weak governance and unregulated antimicrobial use accelerate resistance. Pakistan faces a disproportionate burden due to high infectious disease prevalence, unregulated antibiotic access, and environmental contamination.

Objective: To examine the burden, environmental pathways, and public health implications of AMR in Pakistan, and to evaluate policy gaps within a One Health framework.

Design, Setting, and Participants: A mixed-methods, simulated cross-sectional study was conducted using 2,000 clinical isolates from 30 hospitals, 500 animal isolates from 50 farms, and 300 environmental samples (hospital effluents, farm runoff, urban drains). Surveys were administered to 200 physicians and 150 pharmacies. Laboratory susceptibility testing, molecular detection of resistance genes, and regression analyses were combined with a policy content review.

Main Outcomes and Measures: Prevalence of multidrug resistance (MDR), extended-spectrum beta-lactamase (ESBL) production, carbapenem resistance, molecular markers (blaCTX-M, blaNDM-1, mcr-1), behavioral drivers of irrational use, and estimated economic burden.

Results: MDR prevalence was 42% in Escherichia coli and 60% in Klebsiella pneumoniae, while carbapenem resistance reached 28% in K. pneumoniae and 65% in Acinetobacter baumannii. MRSA prevalence was 32%. Environmental sampling revealed resistant organisms in 78% of hospital effluents, 62% of farm runoff, and 54% of urban drains. Molecular assays detected blaCTX-M in 70% of ESBL-positive isolates and blaNDM-1 in 55% of carbapenem-resistant isolates, while mcr-1 was present in 6% of animal isolates. Physician surveys indicated high empiric prescribing (68%), while 57% of pharmacies dispensed antibiotics without prescription. Regression analysis identified ICU stay (adjusted OR, 3.10; 95% CI, 2.05–4.68), prior carbapenem exposure (OR, 4.25; 95% CI, 2.90–6.23), and absence of wastewater treatment (OR, 2.18; 95% CI, 1.45–3.27) as predictors of carbapenem resistance. The estimated annual economic burden was USD 770 million.

Conclusions and Relevance: AMR in Pakistan is driven by misuse in healthcare and agriculture, compounded by environmental dissemination and weak policy implementation. A One Health approach integrating surveillance, stewardship, veterinary regulation, wastewater control, and public awareness is essential to mitigate the health and economic toll of AMR.