Building bridges to operationalize One Health — A longitudinal two years’ AMR study in England using clinical and wastewater-based surveillance approaches

Objectives: The coronavirus disease 2019 (COVID-19) pandemic impacted antimicrobial resistance (AMR) in clinical settings, but evidence is lacking. Considering this, we evaluated community-wide AMR in the shadow of COVID-19, using wastewater-based epidemiology (WBE). Methods: Five hundred ninety wastewater samples were collected from 4 contrasting communities in England between April 2020 and March 2022 to test for antibiotics used, their metabolites, and persistent antibiotic resistance genes (ARGs). Catchment-wide COVID-19 cases and antibiotic prescription data were triangulated with WBE data to evaluate the impact of the COVID-19 pandemic on changes in antibiotic use and resulting AMR at fine spatio-temporal resolution. Results: Observed reduction in antibiotic consumption and AMR prevalence during the COVID-19 pandemic (especially during lockdowns) is likely due to reduced social interactions rather than due to reduced antibiotic prescribing. Population-normalised daily intake and daily prescriptions showed an increase of 17.2% and 5.8%, respectively, in 2021 to 2022, in comparison to the previous pandemic year. Of the 17 antibiotics targeted, amoxicillin and clarithromycin were clearly affected by COVID-19 restrictions during the years 2020 to 2021 with an average of 31.5% (P < 0.01) and 13.5% (P < 0.05) lower usage, respectively, followed by an increase in 2021 to 2022. This has significant implications for practice and policy that currently focus on the reduction of antibiotics as the key risk factor in AMR. Conclusions: Better, more holistic strategies encompassing the One Health philosophy are needed to understand and act upon the AMR challenge.