Hospital wastewater treatment efficacy is conventionally assessed by total antibiotic resistance gene (ARG) abundance; however, whether this metric accurately reflects biosafety risk remains poorly defined. Using a one-year longitudinal metagenomic survey (bimonthly sampling; n = 18 per group), we simultaneously profiled the resistome, virulome, and mobilome of hospital wastewater influent and effluent; stratified functional gene abundances by genomic origin; quantified ARG–mobile genetic element (MGE) colocalization; and characterized multicategory gene cocarriage across the 15 most abundant pathogenic species. Although the abundance of total strict ARGs decreased significantly in the effluent (p = 0.038), the abundances of metal resistance genes and virulence factors increased concurrently (both p < 0.01), and 8 of the 20 ARG subtypes were enriched rather than removed. This decline was driven exclusively by a reduction in the number of plasmid-encoded ARGs (p < 0.001), whereas genes encoding chromosomal virulence factors, metal resistance genes, biocide resistance genes, and MGEs were significantly enriched in the effluent (all p < 0.05). The normalized ARG–MGE colocalization rate was significantly greater in the effluent (p = 0.028), with a concurrent shift toward transposase-mediated chromosomal mobilization. Pathogen-associated metagenomic assemblies of clinically relevant species exhibited synchronous multicategory resistance coenrichment in the effluent, which is consistent with coselection under antibiotic, biocide, and metal pressures. Total ARG abundance is fundamentally decoupled from biosafety risk in treated hospital wastewater, warranting integrated surveillance beyond ARG-centric metrics.
Liu et al. (Sat,) studied this question.