Holistic Approaches to Waterborne Urinary Tract Infections: Genomic Analysis, Antimicrobial Resistance, and Surveillance Strategies

Urinary tract infections (UTIs) are among the most common bacterial infections globally and disproportionately affect women. Increasing evidence suggests that environmental exposures, water insecurity, and antimicrobial resistance (AMR) influence UTI risk, particularly in resource-constrained settings. Using a mixed-methods approach, this research investigates environmental and socio-behavioral contributors to waterborne UTIs in San Cristóbal, Galápagos, and develops scalable environmental surveillance strategies for antimicrobial resistance.Household water samples were analyzed for total coliforms and Escherichia coli (E. coli) to characterize fecal contamination and evaluate potential environmental reservoirs of uropathogenic bacteria. Culture-based and genomic analyses of environmental isolates identified uropathogenic virulence determinants and antimicrobial resistance genes, highlighting household water as a potential environmental reservoir for extraintestinal infection risk. Detection of microbial water quality indicators varied across cistern, tap, and drinking water sources with contamination most frequently observed in drinking water (total coliform: 52.4%, E. coli: 19.0%).Concurrent urine sampling and antimicrobial susceptibility testing identified asymptomatic bacteriuria in 50% of participants, including multidrug-resistant isolates exhibiting resistance to commonly prescribed antibiotic classes. Focus group discussions contextualized these findings, as women described gendered responsibility for household water management and frequently linked perceived water quality to urinary and reproductive health within a broader context of infrastructural distrust, seasonal variability, and structural constraints.Addressing the growing threat of multidrug-resistant organisms requires scalable public health surveillance tools. This work describes a wastewater-based epidemiology framework designed to translate environmental microbial signals into coordinated public health response, with application for antimicrobial resistance surveillance.Together, these findings position UTIs within interconnected human and water systems, demonstrating how environmental contamination, antimicrobial resistance, and gendered structural dynamics may converge to influence vaginal and urinary health. By integrating microbiological analysis, community perspectives, and surveillance system design, this work advances a systems thinking and One Health approach for understanding and responding to UTIs in small island contexts and beyond.