Environmental pathways and drivers of antimicrobial resistance in waterborne Escherichia coli in Pakistan: a one health perspective

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Background Antimicrobial resistance (AMR) is a global health crisis requiring a One Health approach to integrate surveillance across sectors, particularly in water sources, to control its spread. Considering socioeconomic and environmental factors, this study explored Escherichia coli and AMR patterns in water using a One Health approach. Methodology This cross-sectional study assessed E. coli and AMR in drinking and sewerage water across three districts in Khyber Pakhtunkhwa, Pakistan. Multi-stage random sampling yielded 840 water samples from 420 households, along with socio-demographic and AMR awareness data. Microbiological analyses identified E. coli , CRE, and ESBL. The resistance profiles were determined using the disk diffusion method, and the association between socio-demographics and awareness was analyzed. Results The prevalence of E. coli in drinking water was 44 %, with 40 % ESBL, 21 % CRE, and 15 % co-occurrence of ESBL and CRE. Swat had the highest E. coli prevalence in sewerage (78 %) and drinking water (58 %), while Bannu had the highest ESBL levels. Tetracycline resistance was widespread (78 % sewerage and 69 % drinking water). The MAR index showed that 20.5 % of the isolates were resistant to six antibiotics, varying by district. Location influenced the contamination level ( p = 0.002). Access to health (OR = 0.497), veterinary services (OR = 0.881), and frequent medical advice (OR = 1.557) lowered E. coli contamination. Education ( p = 0.002) and locality ( p < 0.001) affected AMR knowledge. Animal area cleaning was significantly correlated with AMR awareness. Conclusion High E. coli and AMR levels in water pose public health risks because they are driven by poor sanitation, limited water access, and low awareness. Better water management, awareness, and antimicrobial control are essential to mitigate AMR spread.