Healthcare-Generated Co-pollutants as Environmental Determinants of Antimicrobial Resistance: Governance Challenges at the Healthcare–Environmental Interface

Abstract Antimicrobial resistance (AMR) is commonly framed as resulting from antimicrobial misuse in clinical practice. While antimicrobial stewardship remains key, this focus on individual behaviour limits engagement with how healthcare systems create material conditions that contribute to the emergence, persistence and spread of resistance. Clinical practices generate healthcare waste, including per- and polyfluoroalkyl substances (PFAS), microplastics and antimicrobials, which enter wastewater systems and surrounding water environments. These are understood as co-pollutants, whose interactions may shape microbial environments, creating conditions that promote microbial adaptation, horizontal gene transfer and the spread of antimicrobial resistance. This study employed a qualitative interpretive meta-synthesis of interdisciplinary empirical and policy literature to examine healthcare-generated co-pollutants as environmental determinants of AMR and their implications for governance. The analysis identifies co-pollutants as contributors to environmental conditions shaping resistance emergence, persistence and spread beyond clinical settings. It further reveals that governance of AMR is fragmented across clinical antimicrobial stewardship, healthcare waste and wastewater management, and environmental regulation, resulting in spatial, temporal and institutional gaps at the healthcare–environmental interface. Drawing on a One Health perspective, the synthesis indicates that AMR emerges within a socio-ecological system linking clinical practices, healthcare waste infrastructures, environmental microbial ecologies and governance arrangements. Integrating healthcare waste governance, wastewater-based resistance surveillance and environmental monitoring into antimicrobial stewardship and national AMR strategies may strengthen efforts to address long-term environmental resistance dynamics and reduce the risk of water environments functioning as reservoirs of resistance. Key messages What is already known on this topicAntimicrobial resistance (AMR) governance has primarily emphasised antimicrobial stewardship, including reducing antimicrobial use and strengthening patient adherence to prescriptions, while the role of healthcare waste in shaping microbial environments and resistance dynamics remains underexplored. What this study addsThis study identifies healthcare-generated co-pollutants (PFAS, microplastics and antimicrobials) as environmental determinants of antimicrobial resistance at the healthcare–environmental interface. It further highlights governance gaps between clinical antimicrobial stewardship, healthcare waste and wastewater management, and environmental pollution surveillance and remediation. How this study might affect research, practice or policyThe findings support integrating healthcare waste management, wastewater governance and environmental resistance surveillance into antimicrobial stewardship and AMR strategies, contributing to more anticipatory and system-oriented approaches to long-term resistance risks.