Mapping the evidence of the effects of environmental factors on the prevalence of antibiotic resistance in the non-built environment

BACKGROUND: Antibiotic resistance increasingly threatens the interconnected health of humans, animals, and the environment. While misuse of antibiotics is a known driver, environmental factors also play a critical role. A balanced One Health approach-including the environmental sector-is necessary to understand the emergence and spread of resistance. METHODS: We systematically searched English-language literature (1990-2021) in MEDLINE, Embase, and Web of Science, plus grey literature. Titles, abstracts, and keywords were screened, followed by full-text reviews using a structured codebook and dual-reviewer assessments. RESULTS: Of 13,667 records screened, 738 met the inclusion criteria. Most studies focused on freshwater and terrestrial environments, particularly associated with wastewater or manure sources. Evidence of research has predominantly focused on Escherichia coli and Pseudomonas spp., with a concentration on ARGs conferring resistance to sulphonamides (sul1-3), tetracyclines (tet), and beta-lactams. Additionally, the People's Republic of China has produced a third of the studies-twice that of the next country, the United States-and research was largely domestic, with closely linked author networks. CONCLUSION: Significant evidence gaps persist in understanding antibiotic resistance in non-built environments, particularly in marine, atmospheric, and non-agricultural settings. Stressors such as climate change and microplastics remain notably under-explored. There is also an urgent need for more research in low-income regions, which face higher risks of antibiotic resistance, to support the development of targeted, evidence-based interventions.