Wastewater is Not a Reliable Proxy for Clinical Carbapenem Resistance Prevalence in E. coli

Antimicrobial resistance (AMR) is a major threat to modern medicine and an emerging environmental pollutant. Wastewater-based monitoring offers a scalable alternative to traditional surveillance by enabling population-level monitoring across One Health compartments. However, it remains unclear how well bacterial variants detected in wastewater reflect those causing clinical infections. Here, we assessed the prevalence of carbapenem-resistant Escherichia coli (CREC) in wastewater from Uppsala, Sweden, and compared wastewater isolates with clinical isolates from the same region and period. We observed partial overlap between wastewater and clinical CREC populations, but several common clinical variants were not detected in wastewater and vice versa. CREC prevalence was an order of magnitude higher in wastewater receiving hospital effluent, yet this did not improve concordance with clinical isolates, suggesting that hospital wastewater may artificially inflate CREC prevalence estimates. These findings indicate that wastewater CREC prevalence does not necessarily reflect the regional clinical burden. Furthermore, metagenomic sequencing of wastewater-derived E. coli populations rarely detected CREC resistance genes, suggesting that CREC abundance is below the detection limit of this approach and that targeted enrichment is required for reliable monitoring. Together, our results show that while wastewater-based monitoring can complement AMR surveillance, it should be interpreted cautiously when used as an indicator of clinical risk.