Ikhwan Yuda Kusuma, Hening Pratiwi, Afriza Pujiati, Septi Nurkhasanah, Dian Ayu Eka Pitaloka
Hospital wastewater in upper middle-income countries (UMICs) is a major source of antibiotic residues, resistant bacteria, and resistance genes due to limited treatment and surveillance. This review synthesizes evidence to assess the scale of the problem, highlight knowledge gaps, and guide strategies to curb antimicrobial resistance spread. Conducted under PRISMA guidelines, the review analyzed studies from 2015 to 2025 on antibiotic residues, resistant bacteria, and resistance genes in hospital wastewater from UMICs, with emphasis on treatment technologies and public health risks. Fifty-seven studies showed that hospital wastewater in UMICs contains high levels of antibiotic residues, resistant bacteria, and resistance genes, even after conventional treatment. Multidrug-resistant pathogens such as E. coli , K. pneumoniae , P. aeruginosa , and A. baumannii were frequently reported, with resistance to last resort antibiotics including carbapenems and colistin. Findings underscore limitations of conventional treatment, risks of horizontal gene transfer, and urgent need for advanced technologies and stronger public protection measures. © 2026 Elsevier B.V.
Pharmacy Study Program, Faculty of Health, Universitas Harapan Bangsa, Purwokerto, 53182, Indonesia; Department of Pharmacy, Faculty of Health Sciences, Universitas Jenderal Soedirman, Purwokerto, 53122, Indonesia; Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Sumedang, 45363, Indonesia
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