Antibiotics transformed modern medicine, turning once-fatal infections into treatable conditions and enabling complex procedures such as surgeries and cancer therapy. Nevertheless, the growing phenomenon of antibiotic resistance— where bacteria evolve to survive drugs designed to eliminate them— now threatens these gains, posing a significant public health challenge. This crisis extends beyond clinical settings and encompasses human health, animal health, agriculture, and environmental systems. The One Health approach offers a comprehensive framework to understand and respond to antibiotic resistance by acknowledging the interdependence of humans, animals, and ecosystems.
Antibiotic resistance develops through bacterial adaptation and gene exchange under selective pressure from antibiotic use. Overuse and misuse of antibiotics in human healthcare contribute substantially to this process. In many regions, antibiotics are prescribed empirically for conditions such as viral infections or are obtained without prescriptions, fostering inappropriate use. These practices encourage resistant strains to flourish, leading to increased frequencies of multidrug-resistant organisms circulating within communities and healthcare institutions.
Research in Pakistan illustrates this pattern vividly. A recent cross-sectional study from the Swabi district of Khyber Pakhtunkhwa found that common urinary tract infection pathogens, especially Escherichia coli and Klebsiella species, exhibited high levels of resistance to first-line antibiotics including ampicillin and trimethoprim-sulfamethoxazole, with frequent multidrug resistance and extended-spectrum β-lactamase (ESBL) production complicating empiric therapy choices. This underscores the need for region-specific antibiograms and stewardship efforts to guide effective treatment.
These clinical trends are paralleled in community settings. A study conducted in Lahore and Dera Ismail Khan revealed high prevalence of antibiotic-resistant bacteria in the oral microbiome of healthy individuals, with Staphylococcus aureus and Enterococcus faecalis showing resistance to common antibiotics like penicillin and tetracycline. The research also found a significant association between recent antibiotic use and resistance, highlighting how routine consumption patterns contribute to broader resistance ecology.
The contribution of animals and food systems to antibiotic resistance is equally significant in Pakistan. Investigations into animal-derived food samples, including meat, dairy, poultry, fish, and environmental sources, found nearly 30 percent harboured Enterobacterales with significant resistance to antibiotics such as beta-lactams, ciprofloxacin, and tetracycline. While last-resort drugs like colistin remained more effective phenotypically, the detection of diverse resistance profiles across food supply chains indicates substantial risks of transmission from farm to fork.
Environmental pathways also play a crucial role in resistance dissemination. Studies exploring contamination in ecosystems such as the River Ravi show migratory birds and environmental samples carrying antibiotic-resistant bacteria, including E. coli, Staphylococcus aureus, and Pseudomonas species, often highly resistant to commonly used antibiotics. These findings reflect human and environmental interactions that facilitate the spread of resistant organisms beyond clinical or agricultural boundaries.
Data from Pakistan confirm that antibiotic resistance is not merely a theoretical threat but a tangible and escalating reality. Systematic analyses report high median resistance of common pathogens to frequently prescribed antibiotics, including nearly universal resistance of Staphylococcus aureus to penicillin and significant resistance of Salmonella and Acinetobacter species to multiple drugs. Such patterns emerge in both community and healthcare contexts, pointing to pervasive misuse, limited regulatory oversight, and inadequate surveillance.
The One Health approach recognises that these patterns stem from connected drivers across sectors. In human health, stewardship initiatives that promote evidence-based prescribing and strengthen diagnostic capabilities can reduce unnecessary antibiotic use. Rapid diagnostics, for example, can limit empirical broad-spectrum therapy, ensuring antibiotics are prescribed only when necessary. These measures are crucial in Pakistan, where high empiric use and unregulated antibiotic access remain major challenges.
Antibiotic resistance is a complex, multifaceted threat that transcends traditional boundaries between disciplines and sectors. The evidence from Pakistan—spanning clinical resistance, environmental contamination, livestock practices, and genetic analyses—illustrates the interconnected nature of this challenge. A One Health approach that recognises and addresses these interdependencies offers the most promising path to mitigating antibiotic resistance and safeguarding public health, animal welfare, and environmental integrity for future generations.
In veterinary and agricultural sectors, inappropriate antibiotic use for disease prevention and growth promotion fuels resistance among livestock. A study of livestock stakeholders in Pakistan’s poultry and dairy sectors found high rates of antibiotic use without veterinary prescriptions, with Staphylococcus aureus and E. coli isolates exhibiting resistance rates above 80 percent. Survey data also highlighted gaps in awareness of antimicrobial resistance among farmers, directly correlating with irrational antibiotic use practices. These results emphasise the need for targeted educational interventions and robust veterinary stewardship policies.
Beyond clinical and agricultural settings, molecular research reveals mechanisms that enable resistance genes to disseminate across ecosystems. Investigations into plasmids in Enterobacteriaceae from Pakistan showed that a wide range of resistance genes conferring resistance to multiple antibiotic classes are carried on mobile genetic elements capable of horizontal transfer across species and ecological niches. Such evidence underlines how resistance genes circulate within environments shared by humans, animals, and food chains, strengthening the rationale for integrated One Health surveillance and interventions.
National policy responses in Pakistan have begun to recognise the urgency of the issue, but implementation remains inconsistent. Weak regulatory frameworks allow antibiotics to be dispensed without prescription, and enforcement of stewardship guidelines is limited. Environmental pathways—such as hospital wastewater, untreated sewage, and agricultural runoff—continue to serve as reservoirs and transmission routes for resistant bacteria and resistance genes, underscoring gaps in environmental health management. A recent mixed methods analysis estimated high prevalence of multidrug-resistant organisms in clinical and farm settings, with significant proportions of resistant isolates carrying carbapenemase and ESBL genes, and highlighted the economic burden associated with AMR in Pakistan.
Public awareness and behavior also play critical roles. Studies exploring perceptions among the general public and healthcare practitioners in Pakistan reveal widespread misconceptions about antibiotic resistance and frequent practices of self-medication without professional guidance. These behavioural patterns contribute to inappropriate antibiotic consumption, further compounding resistance pressures in both community and clinical contexts.
Addressing antibiotic resistance within a One Health framework requires integrated strategies that span surveillance, stewardship, education, policy, and research. Surveillance systems must incorporate data from human health, animal health, and environmental sources to detect emerging resistance trends and inform policy decisions. Stewardship programmes should be strengthened across clinical and veterinary settings with guidelines tailored to local epidemiology. Educational campaigns can raise awareness among healthcare providers, farmers, and the public to change prescribing and consumption behaviours. Regulatory measures to control antibiotic sales and enforce prescription requirements are essential to curb misuse.
Scientific advances such as genomic sequencing, molecular surveillance, and data-driven analytics can enhance understanding of resistance dynamics and support targeted interventions. These tools can elucidate transmission pathways and resistance mechanisms across sectors, providing insights that inform both local and national strategies. At the same time, collaboration among government agencies, academic institutions, healthcare organisations, and community stakeholders is critical for coordinated action.
Antibiotic resistance is a complex, multifaceted threat that transcends traditional boundaries between disciplines and sectors. The evidence from Pakistan—spanning clinical resistance, environmental contamination, livestock practices, and genetic analyses—illustrates the interconnected nature of this challenge. A One Health approach that recognises and addresses these interdependencies offers the most promising path to mitigating antibiotic resistance and safeguarding public health, animal welfare, and environmental integrity for future generations.
