A Comprehensive Framework of Health Risk Assessment for Antibiotic Resistance in Aquatic Environments: Status, Progress, and Perspectives

Antibiotic resistance (AR), driven by antibiotics as emerging pollutants, has become a critical global health threat, jeopardizing both environmental and human health. The persistence and spread of AR in aquatic ecosystems are governed by the intricate interplay between antibiotics, antibiotic resistance genes (ARGs), and antibiotic-resistant bacteria (ARB), which collectively influences its occurrence, transportation, and fate in aquatic ecosystems. However, most assessments focus primarily on antibiotics and ARGs, often relying on single-factor criteria while overlooking critical influence factors such as ARG forms, non-antibiotic chemicals, antibiotic pressure, and microbial competition. Furthermore, many fail to incorporate potential future risks, limiting their predictive accuracy and overall effectiveness in addressing AR in aquatic environments. To bridge these research gaps, we introduce a comprehensive health risk assessment framework that integrates the interactions among antibiotics, ARGs, and ARB. The proposed approach comprises four steps: 1. Determining the type of water body; 2. Performing model simulations; 3. Assessing antibiotics and ARGs; and 4. Evaluating ARB. Finally, a comprehensive risk index for AR is established, along with a corresponding hierarchical risk ranking system. Moreover, to demonstrate the practical application of the framework, an assessment of antibiotic resistance risk was conducted using a typical lake in Northeast China as a case study, indicating the efficacy of the proposed framework in quantifying the multidimensional health risk of AR. This framework not only provides a crucial foundation for dynamic health risk assessment, but also paving the way for more effective mitigation strategies to safeguard both aquatic ecosystems and human health in the future.