## 3 Antibiotic Resistance in Hospital and Municipal Wastewater
### Regional Variation of ARGs in MWW  
The AMR resistance of various MWW samples have been assessed in Asian countries (India, China, Singapore and South Korea), European countries (Poland, Portugal, Sweden, Spain, Ireland, Germany, Cyprus, Finland and Norway) and North American countries (Canada and USA). Based on these studies, the MWW of developing countries such as India, China and Iran and developed countries such as Portugal and Poland displayed large quantities of ARGs ranging from \(10^{2}\) to \(10^{10}\) copies/mL [11; 15; 66; 76; 78], whereas the MWW samples from countries like Japan, South Korea, Singapore and Sweden [52; 55; 67; 79] showed a moderate concentration of ARGs (from \(10^{3}\)-\(10^{6}\) copies/mL). The lowest amounts of ARGs (ranging from \(10^{1}\)-\(10^{3}\) copies/mL) were detected in MWW samples tested from Canada and Northern European countries like Spain, Ireland, Germany, Cyprus, Finland and Norway [14; 17].  
Of these countries, the Indian MWW samples primarily comprises genes resistant towards antibiotics such as tetracycline (\(tetA\), \(tetB\)), macrolide-lincosamide-streptomycin(MLS) (\(ermB\), \(ereA\)) and beta-lactams (\(bla_{OXA}\) and \(bla_{TEM}\)) and multidrug (\(mexA\)) in ARG carriers such as \(P\). aeruginosa, \(E\). coli, and _Acinetobacter_ species [15]. Conversely, in Chinese MWW samples, the vancomycin (\(VanA\), \(VanB\)), sulfonamide (\(sul1\), \(sul2\)) and beta-lactams resistant genes were more prevalent in MWW carrier organisms like \(S\). aureus, \(K\). pneumoniae and \(Enterococcus\) species [74; 78]. ARGs such as \(aac(6^{\prime})\)-\(lb\)-\(cr\), \(qnrS2\), (_quinolone resistance_) \(bla_{TEM}\) (\(beta\)-lactam), \(ermB\)(\(macrolide\)) and \(sull\) (_sulfonamide_) were documented to be predominant in urban cities in Portugal [66]. On the other hand, in Iran, the most abundant ARGs were Gentamicin resistance (\(aac(3)\)-\(l\)), Chloramphenicol resistance (\(cmlA1\)) and Ceftazidine resistance (\(ctx\)-\(m\)-32) genes [11]. In Poland, the MWW samples were reported to contain antibiotic resistant organisms such as Methicillin-resistant _Staphylococcus aureus_ and Vancomycin-resistant \(Enterococci\) species [76]. The ARGs such as \(optrA\), \(mcr\), \(cft\), \(sul4\), and gar_ were most prevalent in Swedish MWWs, where _S. aureus_, _Enterococcus_ species and _E. coli_ are the major ARG carriers [67]. In addition, the Japanese MWW samples were found to contain a vast quantity of _sull_, _qacE_, and _blaCTX-M_, which confer resistance against sulfonamides, beta-lactam and multidrug, which are the most predominant ARGs [79]. ARGs such as _blaTEM_, _blaOXA_ (beta-lactam resistance) and _tetM_ (tetracycline resistance) were the most abundant ARGs in MWW samples of South Korea and Singapore [52; 55]. Lastly, Canada and northern European countries like Spain, Ireland, Germany, Cyprus, Finland and Norway exhibited relatively lower levels of _aadA_, _mecA_, _sull_, _emb_, _tetC_, _cmxA_, _blaoxan_, _quacEdelta1_, _ernF_ and _tetQ_, where the most abundant ARGs were carried by _Escherichia coli_, _Pseudomonas aeruginosa_, _Staphylococcus aureus_, _Enterococcus ficeium_, and _Streptococcus_ spp in MWW samples [17].