From water to wards: status of integrated preventive strategies to break the chain of infection and antimicrobial resistance in Pakistan

Background: Antimicrobial resistance (AMR) presents a serious and growing public health threat in Pakistan. To reduce risk of resistant infections, it is crucial to strengthen preventive efforts through improved water, sanitation, and hygiene (WASH) and robust infection prevention and control (IPC) measures. Methods: A narrative literature review along with document analysis methodology approach was chosen given the broad, heterogeneous nature of the topic, encompassing various intervention types and study designs. Results: The review identified a growing body of evidence on IPC and WASH in Pakistan, predominantly from urban centers after 2018. While most healthcare facilities fail to meet WHO IPC standards, targeted training and WASH-FIT (Facility Improvement Tool) initiatives have improved compliance and hygiene behaviors. Community-based programs such as handwashing promotion, improved water infrastructure, and education significantly reduced diarrheal diseases and antibiotic use, highlighting their potential role in mitigating antimicrobial resistance. Conclusion: Despite pockets of progress, Pakistan's current preventive efforts are insufficient and limited to few settings contain AMR. Strengthening WASH infrastructure, enforcing IPC standards and instituting antimicrobial stewardship to reduce antibiotics prophylaxis are all urgently needed to break the chain of resistance from community water sources to hospital wards.