Baseline screening for the presence of antimicrobial resistance in E. coli isolated from Kuwait's marine environment

From tide to table: A whole-year, coastal-wide surveillance of antimicrobial resistance in Escherichia coli from marine bivalves

This work is the first of its kind to report a whole-year and coastal-wide surveillance of antimicrobial resistance (AMR) of Escherichia coli with samples from the EU imposed Norwegian surveillance programme for marine bivalves. In total, 390 bivalve samples collected from January to December in 2016 at 59 different harvest locations, were examined. The occurrence of resistant E. coli in relation to the concentration of E. coli was also analysed. From each sample with E. coli (n = 261), one isolate was susceptibility tested against a panel of 14 antimicrobials from ten classes. The occurrence of resistance to at least one antimicrobial was 8.4 %. Resistance to tetracycline was most commonly detected (5.7 %), followed by resistance to ampicillin (4.6 %) and sulfamethoxazole (3.1 %). The occurrence of extended spectrum cephalosporin (ESC)-resistant E. coli, quinolone-resistant E. coli (QREC) and carbapenem-resistant Enterobacteriaceae (CRE) were detected through selective screening in 3.3 %, 12.8 % and none of the samples, respectively. Among the ESC-resistant E. coli, the blaCTX-M-15 gene was detected in nine isolates, where two isolates also carried the blaCMY-42 gene, followed by blaCTX-M-3 in two and blaCTX-M-1 in one. One isolate was resistant to ESC due to the n.-42C>T mutation in the AmpC gene. Only the presence of QREC clustered significantly (p < 0.013) in space including nine harvest locations. An increased risk (OR 9.4) of detecting ESC-resistant E. coli or QREC was found for samples with E. coli concentrations above the threshold of Class A for direct distribution to the market (i.e. 230 E. coli/100 g). However, five of the ESC-resistant E. coli and 26 of the QREC positive samples, had levels of E. coli below the threshold, thus from areas cleared for sale. Among the 17 ESC-resistant E. coli subjected to whole genome sequencing, two originated from two samples of great scallops and two samples of flat oysters, which are often consumed raw or lightly processed. One of these isolates belonged to the high-risk clone sequence type 131 and carried a plasmid born senB gene encoding the Shigella enterotoxin 2 (ShET2) attributed to cause watery diarrhoea in infections caused by Enteroinvasive E. coli (EIEC). Thus, our study shows that there is a potential risk for transmission of resistant and pathogenic E. coli to the consumers from these products.

Antibiotic Resistance Mediated by Escherichia coli in Kuwait Marine Environment as Revealed through Genomic Analysis

Antibiotic-resistance gene elements (ARGEs) such as antibiotic-resistance genes (ARGs), integrons, and plasmids are key to the spread of antimicrobial resistance (AMR) in marine environments. Kuwait's marine area is vulnerable to sewage contaminants introduced by numerous storm outlets and indiscriminate waste disposal near recreational beaches. Therefore, it has become a significant public health issue and warrants immediate investigation. Coliforms, especially Gram-negative Escherichia coli, have been regarded as significant indicators of recent fecal pollution and carriers of ARGEs. In this study, we applied a genome-based approach to identify ARGs' prevalence in E. coli isolated from mollusks and coastal water samples collected in a previous study. In addition, we investigated the plasmids and intl1 (class 1 integron) genes coupled with the ARGs, mediating their spread within the Kuwait marine area. Whole-genome sequencing (WGS) identified genes resistant to the drug classes of beta-lactams (blaCMY-150, blaCMY-42, blaCTX-M-15, blaDHA-1, blaMIR-1, blaOKP-B-15, blaOXA-1, blaOXA-48, blaTEM-1B, blaTEM-35), trimethoprim (dfrA14, dfrA15, dfrA16, dfrA1, dfrA5, dfrA7), fluroquinolone (oqxA, oqxB, qnrB38, qnrB4, qnrS1), aminoglycoside (aadA2, ant(3'')-Ia, aph(3'')-Ib, aph(3')-Ia, aph(6)-Id), fosfomycin (fosA7, fosA_6, fosA, fosB1), sulfonamide (sul1, sul2, sul3), tetracycline (tet-A, tet-B), and macrolide (mph-A). The MFS-type drug efflux gene mdf-A is also quite common in E. coli isolates (80%). The plasmid ColRNAI was also found to be prevalent in E. coli. The integron gene intI1 and gene cassettes (GC) were reported to be in 36% and 33%, respectively, of total E. coli isolates. A positive and significant (p < 0.001) correlation was observed between phenotypic AMR-intl1 (r = 0.311) and phenotypic AMR-GC (r = 0.188). These findings are useful for the surveillance of horizontal gene transfer of AMR in the marine environments of Kuwait.

Metagenomic profiling of antibiotic resistance genes in Red Sea brine pools

Antibiotic resistance (AR) is an alarming global health concern, causing an annual death rate of more than 35,000 deaths in the US. AR is a natural phenomenon, reported in several pristine environments. In this study, we report AR in pristine Red Sea deep brine pools. Antimicrobial resistance genes (ARGs) were detected for several drug classes with tetracycline and macrolide resistance being the most abundant. As expected, ARGs abundance increased in accordance with the level of human impact with pristine Red Sea samples having the lowest mean ARG level followed by estuary samples, while activated sludge samples showed a significantly higher ARG level. ARG hierarchical clustering grouped drug classes for which resistance was detected in Atlantis II Deep brine pool independent of the rest of the samples. ARG abundance was significantly lower in the Discovery Deep brine pool. A correlation between integrons and ARGs abundance in brine pristine samples could be detected, while insertion sequences and plasmids showed a correlation with ARGs abundance in human-impacted samples not seen in brine pristine samples. This suggests different roles of distinct mobile genetic elements (MGEs) in ARG distribution in pristine versus human-impacted sites. Additionally, we showed the presence of mobile antibiotic resistance genes in the Atlantis II brine pool as evidenced by the co-existence of integrases and plasmid replication proteins on the same contigs harboring predicted multidrug-resistant efflux pumps. This study addresses the role of non-pathogenic environmental bacteria as a silent reservoir for ARGs, and the possible horizontal gene transfer mechanism mediating ARG acquisition.

Antibiotic Resistance Genes in Aerosols: Baseline from Kuwait

Antimicrobial resistance (AMR) is one of the biggest threats to human health worldwide. The World Health Organization (WHO, Geneva, Switzerland) has launched the "One-Health" approach, which encourages assessment of antibiotic-resistant genes (ARGs) within environments shared by human-animals-plants-microbes to constrain and alleviate the development of AMR. Aerosols as a medium to disseminate ARGs, have received minimal attention. In the present study, we investigated the distribution and abundance of ARGs in indoor and outdoor aerosols collected from an urban location in Kuwait and the interior of three hospitals. The high throughput quantitative polymerase chain reaction (HT-qPCR) approach was used for this purpose. The results demonstrate the presence of aminoglycoside, beta-lactam, fluoroquinolone, tetracycline, macrolide-lincosamide-streptogramin B (MLSB), multidrug-resistant (MDR) and vancomycin-resistant genes in the aerosols. The most dominant drug class was beta-lactam and the genes were IMP-2-group (0.85), Per-2 group (0.65), OXA-54 (0.57), QnrS (0.50) and OXA-55 (0.55) in the urban non-clinical settings. The indoor aerosols possessed a richer diversity (Observed, Chao1, Shannon's and Pielou's evenness) of ARGs compared to the outdoors. Seasonal variations (autumn vs. winter) in relative abundances and types of ARGs were also recorded (R² of 0.132 at p < 0.08). The presence of ARGs was found in both the inhalable (2.1 µm, 1.1 µm, 0.7 µm and < 0.3 µm) and respirable (>9.0 µm, 5.8 µm, 4.7 µm and 3.3 µm) size fractions within hospital aerosols. All the ARGs are of pathogenic bacterial origin and are hosted by pathogenic forms. The findings present baseline data and underpin the need for detailed investigations looking at aerosol as a vehicle for ARG dissemination among human and non-human terrestrial biota.

Metagenomes from Coastal Sediments of Kuwait: Insights into the Microbiome, Metabolic Functions and Resistome

Coastal sediments in the proximity of wastewater and emergency outfalls are often sinks of pharmaceutical compounds and other organic and inorganic contaminants that are likely to affect the microbial community. The metabolites of these contaminants affect microbial diversity and their metabolic processes, resulting in undesirable effects on ecosystem functioning, thus necessitating the need to understand their composition and functions. In the present investigation, we studied the metagenomes of 12 coastal surface sediments through whole genome shot-gun sequencing. Taxonomic binning of the genes predicted about 86% as bacteria, 1% as archaea, >0.001% as viruses and Eukaryota, and 12% as other communities. The dominant bacterial, archaeal, and fungal genera were Woeseia, Nitrosopumilus, and Rhizophagus, respectively. The most prevalent viral families were Myoviridae and Siphoviridae, and the T4 virus was the most dominant bacteriophage. The unigenes further aligned to 26 clusters of orthologous genes (COGs) and five carbohydrate-active enzymes (CAZy) classes. Glycoside hydrolases (GH) and glycoside transferase (GT) were the highest-recorded CAzymes. The Kyoto Encyclopedia of Genes and Genomes (KEGG) level 3 functions were subjugated by purine metabolism > ABC transporters > oxidative phosphorylation > two-component system > pyrimidine metabolism > pyruvate metabolism > quorum sensing > carbon fixation pathways > ribosomes > and glyoxalate and dicarboxylate metabolism. Sequences allying with plasmids, integrons, insertion sequences and antibiotic-resistance genes were also observed. Both the taxonomies and functional abundances exhibited variation in relative abundances, with limited spatial variability (ANOVA p > 0.05; ANOSIM-0.05, p > 0.05). This study underlines the dominant microbial communities and functional genes in the marine sediments of Kuwait as a baseline for future biomonitoring programs.

Hierarchical porous TiO2 with a uniform distribution of anchored gold nanoparticles for enhanced photocatalytic efficiency and accelerated charge separation for the degradation of antibiotics

A novel approach to synthesize porous Au/TiO₂ nanocomposites has been achieved through a pyrolytic strategy by employing NH₂-MIL-125(Ti) as a TiO₂ precursor, and photo-deposition of Au nanoparticles (NPs) onto porous nanocrystalline TiO₂ with varying Au contents (0.05-0.5%). TEM images of Au/TiO₂ nanocomposites showed that TiO₂ particles were spherical structures, highly dispersed, and homogeneous with diameters of 10-15 nm, and Au NPs (20-30 nm) were anchored onto porous TiO₂ matrices with a uniform distribution. The synthesized Au/TiO₂ nanocomposites were assessed through the degradation of two antibiotic models, metronidazole (MNZ), and trimethoprim (TMP), under visible light and compared with undoped TiO₂ and commercial TiO₂ (P-25). The synthesized Au/TiO₂ photocatalyst revealed enhanced photocatalytic performance in the mineralization (80%) and degradation (100%) of MNZ and TMP in both water matrices compared to undoped TiO₂ (60%, 76%) and commercial P-25 (48%, 65%). The obtained 0.1% Au/TiO₂ nanocomposite could complete the mineralization of TMP and MNZ with rate constant values (4.47 × 10^-3 min^-1 and 5.23 × 10^-1 min^-1) owing to the large well-developed porosity and high surface area of TiO₂ and the small size of Au NPs with high dispersity, surface plasmon resonance, and stability. The recyclability of the 0.1% Au/TiO₂ nanocomposite exhibited high durability without the leaching or loss of photocatalytic performance after four cycles. Complete degradation was achieved within 100 min in the water matrix from real wastewater, indicating promising results for the degradation of pharmaceuticals in the different water matrices. The present work opens a new route to synthesize low-cost, effective, and high photocatalytic performance nanocomposites with a small Au content as a cocatalyst onto semiconductor materials.

A systematic review and meta-analysis on antimicrobial resistance in marine bivalves

Bivalves are filter-feeding animals able to accumulate contaminants and microorganisms, either of marine or terrestrial origin. The aim of this study was to describe the prevalence of antimicrobial resistance (AMR) in bacterial isolates from bivalves using a systematic review of the literature. Comprehensive searches of MEDLINE, EMBASE, and Web of Science were carried out, based upon a registered protocol (PROSPERO), and following the preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. The methodological quality of the included studies was assessed using a modified Hoy checklist. Meta-analyses of prevalence were carried out using random-effects models. In total, 103 articles were selected from 1,280 records and were included in the final analysis. The studies were from Asia (n = 54), Europe (n = 27), South and North America (n = 10 and n = 6, respectively), Africa (n = 2), Oceania (n = 1), and multicentre and intercontinental (n = 3). The meta-analysis of multiple antibiotic resistance (MAR) index revealed Aeromonas spp. as the genus with the highest prevalence of AMR (37%), followed by Vibrio spp. (34%), Salmonella spp. (18%), and Escherichia coli (15%). Resistance to third/fourth/fifth generation cephalosporins and fluoroquinolones, two highest priority, critically important antimicrobials (HPCIA), was recorded in approximately 10% of E. coli isolates. Resistance to carbapenems was very low (<2%) in Salmonella spp. and in E. coli, but was found in 5% of Vibrio spp. and in more than a third of Aeromonas spp. isolates. In aquatic bacteria, resistance to carbapenems was higher in Asian than in European isolates. Our study shows the presence of antibiotic resistant bacteria (ARB), including bacteria resistant to HPCIA, in marine bivalves, posing a risk for consumers.

Establishing a marine monitoring programme to assess antibiotic resistance: A case study from the Gulf Cooperation Council (GCC) region

The World Health Organization considers antimicrobial resistance as one of the most pressing global issues which poses a fundamental threat to human health, development, and security. Due to demographic and environmental factors, the marine environment of the Gulf Cooperation Council (GCC) region may be particularly susceptible to the threat of antimicrobial resistance. However, there is currently little information on the presence of AMR in the GCC marine environment to inform the design of appropriate targeted surveillance activities. The objective of this study was to develop, implement and conduct a rapid regional baseline monitoring survey of the presence of AMR in the GCC marine environment, through the analysis of seawater collected from high-risk areas across four GCC states: (Bahrain, Oman, Kuwait, and the United Arab Emirates). 560 Escherichia coli strains were analysed as part of this monitoring programme between December 2018 and May 2019. Multi-drug resistance (resistance to three or more structural classes of antimicrobials) was observed in 32.5% of tested isolates. High levels of reduced susceptibility to ampicillin (29.6%), nalidixic acid (27.9%), tetracycline (27.5%), sulfamethoxazole (22.5%) and trimethoprim (22.5%) were observed. Reduced susceptibility to the high priority critically important antimicrobials: azithromycin (9.3%), ceftazidime (12.7%), cefotaxime (12.7%), ciprofloxacin (44.6%), gentamicin (2.7%) and tigecycline (0.5%), was also noted. A subset of 173 isolates was whole genome sequenced, and high carriage rates of qnrS1 (60/173) and bla _CTX-M-15 (45/173) were observed, correlating with reduced susceptibility to the fluoroquinolones and third generation cephalosporins, respectively. This study is important because of the resistance patterns observed, the demonstrated utility in applying genomic-based approaches to routine microbiological monitoring, and the overall establishment of a transnational AMR surveillance framework focussed on coastal and marine environments.

Antibiotic Resistance Genes Associated with Marine Surface Sediments: A Baseline from the Shores of Kuwait

Marine sediments are a sink for antibiotic resistance genes (ARGs) and antibiotic-resistant microbes (ARMs). Wastewater discharge into the aquatic environment is the dominant pathway for pharmaceuticals reaching aquatic organisms. Hence, the characterization of ARGs is a priority research area. This baseline study reports the presence of ARGs in 12 coastal sediment samples covering the urban coastline of Kuwait through whole-genome metagenomic sequencing. The presence of 402 antibiotic resistance genes (ARGs) were recorded in these samples; the most prevalent were patA, adeF, ErmE, ErmF, TaeA, tetX, mphD, bcrC, srmB, mtrD, baeS, Erm30, vanTE, VIM-7, AcrF, ANT4-1a, tet33, adeB, efmA, and rpsL, which showed resistance against 34 drug classes. Maximum resistance was detected against the beta-lactams (cephalosporins and penam), and 46% of genes originated from the phylum Proteobacteria. Low abundances of ESKAPEE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumonia, Acinetobacter baumanii, Pseudomonas aeruginosa, Enterobacter sps., and Escherichia coli) were also recorded. Approximately 42% of ARGs exhibited multiple drug resistance. All the ARGs exhibited spatial variations. The major mode of action was antibiotic efflux, followed by antibiotic inactivation, antibiotic target alteration, antibiotic target protection, and antibiotic target replacement. Our findings supported the occurrence of ARGs in coastal marine sediments and the possibility of their dissemination to surrounding ecosystems.

Integration assay of bacteriological risks in marine environment using salmonella spp and multimarker response in the bivalve Donax trunculus: Novel biomonitoring approach

Microbiological contamination is one of the riskiest forms of human contamination in seawater, which threaten the stability of ecosystems and human health. In this study, we study the accumulation of a pathogenic bacteria Salmonella spp; isolated from the marine environment, in the soft tissue of Donax trunculus (Mollusca, Bivalvia), a commonly used as a bioindicators species for aquatic ecosystems monitoring, under laboratory conditions during both exposure and recovery periods. These bacteria were added in seawater at three concentrations previously determined against sentinel specie at three exposure periods (24, 48 and 96 h). In a second series of experiments, exposed specimens were afterward transplanted to clean water to assess the recovery pattern. The mortality rate of bivalves was determined as biomarker of general stress. Our findings suggest that microbiological contamination by Salmonella spp was gradually incorporated into the body of D. trunculus causing a significant induction of enzymatic activity of acetylcholinesterase (AChE), Catalase (CAT), glutathione-S-transferase (GST) and malondialdehyde (MDA) levels, as a function of time and concentration. Exposure to a bacterial concentration of 5.10⁴ bacteria/liter resulted in the mortality of more than 80% of the specimens. This study is to test the pathogenicity of Salmonella strains at concentrations close to those of the marine environment, and their effects on biomarkers, thus deducing the existence of an exponential relationship between bacterial concentrations and enzymatic response. The principal component analysis shows that the four biomarkers had similar variation with bacterial concentrations, while two groups were obtained to change following the exposure time (CAT-GST and AChE-MDA). This study provides new findings on the potential accumulation of pathogenic bacteria associated with neurotoxicity and oxidative stress in the wedge clam Donax trunculus.

Virulence and phylogenetic groups of Escherichia coli cultured from raw sewage in Kuwait

In Kuwait, some untreated sewage is discharged into the sea which poses health risks. Therefore, we determined the virulence traits and the phylogenetic groups of E. coli cultured from raw sewage. Sewage was collected once every month for 12 months with culturing of a total of 140 E. coli isolates. E. coli was typed by the methods of Clermont. The five pathotypes of diarrheagenic E. coli (DEC), and extra-intestinal pathogenic E. coli (ExPEC) were detected by specific PCR assays. Four virulence genes which correlate with pathogenicity in animal models, were used for the first time for detection of ExPEC—vat (vacuolating auto-transporter toxin), fyuA (yersiniabactin receptor), chuA (heme-binding protein), and yfcV (major subunit of putative chaperon-usher fimbria). Most E. coli belonged to phylogenetic groups A (65[45%]) and B1 (34[24.3%]). Three (2.1%) isolates were DEC, while 14 (10%) isolates were ExPEC mostly in group B2 (57.1%). A relatively high prevalence of ExPEC in sewage has public health implications.

Grimontia sedimenti sp. nov., isolated from benthic sediments near coral reefs south of Kuwait

A Gram-stain-negative, rod and rod-curved shaped motile bacterium designated strain S25^T was obtained from benthic sediment collected near the Kubbar Island coral reefs south of Kuwait. Phenotypic analysis revealed that strain S25^T was slightly halophilic, mesophilic and facultative anaerobic, fermenting d-glucose, d-ribose, d-mannose, d-mannitol, maltose, fructose, gentiobiose, cellobiose, melibiose, trehalose and sucrose. It was positive for oxidase and indole production and negative for arginine dihydrolase and lysine and ornithine decarboxylases. It contained C_16 : 1  ω7c/C_16 : 1  ω6c (summed feature 3), C_18 : 1 ω7c (summed feature 8) and C_16 : 0 as the major fatty acids. Strain S25^T grew optimally at 30 °C and pH 8 in the presence of 3 % (w/v) NaCl. Phylogenetic analysis based on 16S rRNA sequences revealed that strain S25^T is related to species of the genus Grimontia, having 99.15 % similarity to 'Grimontia indica' AK16^T, 99.08 % to Grimontia celer 96-237^T and 98.66 % to Grimontia marina IMCC 5001^T. The DNA G+C content was 48.8 mol% and the full genome analysis for the strain S25^T showed that the bacterium has a genome size of 5 158 621 bp and contains 4730 predicted protein-encoding genes. The average nucleotide identity values between the S25^T genome and the genomes of its nearest matches ranged between 81.39 and 94.16 %. The strain was distinguishable from the phylogenetically related genera through differences in several phenotypic properties. On the basis of the phenotypic, phylogenetic and genetic data, strain S25^T represents a novel species in the genus Grimontia, for which the name Grimontia sedimenti sp. nov. is proposed. The type strain of Grimontia sedimenti is S25^T (=DSM 28878^T=LMG 28315^T).

Three-dimensional numerical modelling of transport, fate and distribution of microplastics in the northwestern Arabian/Persian Gulf

Marine plastic litter has been a major concern over the past decade particularly in semi-enclosed seas such as the Arabian/Persian Gulf, which are likely to impose a relatively higher threat to ecosystem and human health. In this work, we have focused our efforts on the transport features of marine surface microplastics (MPs) in the Gulf. The assessment utilizes a 3D hydrodynamic model of the northern Gulf which was coupled with a particle tracking model. We have considered five release locations and investigated two dominant wind conditions by applying different numerical scenarios. The results revealed that the northerly winds result in high dispersion and seaward transport of MPs in the open coastal zones, while in semi-enclosed regions they result in high trapping and beaching verified by visual investigation. The study shows that further detailed field investigations are warranted to enable the models to better parameterize the fate and distributions of MPs.

Patterns of antimicrobial resistance observed in the Middle East: Environmental and health care retrospectives

Antimicrobial resistance is one of the biggest worldwide challenging problems that associates with high morbidity and mortality rates. The resistance of bacteria to various antibiotic classes results in difficulties in the treatment of infectious diseases caused by those bacteria. This paper highlights and provides a critical overview of observational and experimental studies investigating the presence of antibiotic resistant bacteria in different environments in Middle East countries and the mechanisms by which bacteria acquire and spread resistance. The data of this research considered the published papers within the last ten years (2010-2020) and was carried out using PubMed. A total of 66 articles were selected in this review. This review covered studies done on antibiotic resistant bacteria found in a wide range of environments including foods, animals, groundwater, aquatic environments as well as industrial and hospital wastewater. They acquire and achieve their resistance through several mechanisms such as antibiotic resistant genes, efflux pumps and enzymatic reactions. However, the dissemination and spread of antibiotic resistant bacteria is affected by several factors like anthropogenic, domestic, inappropriate use of antibiotics and the expulsion of wastewater containing antibiotic residues to the environments. Therefore, it is important to increase the awareness regarding these activities and their effect on the environment and eventually on health.

An assessment of microplastics threat to the marine environment: A short review in context of the Arabian/Persian Gulf

Microplastics are recognised as a (persistent) pollutant and are believed to be ubiquitous in the marine environment. The importance of this issue is evident from the large number of technical publications and research efforts within the past decade. However, the Arabian (Persian) Gulf region has few reported datasets in spite of being an area with excessive plastic use and a hefty generation rate of plastic solid waste. This communication aims at stimulating a discussion on this topic focusing on the available regional and international datasets, along with the environmental conditions that are likely to contribute to the disintegration and transport of the plastic debris rendering it as microplastic. This work also highlights some of the constraints in sampling techniques, identification methods, and the reported units of microplastics. Most studies employ neuston nets of variable dimensions that samples different thicknesses of surface water, which also posses a major constraint in standardising field sample collection. Extrapolation of a trawl to units such as particles.km^-2 without considering the fact that neuston nets collect three-dimensional samples, is also another aspect discussed in this communication. This study also intends to initiate a discussion on standardising the practices across the region to enable an intercomparison of the reported data. In addition, it calls for a comprehensive assessment using the standardized methodology for putting a mitigation plan for microplastics as a potential threat detected in environmental sinks.

Antimicrobial resistance in the Gulf Cooperation Council region: A proposed framework to assess threats, impacts and mitigation measures associated with AMR in the marine and aquatic environment

It is becoming increasingly clear that the genetic diversity and abundance of antimicrobial resistance (AMR) in non-clinical settings has been underestimated and that the environment plays an integral role in enabling the development of AMR. Due to specific demographic and environmental factors the Gulf Cooperation Council (GCC) region may be particularly susceptible to the threat of AMR, with the marine and aquatic environment potentially playing a specific role in its development and propagation. The demographic factors include rapid population growth, significant international population movements, heavy antibiotic use and insufficient antibiotic stewardship. Environmental factors leading to susceptibility include notable inputs of untreated sewage effluent, high ambient water temperatures, elevated concentrations of heavy metals, and poorly regulated use of antimicrobials in veterinary settings. However, to date there is only a limited understanding of the role that this environment plays in enabling the emergence and propagation AMR in this region. This article provides an overview of the risk associated with AMR in the marine and aquatic environment in the GCC region and proposes a framework for understanding how such environments interact with the wider development and propagation of resistance. It identifies priority actions aligned with the World Health Organisation AMR Global Action Plan and associated national action plans to evaluate the role of marine and aquatic systems relative to the wider factors driving AMR emergence and propagation. The proposed framework and actions to evaluate the role of marine and aquatic environments in driving propagation and emergence of AMR are equally applicable at the regional and national level beyond the GCC.