Smog-driven antimicrobial resistance in Pakistan (2013-2023): a decade of evidence linking PM2.5 peaks, respiratory infections, and MDR/XDR pathogensAbstract
Pakistan is facing a dual threat in which worsening air pollution is unfolding alongside a fast-growing burden of antimicrobial resistance (AMR). A growing body of evidence indicates that sustained exposure to fine particulate matter (PM2.5) can weaken airway defenses and disturb respiratory microbial balance, creating conditions that may increase infection risk and, indirectly, antibiotic demand, both of which can intensify resistance selection. In this study, we synthesize evidence published between 2013 and 2023 from environmental monitoring reports, epidemiological and clinical surveillance, microbiology/AMR datasets, and mechanistic studies (including WHO-linked reporting and AMR monitoring records) to clarify how air pollution may influence the biological and operational dynamics of AMR in Pakistan. We contextualize national trends through high-exposure urban centers, Lahore, Faisalabad, Karachi, and Peshawar, where severe winter smog episodes can produce short-lived peak PM2.5 readings exceeding 400 µg/m3 (peak event levels rather than seasonal averages). Across multiple data streams, these peak exposure periods commonly coincide with rises in respiratory illness presentations, including pneumonia and other lower respiratory tract infections. Separately, AMR surveillance over the same decade highlights persistent and, in many settings, increasing burdens of priority resistant organisms, including Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, Staphylococcus aureus, and drug-resistant tuberculosis. Mechanistic evidence supports biological plausibility: particulate exposure is associated with impaired mucociliary clearance, dampened innate immune signaling, altered airway microbiota structure, and changes that can favor microbial adhesion and persistence, effects that plausibly increase infection susceptibility and treatment volume. We bring these strands together in an integrated framework that links pollution-control actions (emission reduction, smog mitigation, indoor exposure protection) with AMR actions (seasonally intensified stewardship, strengthened diagnostics during smog peaks, and hotspot-aligned surveillance). Key limitations include uneven regional surveillance coverage, confounding by viral seasonality and indoor pollution, and variability in laboratory reporting, underscoring the need for coordinated, ecosystem-based strategies that treat air-quality management as part of AMR prevention.
Keywords:
air pollution; PM2.5; environmental contamination; microbial ecology; antimicrobial resistance; MDR; XDR; respiratory microbes; Pakistan; environmental biology; syndemic interactions
Resumo
O Paquistão enfrenta uma dupla ameaça: o agravamento da poluição atmosférica ocorre em paralelo ao rápido crescimento da resistência antimicrobiana (RAM). Um número crescente de evidências indica que a exposição contínua a partículas finas (PM2.5) pode enfraquecer as defesas das vias aéreas e perturbar o equilíbrio da microbiota respiratória, criando condições que podem aumentar o risco de infecção e, indiretamente, a demanda por antibióticos, ambos fatores que podem intensificar a seleção de resistência. Neste estudo, sintetizamos evidências publicadas entre 2013 e 2023 a partir de relatórios de monitoramento ambiental, vigilância epidemiológica e clínica, conjuntos de dados de microbiologia/RAM e estudos mecanísticos (incluindo relatórios vinculados à OMS e registros de monitoramento de RAM) para esclarecer como a poluição atmosférica pode influenciar a dinâmica biológica e operacional da RAM no Paquistão. Contextualizamos as tendências nacionais por meio de centros urbanos de alta exposição, como Lahore, Faisalabad, Karachi e Peshawar, onde episódios severos de smog invernal podem produzir picos de PM2.5 de curta duração, superiores a 400 µg/m3 (níveis de pico do evento, e não médias sazonais). Em diversas fontes de dados, esses períodos de pico de exposição geralmente coincidem com o aumento de casos de doenças respiratórias, incluindo pneumonia e outras infecções do trato respiratório inferior. Em paralelo, a vigilância da resistência antimicrobiana (RAM) na mesma década destaca a persistência e, em muitos locais, o aumento da carga de organismos resistentes prioritários, incluindo Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, Staphylococcus aureus e tuberculose resistente a medicamentos. Evidências mecanísticas sustentam a plausibilidade biológica: a exposição a partículas está associada à depuração mucociliar prejudicada, à sinalização imune inata atenuada, à alteração da estrutura da microbiota das vias aéreas e a mudanças que podem favorecer a adesão e a persistência microbiana, efeitos que plausivelmente aumentam a suscetibilidade à infecção e o volume de tratamento. Reunimos esses aspectos em uma estrutura integrada que vincula ações de controle da poluição (redução de emissões, mitigação da poluição atmosférica, proteção contra exposição em ambientes fechados) a ações de resistência antimicrobiana, como gestão intensificada sazonalmente, diagnósticos reforçados durante picos de poluição atmosférica e vigilância alinhada a pontos críticos. As principais limitações incluem cobertura desigual da vigilância regional, fatores de confusão relacionados à sazonalidade viral e à poluição em ambientes fechados, e variabilidade nos relatórios laboratoriais, ressaltando a necessidade de estratégias coordenadas e baseadas no ecossistema que tratem a gestão da qualidade do ar como parte da prevenção da resistência antimicrobiana.
Palavras-chave:
poluição do ar; PM2.5; contaminação ambiental; ecologia microbiana; resistência antimicrobiana; MDR; XDR; microrganismos respiratórios; Paquistão; biologia ambiental; interações sindêmicas
1. Introduction
The convergence of environmental degradation and microbial resistance is increasingly recognized as one of the defining heal th challenges of this century. In Pakistan, rapid industrial expansion, rising traffic emissions, and recurrent seasonal crop-residue burning have contributed to a marked deterioration in air quality, most visibly across Punjab’s major urban corridor (Ali et al., 2022; Riaz and Hamid, 2018). At the same time, antimicrobial resistance (AMR) has progressed from a clinical concern to a national public-health threat, steadily eroding the reliability of routine antibiotic therapy (Bilal et al., 2021; IHME, 2023).
Cities including Lahore, Faisalabad, Multan, and Karachi experience repeated wintertime air-quality emergencies, with hazardous AQI readings most often concentrated between October and January. These episodes are characterized by dense smog, an aerosol-rich mixture dominated by fine particulate matter (PM2.5) with important contributions from nitrogen dioxide (NO2) and sulfur oxides, capable of penetrating deep into the lower airways. Evidence from respiratory biology supports a clear pathway for harm: particulate exposure impairs mucociliary clearance, injures epithelial and alveolar barriers, and weakens frontline innate immune responses, collectively increasing vulnerability to respiratory infection (Aguilera et al., 2021; Nozza et al., 2021; WHO, 2018).
Air pollution and AMR are each well established as global priorities. What has received less sustained attention is how these crises may reinforce one another in high-burden settings. In Pakistan, where severe seasonal pollution overlaps with constrained diagnostic capacity and high antibiotic consumption, the interaction may be especially consequential. This review therefore examines the smog–AMR interface over the past decade (2013–2023) with five objectives: (1) to describe the trajectory and burden of AMR in Pakistan; (2) to summarize the rise and spatial, seasonal patterning of smog and ambient air pollution over the same period; (3) to integrate mechanistic and epidemiological evidence that links pollution exposure to infection risk and resistance selection; (4) to highlight public-health implications, particularly for vulnerable groups; and (5) to propose actionable recommendations, including strengthened surveillance and coordinated international engagement. While selected institutional findings from blood and urine culture reports are referenced where relevant, the primary contribution of this article is a structured synthesis of the broader evidence base and a clear identification of gaps that require urgent, policy-relevant research.
During smog peaks, multiple hospital and surveillance reports describe coincident rises in respiratory illness presentations, particularly pneumonia, bronchitis, and exacerbations of chronic airway disease. In these periods, antibiotics are commonly initiated empirically, often before microbiologic confirmation, a practice that can intensify selection pressure and accelerate the emergence and spread of multi-drug resistant (MDR) and extensively drug-resistant (XDR) organisms (Hashmi et al., 2021; Mayo Hospital Lahore, 2021; Nishtar Hospital, 2020; One Health Trust, 2018). By bringing together environmental trends, infection patterns, and resistance data across 2013–2023, this review maps a syndemic overlap in which smog-driven respiratory vulnerability and antibiotic pressure may combine to worsen both the infectious burden and the AMR trajectory. The analysis supports an integrated response that treats air-quality action as part of infection prevention and AMR containment, rather than as a separate environmental agenda.
1.1. Smog formation: sources and mechanisms
Industrialization and Vehicular Emissions Pakistan's rapid urban sprawl has come at the cost of environmental regulation. In Lahore, Faisalabad, and Karachi, unfiltered emissions from brick kilns, steel foundries, and cement plants contribute massively to particulate matter (PM10 and PM2.5) (Ali et al., 2022; WWF-Pakistan, 2022). Rapid growth in road traffic, including two-stroke rickshaws, aging diesel trucks, and petrol motorcycles, contributes to carbon monoxide (CO), hydrocarbons (HC), and PM2.5 emissions; prolonged occupational exposure to urban traffic pollution has also been associated with impaired respiratory function (Ali et al., 2022; Sancini et al., 2010). Brick Kilns and Crop Residue Burning Over 20,000 traditional brick kilns in Pakistan operate without emission controls. Punjab accounts for nearly 60% of them, concentrated around Sheikhupura, Kasur, and Gujranwala (WWF-Pakistan, 2022). Seasonal burning of wheat and rice stubble, especially from October to November, creates plumes of black carbon and fine soot, triggering smog conditions when combined with winter temperature inversions (Ali et al., 2022). Meteorological Triggers Temperature inversion, low wind speeds, and high humidity cause smog entrapment close to the ground. This results in reduced visibility, stagnant air, and heightened pollutant concentration (Ali et al., 2022).
1.2. Health effects of smog exposure
Pulmonary Impacts Smog exposure leads to oxidative stress, DNA damage, and inflammation in respiratory epithelial cells (Nozza et al., 2021). This increases susceptibility to infections and accelerates disease progression in patients with asthma, COPD, or pulmonary fibrosis (Aguilera et al., 2021; WHO, 2018). Systemic Health Effects Fine particulates (<2.5 µm) enter the bloodstream, triggering cardiovascular stress, elevated blood pressure, and stroke risk. Vulnerable populations include the elderly, children, and individuals with comorbidities (Pope et al., 2009). Impact on Daily Life and Economy Visibility reduction affects transportation, school attendance, and industrial productivity. Frequent smog advisories in Lahore, Islamabad, and Gujranwala have led to school closures, flight cancellations, and increased indoor confinement (Human Rights Watch, 2024; Punjab Health Department, 2024).
2. The Global Public-Health Challenge of Antimicrobial Resistance (AMR)
2.1. Global context
AMR is widely recognised as one of the most serious threats to global health, food security and development. The World Health Organization (WHO) warns that without urgent action, common infections, injuries and surgeries could become high risk again. Research suggests that antimicrobial-resistant infections may cause millions of deaths annually worldwide if trends continue (WHO, 2023).
2.2. The AMR situation in Pakistan
In Pakistan, AMR represents a major and growing burden. A systematic review covering human samples over a 10-year period found widespread and increasing resistance across multiple pathogens. The 2018 “Situation Analysis Report on Antimicrobial Resistance in Pakistan” by the Global Antibiotic Resistance Partnership (GARP-Pakistan) documented deficiencies in surveillance, infection control, excessive antibiotic use in humans and animals, and high mortality from MDROs (multi-drug-resistant organisms). More recently, modelling indicates that in 2021 Pakistan experienced an estimated ~39,700 deaths attributable to AMR (with ~161,000 deaths associated with AMR). An ASM magazine article notes that in 2019 Pakistan recorded ~59,200 deaths directly attributable to AMR, and ~221,300 associated deaths (making AMR the 3rd-leading cause of death in that year in Pakistan). Priority pathogens include Salmonella enterica (including XDR typhoid), Staphylococcus aureus (including MRSA), carbapenem-resistant Enterobacterales (e.g., Escherichia coli, Klebsiella pneumoniae), New Delhi metallo-β-lactamase 1 (NDM-1), and mcr-1 plasmid-mediated colistin resistance. Key drivers in Pakistan include: unregulated antibiotic prescribing, over-the-counter access to antibiotics, lack of antibiotic stewardship, poor infection control in healthcare settings (instrument sterilisation, hand hygiene, overcrowding), high antibiotic use in veterinary/agriculture sectors including poultry and livestock, and weak surveillance. This background underscores that AMR in Pakistan is not only a national problem but has global implications via travel, trade, and cross-border transmission (ASM, 2023; Bilal et al., 2021; IHME, 2023; One Health Trust, 2018).
2.3. The rising burden of smog and consequent loss of life expectancy in Pakistan
2.3.1. The air pollution/smog crisis
Pakistan is among the most severely affected countries globally when it comes to air pollution and smog episodes. For example, in 2024 the Human Rights Watch reported that the city of Lahore again topped world rankings of worst air quality, with PM2.5 peaking at hundreds of micrograms/m3 (exceeding WHO safe limits by many times) and life expectancy in Lahore cut by up to 7 years. A recent systematic review of Pakistan’s urban areas found that industrial activities, vehicular emissions, crop residue burning, brick kilns, and waste burning are major contributors to smog and particulate matter (PM2.5 and PM10) pollution. Smog has become a “fifth season” in Punjab, whereby heavy crop-burning episodes, meteorological inversion, and industrial/vehicular emissions combine to produce dense air pollution episodes (Ali et al., 2022; Human Rights Watch, 2024; Riaz and Hamid, 2018).
2.3.2. Health and life-expectancy impacts
The health consequences of such air pollution are substantial: increased rates of respiratory illnesses (asthma, chronic obstructive pulmonary disease, infections), cardiovascular disease, lung cancer, adverse birth/childhood outcomes, and overall increased mortality. Specifically, the Air Quality Life Index estimated that air pollution in Pakistan shortens average life expectancy by ~3.9 years nationwide, with Lahore experiencing up to a 7-year reduction. Smog episodes also impose acute health burdens: for example, one AP News article reported over 1.8 million people in Punjab seeking care for smog-related illness in one month (Associated Press of Pakistan, 2024; EPIC, 2025; Human Rights Watch, 2024).
2.3.3. Regional and temporal trajectory (2013–2023)
While some of the data referenced in your original draft (e.g., Lahore in 2016 ranked 5th most polluted) may require updating, the trend is clear: worsening air quality in many Pakistani cities, especially in the Punjab province (Lahore, Multan, Faisalabad, Gujranwala), with repeated winter smog episodes. There is also increasingly granular satellite imaging research identifying aerosol hot-spots, e.g., around highways and industrial zones in Lahore (Ali et al., 2022; EPIC, 2025).
2.4. The Confluence of smog and AMR, an alarming intersection
2.4.1. Mechanistic insights & emerging evidence
Recent literature suggests plausible mechanisms by which air pollution, including particulate matter in smog, may potentiate AMR. Key pathways include: Particulate matter (PM2.5/PM10) may act as carriers of antibiotic-resistance genes (ARGs) and antibiotic-resistant bacteria (ARB), facilitating their dissemination in the environment and inhalation into the respiratory tract. Inhaled pollutants cause respiratory inflammation, immune modulation, and damage to the mucosal microbiome, which may favour colonisation by resistant pathogens or selection of resistance. Airborne pollutants may stress bacteria, inducing horizontal gene transfer and selection for resistance mechanisms in environmental reservoirs. A particular analysis suggests that a 10% rise in PM2.5 is associated with a ~1.1% increase in aggregate antibiotic resistance globally (with higher estimates ~2.6% for Pakistan). Hence, the notion that smog and air pollution may not only harm human health directly but also indirectly by facilitating the propagation and impact of antimicrobial resistance is gaining traction (Malik et al., 2024; Wang et al., 2022; Vieceli et al., 2023).
2.5. Pakistan-relevant evidence
While direct, longitudinal studies in Pakistan linking smog episodes to changing AMR rates remain limited, the context is suggestive. For example: The article “How Airborne Pollutants Fuel Antimicrobial Resistance” points out that Pakistan’s high levels of PM2.5 and weak antimicrobial stewardship create a “perfect storm”. The smog burden in Lahore (and Punjab) creates increased incidence of respiratory infections (which often trigger antibiotic use) and increased hospitalisations, both risk factors for AMR emergence and spread through heightened antibiotic consumption and hospital-based transmission (Malik et al., 2024; One Health Trust, 2018).
2.6. Implications for public health and vulnerable populations
2.6.1. Vulnerable groups
Certain populations are disproportionately affected: infants, neonates, children, pregnant women, older adults, and people with low immune function. These groups are both more susceptible to air-pollution harms and to infections with resistant pathogens. In Pakistan, children under 5 are already at elevated risk from air pollution; smog episodes have led to school closures, clinic surges and warnings from agencies such as UNICEF. Similarly, AMR-related mortality is higher in neonates and children, especially in settings with poor neonatal care and infection control (IHME, 2023; UNICEF Pakistan, 2023).
2.7. Healthcare System & Societal Burden
The confluence of smog and AMR places enormous stress on healthcare systems: increased hospital admissions from pollution-related illnesses, repeated antibiotic prescribing (often empiric and broad-spectrum), longer hospital stays due to resistant infections, increased mortality, and greater costs. In settings such as Pakistan, where healthcare infrastructure is already constrained, this may lead to cascading consequences for health equity and sustainability. Moreover, the societal toll of reduced life expectancy from air pollution (e.g., 3.9 years nationally, up to 7 years in cities such as Lahore) is set against the backdrop of rising AMR-attributable deaths (tens of thousands annually), together representing a formidable burden (Bashir et al., 2022; Safdar et al., 2025).
2.8. Regional and global spill-over
While the bulk of the problem is within Pakistan, there are clear global implications: resistant strains emerging in Pakistan may spread internationally through travel and trade; the socio-economic and environmental drivers (air pollution + AMR) may serve as a model for other low- and middle-income countries; and the global health community’s agenda (e.g., One Health, global AMR surveillance) must incorporate environmental-pollution dimensions. Indeed, the “One Health” article on Pakistan emphasises that combating AMR successfully will require integrating human, animal, environmental and agricultural sectors (ASM, 2023; One Health Trust, 2018).
The prominence of Salmonella (38.39%) aligns with Pakistan’s known burden of typhoid and non-typhoidal Salmonella, including XDR strains in recent years. The presence of Klebsiella (~4.47%), E. coli (~8.53% in blood; ~57.81% in urine samples) is consistent with rising Enterobacterales burdens and urinary tract infections. Resistance trends (e.g., reduced resistance to amoxicillin/ampicillin in urine samples, yet increasing resistance to ciprofloxacin/levofloxacin) reflect the common pattern of older antibiotics losing potency, while dependence on fluoroquinolones and higher generation antibiotics increases (thus selection for resistance occurs). The regional skew (North heavier than Punjab for blood; North heavier for urine) may reflect differential sampling or prevalence but suggests that regional variation should be studied explicitly (Bilal et al., 2021; Mayo Hospital Lahore, 2021; Nishtar Hospital, 2020; PASS, 2018).
The gender distribution (males 55% for blood; females 70% for urine) is plausible: urinary tract infections (UTIs) are more common among females; bloodstream infections may have slight male preponderance depending on hospital- populations. The temporal comparison (2017–2020) showing continuity rather than improvement underscores that AMR remains persistent and perhaps worsening. While the dataset is valuable, the limitations must be acknowledged: possible bias in sampling, lack of national representativeness, missing linkage to environmental exposures (e.g., smog levels) and difficulty in attributing causality. Nonetheless, the data reinforce the emerging theme: high burdens of resistant pathogens in Pakistan. It would be beneficial to link these clinical microbiology data with air-quality / smog data at the same time and location to strengthen the case for a confluence effect (Bilal et al., 2021; PASS, 2018).
2.9. Smog-affected areas (2013–2023 baseline; latest 2023 readings)
Pakistan’s worst smog burden sits across Punjab + KP’s urban belt. The Air Quality Life Index (AQLI) reports 2023 population-weighted PM2.5 and life-expectancy losses for major divisions/cities (selected): Lahore 64.0 µg/m3 (≈ +5.8 years life if cut to WHO guideline), Peshawar 60.2 ( +5.4 y), Kasur 51.9 ( +4.6 y), Sheikhupura 51.3 ( +4.5 y), Islamabad 51.2 ( +4.5 y), Gujranwala 47.0 ( +4.1 y), Rawalpindi 47.4 ( +4.2 y), Multan 44.8 ( +3.9 y), Sialkot 44.1 ( +3.8 y), Muzaffargarh 42.3 ( +3.7 y), Vehari 43.0 ( +3.7 y), Faisalabad 38.6 ( +3.3 y); Karachi still exceeds WHO but is lower (32.5; +2.7 y). AQLI also notes PM2.5 rose ~56% from 1998→2023 and every Pakistani lives above the WHO limit (EPIC, 2025).
Seasonality & policy timeline. Peak smog hits Oct–Jan each year (post-harvest burning + inversions + traffic/industry). Punjab issued the Punjab Environmental Protection (Smog Prevention and Control) Rules, 2023 (Punjab, 2023) targeting brick kilns, crop burning and vehicular emissions. In Nov 2023, Punjab repeatedly declared health emergencies/closures in Lahore, Multan and 17+ districts, citing AQI readings > 600–1100 and surges in respiratory cases (millions affected) (Ali et al., 2022; Punjab Health Department, 2024).
2.10. Infections during the same timeline (airborne/LRI & pneumonia)
Lower respiratory infections (LRIs) remain among Pakistan’s top causes of morbidity and death, with South Asia having the highest childhood pneumonia incidence globally. IHME/GBD tools and UNICEF show South Asia ~2,500 pneumonia cases per 100,000 children/year and LRIs as a leading killer of under-5s. While national series fluctuate year-to-year (COVID-era NPIs temporarily suppressed influenza/RSV), LRIs persist at high levels through 2013–2023. Local signals from Lahore & Punjab during smog peaks. Multiple studies and reports document sharp rises in respiratory symptoms and hospital admissions during winter smog weeks in Lahore: cough/wheeze/SOB spikes; admissions roughly doubling in peak episodes; smog-season surges in asthma/bronchitis/COPD. Government emergency orders in 2023 explicitly cited >30,000 new respiratory complaints in days. Influenza/RSV context. Pakistan reports to WHO FluNet; influenza seasons overlay smog months (Nov–Mar), amplifying hospital burden. RSV is a major infant pathogen with documented hospitalizations and mortality in Karachi cohorts, again peaking in cool seasons that overlap with smog. Put together: recurrent Oct–Jan smog coincides with respiratory virus seasons, higher clinic/hospital visits, and empiric antibiotic use, all ingredients that can accelerate AMR selection and spread. Smog-affected industrial and urban corridors and their 2023 PM2.5 values are presented in Figure 1 (EPIC, 2025; Punjab Health Department, 2024; UNICEF Pakistan, 2023).
Smog-affected industrial and urban corridors in Pakistan. (A) Schematic locations of selected high-exposure cities and principal corridor connections; (B) Population-weighted annual mean PM2.5 concentrations for 2023, as reported in the Air Quality Life Index 2025 annual update. The boundary is schematic and used only for visualization; PM2.5, particulate matter with an aerodynamic diameter of 2.5 µm or less (EPIC, 2025).
2.11. Drug-resistant organisms shaping respiratory care in Pakistan
Across Pakistan’s tertiary hospitals, especially intensive care units, respiratory infections are increasingly managed in the shadow of multidrug resistance. Carbapenem-resistant Acinetobacter baumannii and Klebsiella pneumoniae are repeatedly reported at high levels in critical-care settings, and they are frequently implicated in severe hospital-acquired and ventilator-associated pneumonias. Local series and pooled analyses commonly describe substantial carbapenem resistance among E. coli and Klebsiella isolates, often in the range of ~25–40% or higher, alongside MDR/XDR A. baumannii in ventilated patients. MDR Pseudomonas aeruginosa is also a recurring problem in mechanically ventilated populations, mirroring the broader ICU pattern seen across South Asia (Bilal et al., 2021; PASS, 2018; WHO, 2023).
Alongside gram-negative resistance, MRSA remains firmly established in both hospital and community contexts. Regional syntheses across SAARC settings have reported meaningful colonization among healthcare workers, an important issue when patient volumes surge and infection-control systems are stretched (Bilal et al., 2021).
Two additional resistant threats, while not purely “pneumonia pathogens,” strongly influence the same prescribing environment and hospital capacity. XDR typhoid, first widely reported from Sindh from 2016 onward, is a clear marker of Pakistan’s wider resistance ecology; the shift toward fewer effective oral options has increased reliance on agents like azithromycin and carbapenems, reinforcing antibiotic pressure that spills over into respiratory care. Drug-resistant tuberculosis adds a parallel burden: national strategy documents and local cohorts emphasize under-diagnosis, treatment gaps, and a substantial MDR fraction among previously treated cases. During winter respiratory peaks, TB care competes for the same beds, diagnostics, and clinical attention, further tightening system capacity (IHME, 2023; One Health Trust, 2018; WHO, 2023).
2.12. Ambient bioaerosols and the smog–AMR plausibility link
A growing set of studies has reported antibiotic-resistant bacteria and resistance markers in airborne particulate matter, supporting biological plausibility for an “airway exposure” pathway, where microbes or resistance genes can be carried on particles and potentially reach susceptible hosts. More broadly, international work has begun to associate higher PM2.5 exposure with higher rates of clinical antibiotic resistance, although these relationships are complex and influenced by confounding factors (healthcare access, antibiotic use patterns, crowding, viral seasons, and surveillance quality). The key point is not that smog “causes” AMR on its own, but that it can plausibly increase infection susceptibility and treatment volume, and that treatment volume is a major driver of resistance selection (Malik et al., 2024; Wang et al., 2022).
2.13. City patterns and seasonal pressure points
In Pakistan’s smog-belt cities, winter air inversions and emissions from traffic, industry, and brick-kilns contribute to repeated November–January air-quality emergencies, with corresponding rises in respiratory presentations. Reports from Punjab and KP commonly describe spikes in asthma, bronchitis, COPD exacerbations, and pneumonia-related admissions during peak-smog weeks, sometimes approaching twofold increases in short time windows, exact magnitudes vary by hospital and study design. Cities frequently discussed in this context include Lahore, Faisalabad, Multan, Gujranwala, Sialkot, Peshawar, and the Rawalpindi–Islamabad corridor, where winter crowding plus seasonal influenza/RSV can intensify pediatric and adult respiratory caseloads. Karachi often records lower PM2.5 than the smog-belt cities, but still exceeds health-based guidelines and carries its own resistance pressures, including the long-running XDR typhoid context, again reinforcing the broader antibiotic ecosystem that shapes resistance risks across syndromes (Ali et al., 2022; Bilal et al., 2021; Punjab Health Department, 2024; Riaz and Hamid, 2018).
2.14. Smog-affected areas in Pakistan
2.14.1. Major urban hotspots
Lahore (Punjab): A consistent smog/air-pollution hotspot. Historical research described Lahore as enduring a “blanket of smog” due to urbanisation, vehicular/industrial emissions, crop-residue burning, and meteorological inversion layers (Riaz and Hamid, 2018). Recent commentary states Lahore again topped the world’s most polluted-city rankings in 2024, with PM2.5 peaks reportedly reaching more than 40 times the WHO guideline (Human Rights Watch, 2024). Peshawar (Khyber Pakhtunkhwa, KP): Identified in reports as one of Pakistan’s most polluted cities, with PM2.5 concentrations many times above WHO targets (EPIC, 2025). Islamabad / Rawalpindi corridor, Gujranwala, Sialkot, Faisalabad, Multan (Punjab): These large urban/industrial zones also report elevated particulate matter (PM2.5/PM10) levels, recurring smog-episodes (especially in autumn/winter) due to crop-burning, industrial emissions, traffic and dust (Ali et al., 2022). Nationwide context: Pakistan’s national average ambient PM2.5 concentration was reported at ~73.7 µg/m3 in 2023 (≈15× WHO guideline of 5 µg/m3) in one dataset. (IQAir, 2024)
2.15. Health burden and life-expectancy loss
The Air Quality Life Index (AQLI) estimated that Pakistan’s air pollution shortens average life expectancy by ~3.9 years; in polluted cities like Lahore or Peshawar the reduction can reach ~5–7 years (EPIC, 2025). Example: Lahore’s winter smog episodes in 2023/24 led authorities to declare health emergencies, with AQI readings exceeding 1,000–1,900 in parts of the city; such levels pose acute health risk (Human Rights Watch, 2024; Punjab Health Department, 2024). Sources of smog: crop residue burning (rice-stubble), brick-kiln emissions, vehicle and industrial output, waste burning, and meteorological trapping (inversions), especially Oct–Jan period (Ali et al., 2022; Riaz and Hamid, 2018). The smog “season” tends to begin in late October and extend into January/February, overlapping with cooler weather, agricultural burning post-harvest, lower dispersion conditions (Human Rights Watch, 2024; Riaz and Hamid, 2018). While older studies (e.g., 2016 ranking that Lahore was 5th most polluted worldwide) exist, recent data show further deterioration and expanded monitoring across cities. The smog burden remains persistent and intensifying, not just a one-off event.
2.16. Infection Burden & MDR/Respiratory Pathogens in the Same Timeline
2.16.1. Respiratory and airborne infection burden
Lower respiratory infections (LRIs), including pneumonia, are among the highest causes of morbidity and mortality in Pakistan (and South Asia broadly). According to the Global Burden of Disease (GBD) data, AMR-associated deaths in Pakistan for 2019 were 59,200 (directly attributable) and 221,300 (associated), placing AMR as the 3rd leading cause of death in Pakistan in 2019 (ASM, 2023; IHME, 2023). Although specific national time-series of respiratory admissions in Pakistan around smog episodes are scarce, media and agency reports during smog episodes (e.g., Lahore/Multan closures in Nov 2024) cite “tens of thousands” of respiratory cases in days, schools/offices closed. (Punjab Health Department, 2024)
Respiratory-viral seasons (influenza, RSV) overlap with smog months; increased infections lead to increased empiric antibiotic prescribing for potential secondary bacterial infection or misdiagnosed bacterial pneumonia. A study on prescribing patterns for upper respiratory tract infections (URTIs) reports high antibiotic use in Pakistan (Hashmi et al., 2021). A national “Situation Analysis Report on AMR in Pakistan” highlights acute respiratory infections (ARI) as a key burden and risk for antibiotic use/misuse. (One Health Trust, 2018)
2.17. Trends in MDR pathogens in respiratory/airborne infections
A systematic review of antibiotic resistance in Pakistan (2009-2020 data) found that Escherichia coli appeared in ~30% of studies (28 of 93) and that Staphylococcus aureus had MRSA in ~49% of cases reported (Bilal et al., 2021). A study of AMR among GLASS priority pathogens in Pakistan (published 2021) indicated that Pakistan initiated national AMR surveillance (PASS) in 2018 aligned with GLASS; the collected data show high resistance rates among key pathogens (PASS, 2018; WHO, 2023). According to IHME/GBD data (2021), the five pathogens with highest AMR-related deaths in Pakistan were: Klebsiella pneumoniae (34,400 deaths), E. coli (31,300), Staphylococcus aureus (28,600), Salmonella Typhi (23,300), and Streptococcus pneumoniae (20,300) (IHME, 2023). Streptococcus pneumoniae carriage isolates in Pakistan showed increasing erythromycin-resistance (from ~20% in 2014/15 to ~30.8% in 2017/18) though penicillin/ceftriaxone resistance remained low in one dataset (Nisar et al., 2021). In primary-care settings, inappropriate antibiotic prescribing for upper respiratory tract infections is common (Hashmi et al., 2021).
2.18. Linking smog, infection and AMR
A study from LUMS/SBASSE (2024) estimates that a 10 % rise in PM2.5 in Pakistan is associated with a 2.6 % increase in antibiotic resistance (global modelling), supporting a plausible environmental link between smog and AMR (Malik et al., 2024). Mechanistic arguments: inhaled particulate matter (PM2.5/PM10) causes respiratory inflammation, alters mucosal immunity, increases susceptibility to infection; also PM may act as vector for antibiotic‐resistant bacteria/genes in the air environment (Nozza et al., 2021; Wang et al., 2022; Vieceli et al., 2023). Thus, areas with heavy smog burden (Lahore, Peshawar, Multan, etc) are likely to see increased respiratory infection incidence, increased empiric antibiotic use (often broad‐spectrum), and thus accelerated selection of MDR organisms, a plausible inference given the data gaps but supported by modelling (Malik et al., 2024).
2.19. MDR pathogens associated with respiratory and airborne infections in Pakistan
A consistent pattern across Pakistan’s high-smog urban centers is the predominance of multidrug-resistant (MDR) and extensively drug-resistant (XDR) pathogens implicated in respiratory and airborne infections. These organisms are not only common causes of pneumonia and severe lower-respiratory tract infections but are also increasingly difficult to treat due to rapidly rising resistance rates. Streptococcus pneumoniae (Nisar et al., 2021). Carriage and clinical isolates in Pakistan have demonstrated a notable rise in macrolide resistance, with erythromycin non-susceptibility increasing from approximately 20% to 30.8% between 2014 and 2017. This trend directly complicates empiric management of community-acquired pneumonia during smog seasons, when pneumococcal infections peak. Staphylococcus aureus (including MRSA). National systematic reviews report methicillin-resistant S. aureus (MRSA) proportions around 49%. MRSA is implicated in both community- and hospital-acquired pneumonia and is especially problematic during periods of increased respiratory illness when hospital overcrowding and compromised air quality heighten transmission risk. Klebsiella pneumoniae. Identified by the GBD framework as one of Pakistan’s highest AMR-associated mortality pathogens (≈34,400 deaths) (IHME, 2023), K. pneumoniae in respiratory and ventilator-associated pneumonia frequently exhibits ESBL production and carbapenem resistance. These profiles leave limited therapeutic options, especially in tertiary-care ICUs during winter smog peaks. Escherichia coli. Although commonly associated with UTIs, E. coli contributes to aspiration and opportunistic pneumonias, particularly in immunocompromised individuals. With an estimated 31,300 AMR-related deaths nationally (IHME, 2023), resistant E. coli strains represent a broader systemic risk that may also intersect with respiratory care. Pseudomonas aeruginosa and Acinetobacter baumannii. ICU-based studies consistently demonstrate high MDR/XDR burdens in ventilator-associated pneumonia (Bilal et al., 2021; PASS, 2018). These pathogens thrive in compromised lung environments, conditions frequently precipitated or worsened by chronic exposure to smog pollutants. Their resistance to multiple antibiotic classes makes them among the most challenging respiratory pathogens in Pakistan. Mycobacterium tuberculosis (MDR/RR-TB). Pakistan’s substantial MDR-TB burden, although not directly caused by smog, overlaps with the respiratory vulnerability induced by poor air quality. Long-term lung injury from particulate exposure can impair host defenses, complicating TB management and increasing susceptibility to infection progression (One Health Trust, 2018; WHO, 2023).
The economic and clinical consequences of these pathogens are substantial. Data from Islamabad–Rawalpindi hospitals show that resistant bloodstream infections add approximately USD 34 in direct and USD 56 in indirect costs per patient. Surveillance remains fragmented: the Pakistan Antimicrobial Resistance Surveillance System (2017–18) highlights significant gaps in data for respiratory pathogens, while prescribing surveys confirm widespread antibiotic misuse for viral URTIs—further intensifying selective pressure (Hashmi et al., 2021; PASS, 2018; Safdar et al., 2025).
2.20. Spatial and Temporal Overlap: Smog - Infection - AMR
Smog-dense cities such as Lahore, Peshawar, and Multan routinely report AQI values exceeding 600–1000 during peak episodes. These periods correspond with marked spikes in respiratory complaints, hospital admissions, and empirical antibiotic prescribing. In these same urban centers, the background prevalence of MDR pathogens, including MRSA, carbapenem-resistant K. pneumoniae, MDR Acinetobacter, and Pseudomonas, creates a clinical environment where respiratory infections are both more severe and more difficult to treat. Although Pakistan lacks high-resolution longitudinal studies definitively linking smog peaks to temporal changes in AMR, modeling work suggests that every 10% increase in PM2.5 may be associated with an approximately 2.6% rise in antibiotic resistance. Thus, from 2013–2023, a consistent ecological pattern emerges: worsening air quality to increased respiratory infections leading to increased empiric antibiotic use and causing selection and amplification of MDR organisms. Regional variation reported across available surveillance sources (e.g., higher MDR burdens in North/Punjab) reflect known pollution gradients, though more rigorous environmental–clinical linkage studies are needed (Bilal et al., 2021; Malik et al., 2024; PASS, 2018; Punjab Health Department, 2024).
2.21. Gaps in evidence and research needs
Critical evidence gaps persist. Pakistan currently lacks integrated datasets that connect: quantified smog exposure (PM2.5/PM10), incidence of specific respiratory infections, antibiotic prescribing patterns, and emergence of MDR pathogens. Hospital antibiograms often lack stratification by respiratory vs. non-respiratory isolates, and real-time reporting is limited. Environmental detection of antibiotic-resistant bacteria or resistance genes in ambient air has begun but remains sparse. Longitudinal time-series tracking smog episodes, pneumonia admissions, and associated antibiotic use are urgently needed. A multi-sectoral data integration platform could substantially strengthen understanding of the smog–AMR nexus (Malik et al., 2024; PASS, 2018; WHO, 2023).
2.22. Implications for policy and action
In high-pollution cities, health systems must anticipate increased respiratory burden during smog months and implement reinforced infection-prevention and antibiotic-stewardship strategies. Empiric treatment guidelines should incorporate the elevated risk of MDR respiratory pathogens, with city-specific antibiograms informing decision-making. Air-quality improvement measures indirectly support AMR mitigation by reducing infection incidence and antibiotic pressure (Hashmi et al., 2021; One Health Trust, 2018).
A coordinated, One-Health–aligned surveillance system should integrate environmental metrics (PM2.5/PM10), respiratory infection data, antibiotic consumption, and AMR patterns at district and provincial levels. Misuse of antibiotics in poultry and livestock, another major driver in Punjab, must also be addressed. Global collaboration and technical assistance are essential, as Pakistan represents a high-burden, high-risk context for the acceleration and export of resistant pathogens (ASM, 2023; One Health Trust, 2018).
3. Discussion
This decade-long synthesis shows that Pakistan is not facing two parallel crises, smog and AMR, but a gradually tightening syndemic, in which atmospheric pollution and microbial resistance co-evolve and amplify one another. By triangulating air-quality trajectories, respiratory infection patterns, and AMR data from 2013–2023, our review suggests that smog-intensified respiratory disease is both increasing antibiotic demand and altering the ecological context in which resistant pathogens emerge and spread. Rather than viewing smog as a purely environmental issue and AMR as a purely clinical problem, our findings underscore that both are deeply entangled components of a single, systemic risk landscape.
Across the Punjab–KP urban belt, repeated winter smog episodes have transformed air pollution into a seasonal, predictable stressor for the respiratory system. High PM2.5 levels, recurring temperature inversions, and persistent industrial/vehicular emissions have been accompanied by surges in cough, bronchitis, pneumonia, and asthma exacerbations, with some reports indicating near-doubling of emergency visits during peak smog weeks. In this context, clinicians often face crowded outpatient departments, limited diagnostic capacity, and substantial pressure to prescribe “something strong” for rapidly worsening respiratory symptoms (Ali et al., 2022; Human Rights Watch, 2024; Punjab Health Department, 2024; Riaz and Hamid, 2018). This dynamic is particularly problematic in Pakistan because baseline stewardship is already weak. Over-the-counter antibiotic access, empirical broad-spectrum prescribing for viral upper respiratory tract infections, and incomplete courses are pervasive. Smog does not create these practices, but it intensifies them by driving higher consultation volumes and perceived severity, especially among vulnerable groups such as children, the elderly, and patients with chronic lung disease. In other words, smog acts as a seasonal amplifier of an already risky antibiotic ecosystem, adding a temporal rhythm to the expansion of AMR (Hashmi et al., 2021; One Health Trust, 2018).
Beyond increasing antibiotic demand, smog may also reshape the environmental resistome. Fine particles (PM2.5 and PM10) carry not only inorganic pollutants but also bioaerosols, bacteria, fungi, viruses, and free DNA, including antibiotic-resistant organisms and resistance genes. Emerging studies from high-pollution settings have identified resistance determinants (e.g., bla_NDM, ESBL genes, tetracycline and sulfonamide resistance genes) in ambient particulate matter and urban air samples. These observations support a mechanistic model in which inhaled PM serves as a vehicle and micro-habitat for resistant microbes and genetic material, facilitating their deposition on respiratory mucosa, surfaces, and hospital environments (Malik et al., 2024; Wang et al., 2022; Vieceli et al., 2023).
At the same time, chronic exposure to pollutants drives mucociliary dysfunction, epithelial damage, oxidative stress, and impaired macrophage function, all of which compromise host defenses and may favor colonization by more resilient, often resistant strains. Thus, the lung in a smog-exposed individual is not simply a passive victim of pollution; it becomes a selective niche in which pathogens that tolerate oxidative and inflammatory stress, frequently MDR gram-negative bacilli and MRSA, have a relative advantage. Our review therefore supports a dual-pathway hypothesis: smog enhances both the supply of resistance determinants (through bioaerosols) and the demand for antibiotics (through higher infection incidence), while simultaneously weakening host barriers, thereby making resistant infections more likely and more severe.
Many low- and middle-income countries (LMICs) are experiencing rapid urbanization, industrial expansion, and increasing antibiotic usage, but Pakistan represents an especially instructive sentinel case. First, smog intensity and persistence are among the highest globally, with estimated life-expectancy losses of several years in major cities. Second, the AMR burden is already extreme: tens of thousands of deaths annually are directly attributable to resistant infections, with Klebsiella pneumoniae, E. coli, Staphylococcus aureus, Streptococcus pneumoniae, XDR Salmonella Typhi, MDR/XDR Acinetobacter baumannii, and Pseudomonas aeruginosa forming a highly problematic pathogen complex. Third, structural weaknesses, fragmented surveillance, limited enforcement of emission laws, unregulated antibiotic sales, and overcrowded hospitals, create conditions where environmental and clinical drivers interact without effective checks.
Against this backdrop, the overlapping spatial patterns we highlight, cities that are simultaneously smog hotspots, respiratory-infection hotspots, and AMR hotspots, are unlikely to be coincidental. Even though direct causal time-series linking smog peaks to subsequent shifts in resistance profiles are sparse, the convergence of mechanistic plausibility, ecological context, and observed trends is compelling. Pakistan may therefore act as an early warning model for other LMICs where similar combinations of industrial pollution, weak stewardship, and high infectious-disease burden are emerging (World Bank, 2024; WHO, 2023).
One of the most novel implications of this review is conceptual: air-quality management should be recognized as an upstream AMR intervention. Current policy frameworks tend to treat smog control and AMR containment as separate domains overseen by different ministries, funding streams, and technical communities. Our synthesis suggests this is a strategic mistake. Reducing PM2.5 and related pollutants is likely to: Lower respiratory infection incidence (especially in children, older adults, and outdoor workers), thereby decreasing the number of clinical encounters in which antibiotics are prescribed. Reduce hospital crowding in winter, allowing better infection-prevention and control (IPC) and more judicious antibiotic use. Diminish environmental loads of bioaerosol-bound resistant bacteria and ARGs, weakening one route of dissemination. Improve baseline lung and immune function, potentially reducing progression from mild viral illness to severe bacterial pneumonia requiring broad-spectrum therapy (Aguilera et al., 2021; Nozza et al., 2021; Wang et al., 2022).
Conversely, strong antibiotic-stewardship and IPC programs can “buffer” the health system against the downstream consequences of smog by minimizing inappropriate antibiotic use during seasonal surges. This reciprocity argues for joint planning, for example, pre-smog-season preparedness that couples air-quality alerts with targeted stewardship campaigns, updated empiric guidelines based on city-level antibiograms, and reinforced IPC in high-burden healthcare settings.
A further contribution of this review is to map a research agenda at the interface of atmospheric science, microbiology, and clinical epidemiology. Current evidence in Pakistan is fragmented: air-quality datasets are rarely linked to hospital admission records, antibiotic consumption data, or pathogen-specific resistance patterns. Few studies simultaneously measure ambient PM, bioaerosol composition, individual exposure, microbiological outcomes, and antibiotic use. As a result, the smog–AMR connection is strongly suggestive but still largely inferred rather than directly quantified (PASS, 2018; WHO, 2023).
Future work should prioritize: Longitudinal, city-level time-series that align daily PM2.5/PM10 with respiratory admissions, antibiotic prescribing, and resistance patterns in key pathogens. Environmental microbiology studies of PM-associated bacterial communities and ARGs across seasons and regions, including “before–after” analyses around major policy interventions (e.g., kiln conversion, crop-burning bans). Cohort or case-control studies assessing individual smog exposure, microbiome changes, and risk of MDR infection. Modeling frameworks that combine atmospheric dispersion, infection dynamics, and resistance evolution to estimate the AMR impact of specific air-quality measures.
These approaches would move the field from plausible conceptual pathways to quantified causal estimates, enabling more precise policy prioritization.
3.1. Strengths and limitations of this review
This review has several strengths. It integrates environmental, clinical, microbiological, and policy data over a 10-year window, explicitly focusing on spatial and temporal overlap rather than treating smog and AMR in isolation. It emphasizes mechanisms at multiple scales, from cellular damage and bioaerosols to national-level life-expectancy losses and AMR-attributable mortality, and frames Pakistan as a model for other high-burden settings.
However, important limitations remain. Many of the data sources we synthesize are heterogeneous in quality, including surveillance reports, hospital-specific studies, and media-reported case spikes. National AMR surveillance is still incomplete, especially for respiratory pathogens, and standardized antibiograms stratified by infection site and season are scarce. Air-pollution measurements vary by source and may under-sample peri-urban and rural areas. Most critically, the lack of integrated datasets prevents us from directly proving that specific smog events cause measurable, short-term changes in AMR patterns. Our conclusions therefore rest on convergent evidence rather than on single, definitive causal analyses.
3.2. Towards a global Smog, AMR alliance
Finally, this review argues that Pakistan’s experience should inform a broader global agenda. Countries in South Asia, Sub-Saharan Africa, and parts of Latin America share similar combinations of high PM2.5, unregulated industrial growth, intense antibiotic use, and constrained health systems. Conceptualizing smog and AMR as a paired threat, rather than as parallel crises, opens new opportunities for international collaboration: joint surveillance platforms that overlay air-quality, antibiotic consumption, and resistance data; funding streams that co-finance clean-air infrastructure and AMR stewardship; and One-Health frameworks that explicitly incorporate atmospheric pollution (ASM, 2023; One Health Trust, 2018; World Bank, 2024).
Our study suggests that the burdens of smog and AMR in Pakistan are not merely colliding but increasingly interlocking. Smog intensifies respiratory infections, fuels antibiotic overuse, and may transport resistant microbes and genes, while entrenched AMR amplifies the clinical consequences of pollution-induced illness. Recognizing and addressing this syndemic is essential, not only to protect populations in Pakistan, but also to strengthen global resilience against the combined pressures of environmental degradation and microbial evolution.
4. Conclusion
The convergence of heavy smog burden and high antimicrobial resistance (AMR) in Pakistan between 2013–2023 represents an escalating national crisis. Smog-prone cities such as Lahore, Peshawar, and Multan consistently experience intense respiratory infection pressures. At the same time, Pakistan carries one of the world’s highest loads of AMR, with pathogens including Klebsiella pneumoniae, E. coli, Staphylococcus aureus, and Streptococcus pneumoniae responsible for tens of thousands of deaths each year. The emerging evidence suggests a reinforcing relationship in which smog worsens respiratory morbidity, drives higher antibiotic use, and creates ecological conditions that favor the selection and spread of multidrug-resistant organisms. Together, these patterns signal an urgent need for integrated environmental and infectious-disease monitoring, coordinated preventive policy, and a strong cross-sectoral response. Without decisive intervention, Pakistan will continue to face rising health-care burdens, avoidable mortality, and widening social and economic disruption. The analysis in this review highlights that environmental degradation and antimicrobial resistance cannot be addressed in isolation. Episodes of severe smog weaken respiratory defenses, promote pathogen survival in airborne particulate matter, and overwhelm clinical services, which leads to frequent empirical antibiotic prescribing. In this context, high pollutant exposure, increased infection incidence, and extensive antibiotic misuse interact to accelerate the emergence of resistant bacterial strains. This demonstrates that improving air quality is not only an environmental priority but also a fundamental strategy for reducing infection incidence and lessening antibiotic pressure across hospitals and communities. A national response must therefore combine clean-air reforms with strengthened antimicrobial stewardship, upgraded diagnostic and laboratory capacity, and enhanced infection-prevention practices, particularly during peak smog months. Integrating environmental indicators such as PM2.5 and PM10 levels with hospital admission data, antibiotic consumption patterns, and resistance trends would create a unified early-warning system capable of detecting risk escalation in real time. Such integration is especially critical for high-density urban centers where pollution, respiratory illness, and MDR pathogen prevalence converge most strongly. Pakistan’s situation also carries global relevance. Other low- and middle-income countries with similar combinations of pollution, population density, and antibiotic misuse face comparable vulnerabilities. A coordinated international platform featuring shared surveillance, rapid data exchange, and technical collaboration could significantly strengthen regional and global resilience against the joint threats posed by smog and AMR. Overall, the evidence presented underscores the need for a comprehensive, multi-layered strategy that recognizes the interconnectedness of environmental quality, human health, and microbial evolution. Effective action on air pollution and AMR, pursued together rather than separately, can reduce respiratory disease burden, slow the spread of resistant pathogens, and protect long-term national development. The window for preventive action remains open, but continued delay risks allowing the smog–AMR syndemic to deepen into one of Pakistan’s most consequential public-health challenges of the modern era.
Acknowledgements
We would like to acknowledge technical support of ICMSR-Islamabad Pakistan; ICMSR International Office 5900 Balconies Drive#12581, Austin TX, 78731 USA; and ICMSR International Office 5479 321-323 HIGH ROAD CHADWELL HEATH ESSEX UNITED KINGDOM RM6 6AX. The study is supported by International Center of Medical Sciences Research (ICMSR), Islamabad Pakistan.
Data Availability Statement
No new research data were generated. All evidence synthesized in this review is available in the cited publications and reports.
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