The most direct transmission pathway is via animal products carrying resistant pathogens, which are transported from rural areas to urban consumers. The application of manure in agricultural production forms an indirect pathway, where faeces excreted by livestock, potentially containing antibiotic residues and resistance genes, are applied to fields. Consequently, the food or feed produced may be contaminated with AMR, which is then spread through the food chain to ultimately reach urban consumers.

Antibiotics consumed by animals and humans alike are partially excreted through urine and faeces. Consequently the wastewater system plays an important role in the spread of AMR. Water is an important rural-urban linkage, as contaminations flow along waterways, giving rise to classical upstream-downstream relations. Even modern wastewater treatment plants cannot fully remove resistant genes, leading to their inevitable release into surface water. Hence urban antibiotic consumption (as medication and via the food chain) results in higher concentrations of resistance genes in the water system, therefore spreading resistance from urban to rural areas.