A serious concern for managers of water resources, pathogens in the urban environment easily enter waters through a number of pathways, including discharge of inadequately treated sewage, stormwater runoff, combined sewer overflows and sanitary sewer overflows. Pathogens in US ambient water bodies are regulated under the Clean Water Act (CWA), while pathogens in drinking water supplies are regulated under the Safe Drinking Water Act. Total maximum daily loads (TMDLs) are developed in accordance with CWA regulations for ambient water bodies with bacterial concentrations exceeding the water quality standard, which generally is a measure of a bacterial indicator organism. However, developing a TMDL for a supplementary indicator or pathogen is also required if a use impairment would still exist even after the water body is in compliance with the standard. This occurs because indicator organisms do not reflect the presence of pathogen contamination with complete certainty. The evaluation of pathogen indicators and summary of epidemiological studies presented are resources for those developing TMDLs to achieve water quality standards and restore water bodies to their intended uses.