The complex problem of antimicrobial resistance needs to be combated with a coordinated strategy, supported by governmental and cross-sector collaboration
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Antibiotic resistance is a serious public health concern that calls for more investigation into the self-medication of antibiotics, over-the-counter sale of antibiotics, general awareness about antimicrobial resistance (AMR), as well as the effectiveness of government campaigns and policy enforcement in India. The high rates of antibiotic abuse and overuse, leading to the development of AMR, present serious problems for the nation, especially in rural and underdeveloped regions.
In 2019 alone, antibiotic-resistant illnesses are thought to have directly killed about 300,000 people in India, including newborns; they have also contributed to an additional 1 million deaths. This crisis puts a heavy strain on the healthcare system, jeopardises the effectiveness of antibiotics, and compromises the management of infectious diseases. A major turning point in the country's attempts to fight the drug-resistance problem was the recent introduction of Nafithromycin, the first antibiotic developed locally to treat drug-resistant illnesses. Nafithromycin is being developed with assistance from the Biotechnology Industry Research Assistance (BIRAC) to treat drug-resistant bacteria that cause Community-Acquired Bacterial Pneumonia (CABP).
The high rates of antibiotic abuse and overuse, leading to the development of AMR, present serious problems for the nation, especially in rural and underdeveloped regions.
Antimicrobial resistance occurs when microorganisms like bacteria, viruses, fungi, and parasites evolve to resist drugs that were once effective against them. The overuse of antibiotics, whether from self-medication, overprescription, or incorrect dosage, produces selective pressure that permits resistant bacteria to thrive and grow, increasing the number of populations resistant to antibiotics.
Inaccessible healthcare and a general lack of knowledge about infectious diseases frequently prevent people from seeking medical treatment. As a result, antimicrobial medicines are frequently self-prescribed by people who lack a professional understanding of the dosage and course of treatment. Socio-economic factors like poverty, illiteracy, overpopulation, and starvation make matters worse. Compared to more developed states like Kerala or Tamil Nadu, states with higher rates of poverty and illiteracy like Bihar and Orissa frequently have higher rates of self-medication and inappropriate antibiotic usage. Some bacteria may survive antibiotic treatments that are not completed, providing them with the chance to adapt and flourish. Future infections may be more challenging to treat if these germs develop antibiotic resistance. Resistance poses a significant risk to public health since it might result in more significant health issues that call for more potent or different treatments.
In India, AMR causes more mortality than neoplasms, tuberculosis, and respiratory infections, enteric infections, diabetes, kidney ailments, and disorders impacting mothers and newborns.
Compared to infections from susceptible strains, infections produced by antibiotic-resistant bacteria are linked to up to two times as many adverse effects. These adverse outcomes may be clinical, like a worsening of the illness, or economic, like greater resource use and healthcare expenses. In India, AMR causes more mortality than neoplasms, tuberculosis, and respiratory infections, enteric infections, diabetes, kidney ailments, and disorders impacting mothers and newborns. Antimicrobial resistance is expected to cause 2 million deaths in India alone by 2050. Currently valued at an estimated US$41 billion, India's thriving pharmaceutical industry is a significant contributor to the issue of antibiotic resistance. Attention has been drawn to the competitive dynamics in the antibiotics industry, where intense pressure to increase sales encourages the abuse of antibiotics, especially those produced most recently. The United Nations General Assembly (UNGA) recently introduced the initiative HERA (the Health Emergency Preparedness and Response Authority). It has provided funding for initiatives such as the creation of paediatric anti-tuberculosis medications, metagenomic diagnostics, and the Tuberculosis (TB) vaccine MTBVAC under the EU4Health Programme. HERA also aims to minimise the careless promotion of antibiotics while ensuring that funding mechanisms such as revenue guarantee systems are necessary to promote the development of new antibiotics
In its seventh annual report, the Indian Council of Medical Research's (ICMR) Antimicrobial Resistance Surveillance Network (AMRSN) noted a worrying drop in the efficacy of antibiotics used to treat respiratory illnesses, pneumonia, sepsis and diarrhoea. In 2023, 99,492 samples from public and private healthcare facilities in India—including intensive care units and outpatient settings—were examined. Escherichia coli (E. Coli), Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus were among the samples examined for bacterial resistance. One important discovery was the concerning resistance of E. coli to antibiotics, including ciprofloxacin, levofloxacin, cefotaxime, and ceftazidime, with efficacy frequently falling below 20 percent.
Hospitals and other healthcare institutions are significant producers of antimicrobial waste, either directly through patient secretions or indirectly through the disposal of unwanted medications. This waste provides an environment where bacteria are exposed to antibiotics, potentially supporting the creation and spread of resistant strains in neighbouring environments. According to studies, hospital effluents in India contain high concentrations of tinidazole, sulphonamides, and fluoroquinolones, which can cause genotoxic changes and create resistant microorganisms. Although 80-85 percent of antimicrobial residues may be eliminated by proper wastewater treatment, less than 45 percent of Indian healthcare facilities have the necessary systems, raising worries about the effects of antimicrobial waste on the environment and public health.
India is a significant player in the pharmaceutical industry, with 80-90 percent of the world's antibiotics being produced here. This puts the nation in a unique position to impact AMR policies. India can develop its Active Pharmaceutical Ingredient (API) sector while guaranteeing sustainable practices by striking a balance between stringent environmental laws, which aim to protect the environment from antibiotics effluents since wastewater from industrial areas like Hyderabad's Patancheru-Bollaram industrial estate have hazardously high concentrations of antibiotics (like azithromycin and ciprofloxacin), and economic competitiveness.
In addition to spreading among populations of humans, harmful strains of resistant bacteria can also infect animals and plants as they pass through soil, water and the atmosphere.
The “One Health” approach emphasises collaboration between fields that deal with the health of people, animals, plants, and the environment. In addition to spreading among populations of humans, harmful strains of resistant bacteria can also infect animals and plants as they pass through soil, water and the atmosphere. Since domestic animals and wildlife are the sources of over 60 percent of viruses that cause human diseases, protecting the environment and animals also protects human health.
India has implemented several initiatives under this strategy, such as the National Action Plan (NAP) for AMR, which complies with international guidelines established by the World Health Organization (WHO). The ICMR and the Indian Council of Agriculture Research have partnered on the Integrated One Health Surveillance Network for Antimicrobial Resistance initiative, which seeks to prepare Indian veterinary labs for integrated AMR surveillance.
Antimicrobial stewardship describes measures intended to encourage the best possible use of antibiotic drugs: monitoring dosage, medication selection, delivery method, and period of administration. Stewardship initiatives, supported by the Food and Drugs Administration (FDA) and the WHO, require governmental support and broader implementation in India. Physicians, microbiologists, pharmacologists, nurses, and chemists should all be made to take Antimicrobial Stewardship Programs (AMSP) as a required course in medical education.
Increasing investment in healthcare infrastructure and diagnostics, enforcing stricter laws on the use and disposal of antibiotics, and educating the public about proper antibiotic use are all components of a comprehensive plan to combat antimicrobial resistance (AMR). Access to high-quality healthcare in rural areas, urban-focused initiatives to lessen pharmaceutical pollution, and improved AMR surveillance are crucial. Important elements also include encouraging public-private cooperation, collaborating globally to exchange best practices and coordinate efforts, and supporting research on novel antibiotics and alternative therapies.
There are currently very few studies being conducted in India to test the evidence of the effectiveness of stewardship programs and investigate the use of antibiotics.
Although AMSPs have become more prevalent in urban tertiary care facilities, they are still not used in rural areas. The Indian government has launched several initiatives to address AMR after realising its gravity as a public health concern. Antibiotic prescription rates were high (APR: 63.8 percent in the primary and 60.8 percent in secondary hospitals) and multiple (MPR: 23.8 percent in secondary hospitals) in lower-tier hospitals in West Bengal, India, according to a study. Antimicrobial Stewardship Programmes implementation was found to be facilitated only by infection control measures like committees and audits. These hospitals serve two-thirds of India's population, yet their infection control and AMR containment efforts are not linked, underscoring the necessity for specialised AMSPs.
There are currently very few studies being conducted in India to test the evidence of the effectiveness of stewardship programs and investigate the use of antibiotics. Given that not all regions of India adhere to the ICMR regulations, the existing ASP operations in India demonstrate that much more should be done to improve the situation.
Combating AMR is a complex challenge that requires comprehensive and multi-sectoral strategies that include public awareness-raising campaigns, strengthening regulatory frameworks to limit the sale of over-the-counter medications, and extending antibiotic stewardship programmes, especially in neglected and rural healthcare settings. Although programmes like the “One Health” model and the National Action Plan for AMR have set the foundation, more work remains to address implementation and enforcement gaps. India can help address the AMR problem by encouraging public-private partnerships, providing money to create novel therapies, and ensuring sustainable pharmaceutical practices. Public health protection and the long-term effectiveness of antibiotics require a comprehensive, well-coordinated effort supported by strong governance and cross-sector cooperation.
Madhavi Jha is a Research Intern at the Observer Research Foundation
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