‘The antibiotic pipeline is running dangerously dry’: An Expert Explains threat of antimicrobial resistance

“Globally, the antibiotic pipeline is running dangerously dry. While a few antibiotics have been approved over the past two decades, almost none represent truly new classes or mechanisms of action. As antibiotics are overused, we risk exhausting the limited effectiveness of the drugs we already have — without adequate replacements in sight,” she said. Here, she explains what Indians should know about AMR.

What is the extent of antimicrobial resistance in India now?

Antimicrobial resistance is a silent pandemic. Often dismissed as a hospital-acquired infection or complication, its impact was felt in the Covid phase, when patients were impacted by drug-resistant infections.

In hospitals, which see a high usage of antibiotics, that pressure forces the bacteria to develop ways to survive them primarily through genetic mutations. Then they pass on resistance genes to other bacteria, accelerated by the overuse and misuse of antibiotics in humans. The patient gets admitted with one problem, which could be a myocardial infarction or kidney disease. During the course of hospitalisation or treatment, they may acquire drug-resistant pathogens, which cause infections, some of which claim lives.

It is because of this invisible reason that we don’t have a quantifiable burden of drug-resistant infections in our country or globally. The first figures actually came in 2021, and the attributable number is much smaller, between 1.2 and 1.5 million. We still need a more reliable number, considering we are a big country.

Apart from hospital-acquired infections, there are community acquired infections which are becoming drug-resistant, like typhoid, diarrhoea and pneumonia, which the PM talked about. We do not yet have an exact figure, considering we have 18% of the world’s population. So of the total infections which were estimated, almost 20% are located in India.

How much antibiotic overuse is behavioural?

In India, there is learned behaviour that has happened over time. Whenever Indians have a cough, cold or diarrhoea, they reach out for an antibiotic.

Some wouldn’t wait to find out if their infection is viral or bacterial, not knowing antibiotics don’t work for viral infections. Sometimes, people rely on pharmacists for what they perceive are seasonal infections. Physicians themselves prescribe them for prophylactic use.

Does antibiotic stewardship work?

It is more effective than an overnight ban on over-the counter (OTC) sales.

Take the case of Kerala, the first state to launch the antimicrobial stewardship programme in 2015, which focusses on rationalising antibiotic prescription and awareness at all levels. They banned OTC sales only last year with a reasonable amount of success. It took 10 years.

We have a knife at home but do we use it to kill people? We use it to cut fruits and vegetables. Similarly, we must first internalise what antibiotics are meant for. Only then can we be responsible.

How difficult has it become to treat routine infections?

There are two sides to this. One is getting infected with the drug-resistant bug that requires a next level antibiotic. The other is a community-acquired infection, for example, UTI (urinary tract infection) becoming complicated because of improper and inappropriate use of antibiotics over a period of time. The entire treatment of typhoid happens blind. Salmonella typhi strains are becoming resistant to fluoroquinolones, which were previously being used for treatment of this particular infection. Drugs like ceftriaxone and azithromycin are being overused and risk becoming ineffective for treatment of typhoid.

But the good news is that when you stop using the drugs for a short while, the sensitivity also comes back. For example, in 1990s, typhoid was resistant to three commonly-used drugs: co-trimoxazole, chloramphenicol and amoxycillin.

Then, we stopped using these drugs and shifted to fluoroquinolones. Fifteen years later, research has shown that the old drugs are regaining effectiveness for treating typhoid fever in certain regions. There is evidence that once you bring down the antimicrobial pressure from a certain drug, the sensitivity comes back.

What about the efficacy of diagnostics at the lowest level, which might help in using the right drugs, instead of a broad spectrum antibiotics?

The government has the Free Drugs and Diagnostics Services under the National Health Mission, which is providing free drugs and free diagnostics at all levels of health care. In fact, I led the development of the national essential diagnostic list in 2019 and subsequent revision in 2025 and how it has impacted all levels of healthcare in a few states.

The labs are well-equipped and staffed. In one of the sub-centres in Odisha, we saw quite a few patients visiting during our visit. The staff told us that with free tests, people have stopped going to quacks. So, this is the kind of difference it is making on the ground.

What about ICMR’s new test for identifying multiple diseases via a single test?

In India, the challenge is the simultaneity of infections during certain seasons. So come July-August, you have diarrhoea, typhoid, dengue, malaria and chikungunya. Getting all of them on one panel to be able to detect everything is going to be a challenge.

Is antibiotic use in livestock, agricultural practices and the environment complicating AMR?

First of all, we must find the attributable risk to humans from the antibiotics being used in animals. Some of the antibiotic classes to whom we are seeing very high level of resistance in humans are not used in animals. If we are seeing 60-70% resistance to the drugs used by humans, then the root cause is human behaviour.

ICMR did a study at two sites in Delhi and Vellore with two pathogens, E coli and Klebsiella pneumoniae, drawn from veterinary, environmental and clinical samples. We found a sizeable overlap of antibiotic resistance genes between human and environmental isolates from hospital surroundings, but very minimal overlap between the human and the animal.

What we need to be vigilant about is antibiotic residues from food which continue to persist in your gut microbiome may lead to commensal bugs in your gut flora carrying antibiotic resistance genes. Commensal gut bacteria carrying antibiotic-resistance genes can directly cause drug-resistant infections and indirectly fuel resistance by transferring these genes to pathogenic bacteria.

The gut microbiome functions as a hidden reservoir of antimicrobial resistance, especially under antibiotic pressure. That’s why the FSSAI (Food and Safety Standards Authority of India) lists mentions the antibiotic residue limits on product labelling.

What are the challenges of data collection since that leads to stewardship?

At ICMR, our network is limited to 25 tertiary care hospitals, all of which have well-functioning clinical microbiology labs. We publish the data every year, this being our eighth edition. The reason this cannot be taken as representative of the entire country is that this data is coming from tertiary care hospitals where patients come with a previous history of hospitalisation and excessive antibiotic usage.

That’s why the data that we present has a very high level of resistance. This may not be representative of the general trend in the country. We need to widen the circle of authentic data collection. The Japan Nosocomial Infections Surveillance (JANIS) has data from around 2,000 hospitals.

Are there any alternative therapies that can beat AMR?

One is phage therapy, which involves bacteria-eating viruses. It is effective in treating UTIs.

But it requires a kind of precision to identify which phages will work for your infection. Resistance develops even to phages.T hen you have to use a cocktail of viruses. This is an evolving field and needs customisation for patients depending upon the nature of infection. Then there are monoclonal antibodies, but they are in a nascent stage.