When antibiotics stop working: India's antimicrobial resistance problem, and what hospitals can do

An antibiotic is one of the few medicines that can lose its power for everyone because of how it is used by anyone. Each time bacteria meet an antibiotic, the few that happen to survive go on to multiply. Over time those survivors take over, and the medicine that once cured an infection in two days stops working. This is antimicrobial resistance (AMR): germs no longer respond to the medicines meant to kill them (WHO). It is not the patient who becomes resistant. It is the bacteria, and they spread from person to person, ward to ward and hospital to hospital.

For most of the last century we could rely on a newer, stronger antibiotic when an older one failed. In Indian hospitals today, for some infections, that next medicine is running out.

How big is the problem in India

What the hospital laboratories show

The Indian Council of Medical Research (ICMR) has run a national surveillance network since 2013. Its 2024 report analysed 99,027 culture-positive bacterial isolates from 21 regional centres. These are tertiary care hospitals, and ICMR is careful to say the figures do not describe infections in the community. They do describe what doctors in large hospitals are up against.

• E. coli, the most common cause of urinary infections, is losing ground to carbapenems, a class long kept for serious cases. The share of E. coli isolates still killed by imipenem fell from 81.4% in 2017 to 57.6% in 2024.
• Klebsiella pneumoniae, a frequent cause of bloodstream infection and pneumonia, is worse. Imipenem susceptibility fell from 58.5% to 31.2% over the same years. Only about one in five isolates (20.3%) remained susceptible to cefotaxime, a common third-generation cephalosporin.
• Acinetobacter baumannii, a hospital pathogen of ventilated and very sick patients, was resistant to meropenem in 91.0% of isolates in 2024.
• MRSA (methicillin-resistant Staphylococcus aureus) rose from 33% of S. aureus isolates in 2017 to nearly 53% in 2024.

Network data from intensive care units point the same way. In a study of 26 tertiary hospitals and 89 ICUs between 2017 and 2018, carbapenem resistance was found in 72% of hospital-acquired bloodstream infections caused by Klebsiella and 77% of those caused by Acinetobacter. Central line-associated bloodstream infection rates in neonatal ICUs exceeded 20 per 1,000 central line days (Mathur et al., Lancet Global Health 2022).

Deaths

The largest estimates come from the Global Research on Antimicrobial Resistance (GRAM) studies published in The Lancet. They report two numbers: deaths attributable to resistance (deaths that would not have occurred had the infection been drug-sensitive) and deaths associated with it (deaths in which a resistant infection was involved).

• Worldwide, bacterial AMR was attributable to 1.27 million deaths and associated with 4.95 million deaths in 2019 (Lancet, 2022).
• For 2021, the estimates were 1.14 million attributable and 4.71 million associated deaths globally. In South Asia, about 335,000 deaths were attributable and 1.26 million associated (Lancet, 2024).
• For India alone in 2021, the Institute for Health Metrics and Evaluation estimates 267,000 attributable and 987,000 associated deaths.
• Looking ahead, the 2024 study forecasts 39.1 million deaths attributable to AMR worldwide between 2025 and 2050, with 11.8 million of them in South Asia, the highest of any region. South Asia is also forecast, with Latin America and the Caribbean, to have the highest all-age AMR death rate in 2050.

These are modelled estimates with wide uncertainty ranges. They are still the best evidence we have, and every version so far has pointed in the same direction.

The World Health Organization’s surveillance system adds a regional view. In 2023, about one in six laboratory-confirmed bacterial infections worldwide was resistant to antibiotic treatment. In WHO’s South-East Asia Region, which includes India, the figure was one in three (WHO, October 2025).

Why India is especially exposed

No single cause explains this. Several pressures act together.

Antibiotics are easy to get. Most antibiotics are Schedule H or H1 drugs that should only be sold on a doctor’s prescription. In practice the rule is weakly enforced. In a study of 622 pharmacies in Delhi, Mumbai and Patna, people trained to describe two to three weeks of tuberculosis-like symptoms, with no prescription, were given antibiotics in 37% of visits (Satyanarayana et al., Lancet Infectious Diseases 2016). An analysis of 2019 sales data describes over-the-counter sales of most antibiotics as largely unrestricted (Koya et al., 2022).

We use the wrong mix. India’s per-person antibiotic use is not high by world standards. What stands out is the type. In 2019, private-sector sales came to 5,071 million defined daily doses. Watch-group antibiotics, the WHO category with higher resistance risk, made up 54.9% of that, and Access antibiotics only 27.0%. Formulations without central regulatory approval accounted for 47.1% (Koya et al., 2022). In a national survey at 20 tertiary hospitals in 2021–22, 71.9% of inpatients were on antibiotics. Only 6% were on definitive (culture-directed) therapy; 94% were on empirical therapy, and 55% received antibiotics for prophylaxis rather than treatment (NAP-AMR 2.0, 2025).

A high burden of infection. Where diarrhoea, typhoid, pneumonia and crowded wards are common, more antibiotics are used, and more resistant germs spread. Hospitals are part of this: device-related infections in ICUs are both a source of resistant bacteria and a reason for heavy antibiotic use.

Animals and food. Antibiotics are used in poultry, livestock and fish farming. A 2015 global model forecast that antimicrobial use in food animals would grow 67% worldwide between 2010 and 2030, and 99% in Brazil, Russia, India, China and South Africa (Van Boeckel et al., PNAS 2015). India has since acted: in 2019 the government prohibited colistin for food-producing animals, poultry, aquaculture and animal feed supplements (NAP-AMR 2.0).

Manufacturing waste. India makes a large share of the world’s antibiotics. In 2016, researchers sampled water near bulk drug factories, sewage treatment plants and the Musi river around Hyderabad. All samples from 28 sites contained antimicrobials, and resistant bacteria, including carbapenemase producers, were widespread (Lübbert et al., Infection 2017). The authors linked this to poor wastewater management by the plants.

What India is doing

India has been working on AMR for over a decade, and the policy base is better than many people realise.

• The Chennai Declaration (2012). Indian medical societies met in Chennai in August 2012 and agreed a roadmap for tackling resistance, later published as a five-year plan (Ghafur et al., 2014).
• Schedule H1 and the red line. Under the Drugs Rules, 1945, 24 higher-end antimicrobials are listed in Schedule H1, and pharmacies must keep records of their sale for three years. The Ministry of Health’s “Red Line” campaign asks the public not to take any medicine with a red vertical line on the pack unless a doctor has prescribed it (PIB, 2024).
• National Action Plans. The first National Action Plan on AMR ran from 2017 to 2021. The second, NAP-AMR 2.0 (2025–2029), was launched on 18 November 2025. It gives each participating ministry its own plan with timelines and budgets, and aims to strengthen ownership, coordination between sectors and private-sector engagement (PIB, 2025).
• ICMR stewardship guidance. In 2018 ICMR published an Antimicrobial Stewardship Program Guideline to help hospitals set up their own programmes. Its preface notes plainly that most Indian hospitals lacked the structure and process for stewardship.
• Kerala. In 2018 Kerala became the first state to release its own action plan, KARSAP, drafted jointly by the health, animal husbandry, environment, fisheries and agriculture departments. Its work includes a state surveillance network, a drive to make primary health centres “antibiotic smart”, and a culture-report format that groups results by AWaRe category, developed at Government Medical College, Thiruvananthapuram (ASHE, 2025).
• AWaRe. WHO’s AWaRe system sorts antibiotics into Access, Watch and Reserve groups. WHO set a target of at least 60% Access use, and the 2024 UN political declaration on AMR raised the global goal to 70% by 2030. India has some way to go: in the national hospital survey above, 38% of antibiotic prescriptions were Access and 57% Watch. A 2023 review also noted that the National List of Essential Medicines 2022 does not group its antibiotics by AWaRe category (Manikandan, 2023).

What hospitals can do

Hospitals cannot fix pharmacy sales or factory effluent. They can control what happens inside their own walls, and the evidence that this works is strong.

Run a real stewardship programme

A Cochrane review of 221 studies found that stewardship interventions for hospital inpatients raised the share of patients treated according to antibiotic policy from 43% to 58%. They shortened antibiotic courses by 1.95 days, from an average of 11.0 days, without any difference in deaths (11% in both groups), and probably reduced hospital stay by about a day. Interventions that included feedback to prescribers worked better (Davey et al., 2017).

ICMR’s guideline describes the core team: a physician trained in infectious diseases, a clinical microbiologist and a clinical pharmacist, working with infection control staff and backed by hospital leadership. The team needs protected time, not goodwill alone.

The core practices

These steps appear in ICMR’s stewardship guideline and are well within reach of most hospitals:

1. Culture before antibiotics. Send blood, urine or other cultures before the first dose wherever it is safe to wait. Without a culture, the team cannot de-escalate later, and 94% empirical therapy becomes 100%.
2. Know your own bugs. Publish a hospital antibiogram at least once a year, ideally split by ICU and ward, so empirical choices reflect local resistance rather than habit.
3. Build the formulary around AWaRe. Make Access antibiotics the default for common infections. Require a reason, or approval, for Watch drugs, and restrict Reserve drugs such as colistin to cases agreed with the stewardship team.
4. Review at 48 to 72 hours. Once culture results arrive, narrow the antibiotic, switch to a single drug, or stop it if there is no infection.
5. Switch from IV to oral when the patient can swallow and is improving, using drugs that are well absorbed by mouth. It also lowers the risk of complications from IV lines.
6. Set durations. Write a stop date on every antibiotic order, and keep surgical prophylaxis short rather than letting it drift into days of treatment.
7. Audit and feed back. Measure antibiotic use, share results with each department, and repeat. Feedback is one of the better-proven parts of the evidence base.

Stop infections before they start

Every infection prevented is a course of antibiotics never given. Hand hygiene at the right moments, care bundles for central lines, urinary catheters and ventilators, and isolation of patients carrying resistant organisms are the backbone of infection prevention. NAP-AMR 2.0 names infection control in healthcare facilities as a key strategy, and the 2024 UN declaration set a goal for 90% of countries to meet WHO’s minimum requirements for infection prevention and control programmes by 2030.

Let the system help

Much of this depends on information reaching the right person at the right moment. A hospital information system can carry part of the load: showing the AWaRe group on every antibiotic order, prompting for a culture before the first dose, asking for a stop date, and turning laboratory results into a regular antibiogram. MedBrains, the open-standards hospital information system we build, records the AWaRe group for each antibiotic in the hospital formulary and reports an antibiogram of resistance by ward and organism; the rest is on our list. The principle applies to any system: make the right choice the easy one.

What patients and families can do

• Do not ask for antibiotics for a cold, flu or most viral fevers. Antibiotics act on bacteria, not viruses. If your doctor says you do not need one, that is good care, not neglect.
• Take them exactly as prescribed, at the dose and for the length of time your doctor advises. Ask if you are unsure how long to continue.
• Never share antibiotics or use leftovers, and do not buy them without a prescription. Look for the red line on the pack.
• Keep vaccinations up to date. WHO estimates that vaccines against 24 pathogens could cut global antibiotic use by 22%, about 2.5 billion daily doses a year (WHO, 2024).
• Wash your hands and ask others to. In hospital, it is reasonable to ask a doctor or nurse whether they have cleaned their hands before touching you or your family member.

A closing word

Antimicrobial resistance does not arrive as a single emergency. It arrives as a urinary infection that needs a third antibiotic, a newborn whose bloodstream infection responds to nothing on the shelf, a routine operation that becomes riskier each year. The numbers above are serious, but they are not fixed. The 2024 GRAM study estimates that better care for severe infections and better access to the right antibiotics could avert 92 million deaths worldwide between 2025 and 2050. Much of that work happens in ordinary hospitals, one prescription and one washed pair of hands at a time.

Frequently asked questions

What is the difference between deaths 'attributable to' and 'associated with' antimicrobial resistance?

Attributable deaths are those that would not have happened if the resistant infection had been a drug-sensitive one. Associated deaths are all deaths in which a resistant infection played a part. The second number is always larger (GRAM, The Lancet 2024).

Do the ICMR resistance figures describe infections in the community?

No. The ICMR network collects isolates from tertiary care hospitals, and the report itself says its figures should not be extrapolated to community settings (ICMR AMRSN, 2025).

What is the WHO AWaRe classification?

A WHO grouping of antibiotics into Access (first choices with lower resistance risk), Watch (higher resistance risk, to be used for specific indications) and Reserve (last resort). WHO set a target that at least 60% of a country's antibiotic use should be Access antibiotics; the 2024 UN declaration raised the global goal to 70% by 2030.