Antibiotic resistance is making some infections harder to fight than ever before. Some bacteria have become so resistant that even the strongest antibiotics are useless against them. With fewer options available, doctors are turning to phage therapy–an experimental treatment using viruses found in nature that target and destroy specific bacteria.

Phage therapy has only IND (Innovative New Drug) and compassionate treatment approval by medical regulators like FDA and EMA for individual cases and isn’t widely available. Only a few people around the world have received it. One of the first people in India to take this treatment was Pranav Johri. In 2016, at age 33, he faced a stubborn prostate infection that no antibiotics could cure. After exhausting all options, he turned to phage therapy at Eliava Institute, a century-old institute dedicated to bacteriophage research and application in Georgia.

Ten years ago, getting doctors and medical institutions to even accept the problem of AMR was a huge challenge. Since then, we’ve come to a point where everyone acknowledges the problem, and we’re working on ways to tackle it.

Johri’s experience speaks to the promise of phage therapy in fighting antibiotic-resistant infections, even as access remains limited. We spoke to him, now running Vitalis Phage Therapy which is the official Indian partner of the Eliava Phage Therapy Center, to understand how this treatment fits into the global fight against antimicrobial resistance.

Understanding phage

Q. How long have you been involved in the field of AMR?

My involvement in the field of AMR started from my own experience of going through an antibiotic resistant infection not being able to find answers from the medical community. I live in Delhi and was seeing the top doctors in the city. Unfortunately, they had nothing to offer to a patient suffering from an antibiotic-resistant infection. After multiple failed antibiotic treatments, my doctors declared my infection to be multi-drug resistant and prescribed me a buffet of medicines to ‘manage’ my infection and symptoms since it could not be treated with antibiotics. That led me to look for alternative treatments in cases where antibiotic treatments fail, and that led me to phage therapy. After the successful treatment of my multi-drug resistant infection with phage therapy, my wife and I founded Vitalis Phage Therapy.

We started the initiative with two goals. First, to raise awareness about AMR and its impact on the patient's quality of life, as well as on life itself. Second, to promote phage therapy as an effective way to combat antibiotic-resistant infections. That’s how I got involved in the field of AMR.

Today, we are working with medical institutions, across the country for phage therapy treatments for their patient suffering from antibiotic resistant infections. We’ve organised treatment for cases of urinary tract infections, lung infections, wound infections, and even sepsis.

Q. What is the procedure like? When and why does it fail? 

Phage therapy is not a standardised treatment but a customised approach to tackling bacterial infections using bacterial viruses (phages), the natural predators of bacteria. The specific phage used depends on factors such as the sensitivity of the bacterial strain to that specific phage, whether the infection is acute or chronic and the patient’s condition. The approach is different for each case but is very effective in fighting antibiotic resistance when other treatments no longer work.

Since we started six years ago, we have organised phage therapy treatments for over 250 people, with a success rate of 70–75%. However, success can vary. For example, if someone has a urinary or kidney infection caused by kidney stones, the stones must be removed. Otherwise, they provide a safe place for bacteria, causing the infection to come back.

In some cases, like advanced sepsis, treatment may fail if started too late. This often happens when the patient is already in a coma or the infection in the bloodstream has become too severe.

Q. Why is the treatment not yet popular in India? 

There are many reasons for this, including political, historical, and regulatory factors.

Phage therapy is currently available in India and 145 other countries as a compassionate treatment. Patients can use it as a personalised option because it’s not yet part of standard medical protocols due to regulatory issues.

Today, phage therapy is at least recognised by regulators as a real option for treating bacterial infections. Work is ongoing to research and create ways to make it more available and accessible.

Taking responsibility

Q. What can be done better in terms of creating awareness? 

The challenge in India is that we face two problems: access and excess. In big cities like Delhi, Bangalore, Mumbai, Hyderabad, or Chennai, we deal with excess, where people are overusing and misusing antibiotics. They take antibiotics for conditions where they are not needed, like viral infections, and they don’t follow the correct dosage guidelines.

But if you move 200 kilometres away from the big cities and into the countryside, the problem shifts to access. Most people in rural areas don’t even have pharmacies or drug stores where these medicines are available.

Also read: Inside Tamil Nadu's battle against AMR

Awareness is the biggest challenge and needs to be addressed. Whether it’s in agriculture, the food industry, or animal husbandry, there is so much overuse and misuse of antibiotics. These antibiotics enter our food chain and our bodies.

It's like inoculation: the bacteria gets exposed to antibiotics and develops resistance. When we actually need antibiotics for an infection, the bacteria may already be resistant.

When the season changes and viral infections increase, people start taking antibiotics without thinking. Most aren’t even aware of the risks they’re putting themselves and the community at. Antimicrobial resistance (AMR) is not an individual risk, it’s a community risk. We all share the same water, sewage, and food, so it’s all connected. There’s a concept called One Health, which means we need to address the issue from the perspective of the whole environment and ecosystem, not just in isolation, because that would not be effective.

The government, regulatory bodies, and other stakeholders must focus on raising awareness. We need awareness campaigns like those for smoking. For example, cigarette packages carry clear warnings about the risks of smoking and lung cancer.

We need similar mass campaigns for AMR. Only then will society as a whole recognise the problem. Today, AMR is mostly known only within the scientific and medical communities, and not widely understood by the general public.

Q. What can an individual do? 

There are many things we can do. Most people are taking antibiotics when they don’t need them. Why is this happening? We need to stop it. We need to address the issue at the level of both doctors and pharmacies. Why are they prescribing antibiotics so often?

People should be saying, don’t give me antibiotics. Today, you can even buy colistin at pharmacies, even though it’s a controlled medicine. These issues need to be addressed at the regulatory level. We’re still far behind. While many guidelines exist on paper, there’s a gap when it comes to real-world implementation.

Q. How focused are the stakeholders on the problem of AMR? 

There is growing focus on the issue. Ten years ago, getting doctors and medical institutions to even accept the problem of AMR was a huge challenge. Since then, we’ve come to a point where everyone acknowledges the problem, and we’re working on ways to tackle it.

During COVID, every country tracked the number of infections. If we did the same for AMR, we would see similar numbers. It needs that same level of focus.

We are making progress, but the pace needs to speed up because AMR is not slowing down. It’s growing exponentially.

The problem requires a focused approach, just like how the world responded to COVID, including regulators, medical institutions, and the scientific community. We need the same focus for AMR because it’s just as much of a pandemic. It’s silently killing people because it doesn’t get the same media attention COVID did.

During COVID, every country tracked the number of infections. If we did the same for AMR, we would see similar numbers. It needs that same level of focus.

Also read: What happens when you stop taking antibiotics midway

Mohammad, a 22-year-old son of doctor parents, is no stranger to the routine that comes with an antibiotics prescription. Following through on a course of medication is something he rarely gives a second thought to. But, if the illness is not severe, the Bengaluru resident finds himself forgetting about the need to take them—especially as he begins to recover.

Now, with leftover antibiotics at hand, Mohammad does something that is not unusual for patients—he puts them away in a medicine cabinet for future use. “People have a tendency to save everything. I know many who keep medications for later. It’s the Indian stereotype of hoarding things… my grandmother keeps medications from two to three years ago, and buys them in bulk,” he says.

The growing overuse and misuse of antibiotics in India, and the resultant antimicrobial resistance, is further compounded by issues of personal misuse, from self-medication and overconsumption to patients ending their antibiotic courses prematurely. Though seemingly minor, these habits accelerate the spread of resistant bacteria, making infections harder to treat.

Quick fix much?

For young corporate employees like Bengaluru-based Apoorva, a long antibiotic course can seem like an inconvenience, pushing them to ask doctors for shorter courses when they are afflicted with common infections. “I don’t have the patience for a week-long course,” Apoorva rues, “I often forget to finish it anyway. With work and my personal commitments, I would rather have something stronger and be done with it.”

Dr Mohsin Bawkar, a physician specialising in occupational medicine for over three decades, attests to the prevalence of this sentiment. “Patients worry and ask for an antibiotic when they’re travelling, regardless of whether they need it or not. Working professionals ask for stronger courses because they can’t afford to take leaves at work,” Dr Bawkar says, asserting that the unnecessary use of stronger third-generation drugs worsens resistance.

Those on the other side of the examination table, too, are responsible for furthering this questionable habit. “Some practitioners, especially in smaller cities, skip established guidelines. Instead of starting with penicillin—the most basic antibiotic—they may prescribe stronger options like Augmentin or Cephalosporins, which are third-generation drugs,” the physician says. (Third-generation drugs are a class of medication that are typically more concentrated and effective, but known to pose severe long-term risks in cases where they are prescribed for common infections.)

There have been cases where even infants have been administered potent medications, with the belief that they will recover speedily. “However, a quick recovery doesn’t always mean a complete recovery,” Dr Bawkar warns.

ALSO READ: Why common infections could become killers again

Doubt and discomfort

One among many consequences of Big Pharma’s aggressive promotion of antibiotics is a growing mistrust, or even outright refusal, to take antibiotics. Sanjana, a 22-year-old legal analyst in Bengaluru, has observed such a tendency in her extended family. “More than anything, they’re worried they’re using more than what is necessary—even if the doctor has assured them it’s not the case. They’re petrified of suspected side effects, too. There’s a real reluctance to even take antibiotics sometimes, let alone finish them,” Sanjana says. She has observed older relatives switching to “natural” remedies, such as soups, spice mixes, and fruit and veggie-based concoctions, once they begin to feel slightly better.

Sanjana’s family isn’t alone in this hesitation. Satya Sivaraman, a coordinator at ReAct Asia Pacific, an organisation advocating and working to mobilise policymakers and the public on the issue of antibiotic resistance, highlights the two extremes he has seen —overt scepticism, like the rise of vaccine denial, or flippant overuse of antibiotics, fueled by a lack of curiosity about one’s health and the tendency to outsource bodily well-being to medical practitioners.

What science tells us

“In hospital settings, it makes sense to discontinue a dose before an operation when we administer antibiotics to patients who could face the possibility of being at risk,” says Dr Sonal Asthana, a lead consultant in transplant surgery at Aster Hospital, drawing from his first-hand experiences in dealing with the complexities of antibiotic misuse.

Discontinuation turns problematic in non-clinical set-ups, in cases of bacterial culture or infection, where stopping medication is dangerously counterproductive. “This does not kill all the bacteria; it singles out the bacteria that are going to be resistant to the antibiotic. It’s only killing selective bacteria while the resistant bacteria will thrive and gradually grow immune to the antibiotic,” Dr Asthana cautions. This process, which accelerates the evolution of antibiotic-resistant strains, is termed selective pressure.

Dr. Baliwanth, a paediatrician at Manipal Hospital with a specialised interest in infectious diseases, emphasises the risk of not differentiating between viral infections and bacterial infections. Antibiotics are ineffective against viral infections; thus misdiagnosing a bacterial infection often results in the prescription of antibiotics even when they’re not necessary. The judicious use of antibiotics lies in the right prescription, he crucially points out. “When bacteria are exposed to antibiotics but not fully eradicated, they evolve, developing special enzymes to neutralise and destabilise the drugs,” says Dr Baliwanth. This leads to therapeutic failure, wherein the prescribed treatment no longer achieves its desired recovery and the pathogens survive. 

Sanjana and Satya’s observations bring to light a common underlying hazardous assumption: that one might be ‘over-medicating’ if they complete their antibiotic course even after their symptoms subside.

Through genetic replication, the surviving bacteria reproduce, propagate, and transmit resistance genes within their population, leading to the proliferation of strains that the antibiotic can no longer effectively target. This fosters the spread of multidrug-resistant organisms (MDROs). Not only do incomplete antibiotic regimens reduce their efficacy over time but also contribute significantly to a reservoir of resistant pathogens that compromise infection control and treatment in the future.

ALSO READ: The looming crisis of post-antibiotic era

Where the buck stops

Dr Asthana brings to our attention hospital antibiotic stewardship programs, typically led by infectious disease specialists and microbiologists. “These teams collaborate to recommend appropriate antibiotic treatments and minimise antibiotic use whenever possible. Sure, this is definitely a more personalised approach than a systemic one, but it’s needed in a situation like ours. Both practitioners and the public need to exercise caution,” he says.

Personal responsibility is a crucial piece of this puzzle. When antibiotics are discontinued prematurely, there is the possibility of developing a recurring infection. Your doctor may then prescribe a full course of antibiotics again that needs to be finished in its entirety.

Completing an antibiotic regimen at an individual level is a small yet significant step in ensuring these medications remain effective for everyone.

It has repercussions for the bigger picture of public health and literacy. These informed choices, when made together, can help protect the potency of antibiotics across generations.

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Hyderabad’s origin story begins in the 1590s, when Mohammad Quli Qutub Shah, the fifth sultan of Golconda, dreamed of a city by the Musi river to escape drought and recurring outbreaks of plague and cholera. Over the centuries, the Musi, which originates in Vikarabad and flows into the Krishna River in Nalgonda, nurtured green spaces, sustained communities, and also stood witness to Hyderabad transforming into a bustling IT hub.

Today, however, the river tells a different story. Once clean and vibrant, it is now polluted and frothing, tainted by pharmaceutical waste and superbugs that pose significant threats to public health.

A study by the Indian Institute of Chemical Technology (CSIR-IICT) and Australia’s Commonwealth Scientific and Industrial Research Organisation has uncovered alarming levels of pollutants in the Musi such as commonly used antibiotics like Ciprofloxacin, antidepressants, anti-inflammatory drugs such as Naproxen and Diclofenac, and antifungal medications like Fluconazole.

While the river’s water is no longer used for drinking, it remains a lifeline for irrigation and cattle farming in Nalgonda and other Telangana districts. However, the toxins in the water risk contaminating groundwater, which directly impacts nearby communities.

Misdirected priorities

Despite the immediate and long-term risks, governments seem to be focusing on the wrong priorities. Successive administrations have focused on the river's beautification. But these efforts won't stop the health disaster brewing in the waters of the Musi: antimicrobial resistance (AMR) from consistent exposure to antimicrobials.

Pollution has to be stopped at the source; until then, no amount of cleaning will solve the issue.

Telangana, known for its pharmaceutical industry around Hyderabad, has a poor track record of managing pharma waste. Instead of addressing the main cause of pollution, the state is focusing on beautifying the river to boost tourism. The new Congress government announced a Rs 1.5 lakh crore Musi Riverfront Development Project to improve the river and attract tourists over the next five years. But there’s no clear plan yet. According to Municipal Administration and Urban Development principal secretary Dana Kishore, only Rs 3,800 crore (just 2.53% of the total budget) will go towards cleaning the river, leaving the main issue largely unaddressed.

Clearly, the Musi river needs more than a facelift; it requires urgent measures to curb pharmaceutical pollution and safeguard public health.

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“Pollution has to be stopped at the source; until then, no amount of cleaning will solve the issue,” said Shilpa Krishna, who has researched antimicrobial resistance (AMR) in Hyderabad. “Restoration and beautification will serve the purpose only when the state government takes an initiative to curb pollutants entering water bodies,” she added.

In the 1990s, a public movement against pollution started in response to the release of highly toxic and untreated waste from pharmaceutical and chemical companies near Patancheru and Bollaram in Medak district, close to Hyderabad. To manage the industrial waste in the Patancheru industrial area, a private company called Patancheru EnviroTech Limited (PETL) was set up to collect, treat, and dispose of the waste according to the required standards.

However, public policy expert Narasimha Reddy Donthi said PETL functions mainly as a secondary treatment facility. Industries are supposed to pre-treat wastewater on-site, but the company has been accepting untreated effluents from multiple industries to remain commercially viable. By not properly treating this extra waste to meet the required standards, PETL has made the pollution problem worse.

Also read: Inside Tamil Nadu's battle against AMR

Regulation and enforcement

This brings us to a crucial question: what actions has the Telangana State Pollution Control Board (TSPCB) taken? Tasked with enforcing compliance under the Water (Prevention and Control of Pollution) Act, 1974, TSPCB mandates pollution control measures like Zero Liquid Discharge (ZLD) systems.

“We held a meeting with industry associations in the first week of November and warned them of closures if untreated effluents are discharged into the common treatment plant, which eventually contaminates the Musi River,” said WG Prasanna Kumar, senior social scientist at TSPCB.

The pharma companies even have underground pipelines linked to Musi river to let their toxic waste into the water body.

Pharmaceutical companies in Hyderabad, many of which are US-based, reportedly continue to flout regulations. “It is disappointing that the United States Food and Drug Administration (USFDA) is only concerned about the quality of the medicines but is not bothered if local laws are violated. These companies should not claim to follow good manufacturing practices when disease is being created outside their premises, and the health index of communities living near Musi is at stake,” said environmentalist Lubna Sarwath. She has filed multiple cases with the National Green Tribunal (NGT) about the industrial pollution in Hyderabad’s water bodies.

During her visit to pharmaceutical companies in Hyderabad, she noticed colourful, toxic waste being dumped outside their premises, sparking concerns about pollution. “The pharma companies even have underground pipelines linked to Musi river to let their toxic waste into the water body,” she said.

Looming crisis

Antimicrobial resistance in water bodies is a public health disaster in the making. “Antibiotic effluent released into the rivers and rivulets can leach into the surrounding soil and contaminate the groundwater over time. This creates an environment conducive to the growth of antibiotic-resistant bacteria, which can spread through various water sources and agricultural products,” said Dr Ranga Reddy, president, Infection Control Academy of India. “For humans, exposure to these resistant bacteria can result in infections that are increasingly difficult to treat, posing serious public health risks and contributing to the broader challenge of AMR containment.”

Resistant bacteria lead to infections that are harder to treat, driving up healthcare costs and placing economic strain on affected communities.The situation poses a significant risk of a human health crisis in Telangana. With antibiotic-resistant bacteria on the rise and no new antibiotics being developed, the threat intensifies. Lack of ongoing research means that as resistance builds, patients will require higher doses to achieve the same effect, leading to increased healthcare costs and further economic strain on communities,” said Shilpa.

One Health approach

Studies suggest that adopting the One Health approach and involving local populations can help mitigate the spread of AMR. “Involving local populations in the responsible use and appropriate disposal of antimicrobials constitutes a comprehensive and impactful strategy for promoting awareness of the dangers of antibiotic resistance,” according to a recent study.

Investing in the Musi without addressing its root causes and risks will yield limited results. Sabarmati Riverfront Project is a good case in point. Launched in 2005, the project prioritised urban beautification and a revenue-driven approach. But Sabarmati remains India’s second most polluted river (CPCB 2023). Hence, the budget must prioritise eco-friendly restoration alongside beautification. Such an approach benefits the environment, aligns with international conventions, and protects the health and livelihoods of communities dependent on the Musi river.

The unchecked pollution of the Musi River highlights the urgent need for stronger enforcement, corporate accountability, and systemic change to protect public health and restore the river to its former glory.

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Antibiotic resistance genes (ARGs) are causing a major headache in the healthcare world, helping bacteria become immune to the drugs we use to fight them.

There are two primary ways bacteria become resistant:

Mutation: Bacteria can develop small changes in their DNA, called mutations, which allow them to survive when exposed to antibiotics. These changes can be due to small alterations in their genetic material, like substitutions or deletions.

Horizontal Gene Transfer (HGT): Bacteria can exchange genetic material with other organisms through three main processes: transformation, transduction, and conjugation.

ARGs are particularly problematic for physicians treating infectious diseases because they make bacteria harder, sometimes impossible, to eliminate. In medical terms, ARGs can be housed in plasmids, transposons, and integrons, which act as vehicles for spreading resistance. Tragically, this rise in antimicrobial resistance (AMR) hits children the hardest, especially those under five.

In India, one in five children under five succumb to drug-resistant infections, with nearly 190,000 of these cases linked to sepsis, a severe bloodstream infection.

The maternal-infant resistome

Pregnant women and infants are among the most vulnerable groups affected by ARGs. The maternal-infant resistome is the collection of antibiotic resistance genes shared between mother and child. While resistance genes naturally occur within bacterial populations, the misuse and overuse of antibiotics–both in medical and agricultural contexts–have accelerated their spread.

Did You Know?

Newborns are at heightened risk because their immune systems are still developing, making them more susceptible to infections and resistant bacteria, with potential lifelong health impacts.

“Infants typically acquire (bacteria with) resistance genes as they pass through the birth canal,” said Dr Ramya S R, a professor and microbiologist. "At birth, the infant’s gut microbiome is not yet well-established, and its development depends on various factors, including the type of delivery, feeding methods, and other influences."

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The likelihood of the infant inheriting resistant genes increases if the mother possesses them. “If a mother already carries antibiotic-resistant genes, there's currently no vaccine or direct preventive measure for controlling it,” said Dr Olivia Marie Jacob, a gynaecologist at AIIMS Andhra Pradesh.

In India, the challenge lies in over-the-counter access to antibiotics, allowing people to purchase and consume them without prescriptions. Antibiotics come with specific courses–some for three days, others for five or seven. Once an antibiotic course begins it must be completed, stopping midway after just one or two doses creates selective pressure allowing resistant genes to develop in the gut. Overuse of antibiotics also builds this antibiotic pressure. 

In contrast, in Western countries, a baby may receive antibiotics once or twice in their first year. In India however, a child might be exposed to antibiotics up to 12 times by the age of two. 

“The constant antibiotic exposure creates selective pressure, leading to mutations in the gut microbiota of the child. The most effective prevention strategy is to avoid unnecessary antibiotic use. Most upper respiratory infections in kids such as sore throats, colds and coughs are viral infections with only occasional bacterial involvement. However, we often don’t wait for confirmation and start taking antibiotics, which only adds to the resistance problem,” she added.

Escalating resistance

In recent years, antimicrobial resistance has become a critical public health issue, with links to the poultry and livestock industries. Current projections warn of 10 million AMR-related deaths annually by 2050.

Routine antibiotic use in healthy animals has led to a dangerous buildup of resistance genes in their gut bacteria. When these resistant genes enter the food chain, they pose a potential threat to human health. In India, stronger policies to regulate over-the-counter antibiotic sales for animal husbandry could be key in slowing the spread of AMR.

Detecting AMR

To identify the presence and prevalence of antimicrobial-resistant genes, researchers rely on two primary sampling methods: clinical and environmental.

“Clinical sampling involves collecting stool samples from individuals in the general population, which are then cultured to identify bacteria types and the resistant genes they carry.” Among the commonly detected gut bacteria are Escherichia coli, Klebsiella pneumoniae, Pseudomonas, and Proteus, which can reveal the extent of antibiotic resistance, said Dr Pooja Rao, a microbiologist and expert with the National Action Plan for AMR at KMC Karnataka.

In contrast, environmental sampling focuses on hospital environments, where swabs from various surfaces are cultured to identify resistant genes. Following sample collection, polymerase chain reaction (PCR) techniques help pinpoint specific resistance genes. Both methods provide essential data on how antimicrobial resistance spreads across communities and healthcare facilities. Hospitals record and report this information to the Indian Council of Medical Research (ICMR), which tracks emerging resistant bacterial strains and related fatalities.

National Action Plan

The government, along with the National Medical Council (NMC), has initiated a National Action Plan to combat antimicrobial resistance. This plan involves comprehensive research to determine resistance levels in various bacteria, analysing the prevalence of resistant genes within both gram-positive and gram-negative bacterial groups. By evaluating the percentage of resistance across bacterial species, the initiative aims to inform more effective antimicrobial and diagnostic stewardship practices. It also has a manual for clinical approach for prescribing antimicrobials which can only be used for treatment.

Diagnostic stewardship emphasises collecting the correct sample at the appropriate time, ensuring accurate and timely diagnosis. Antimicrobial stewardship, meanwhile, focuses on administering the right antibiotic to the right patient at the right time, avoiding unnecessary use across the population. 

The government is working with the Indian Council of Medical Research (ICMR) and the NMC to advocate and implement these measures. However, there remains uncertainty regarding the implementation of similar practices within the poultry and animal industries.

A One Health approach, integrating human, animal, and environmental health, is key for combating resistance. Effective stewardship, supported by national initiatives, and stricter regulation in sectors like poultry and animal husbandry, are crucial to safeguarding public health and ecosystems to fight against antimicrobial resistance.

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Last January, Kerala launched AMRITH (Antimicrobial Resistance Intervention for Total Health), an initiative to curb the rampant use of antibiotics. The initiative builds on Kerala’s longstanding commitment to AMR prevention. Back in October 2018, the state collaborated with the Ministry of Health and Family Welfare and the WHO to launch the Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP). A year later, Kerala Antimicrobial Resistance Surveillance Network (KARS-NET) came about. The network aimed to standardise AMR surveillance, track emerging resistance patterns, and provide critical data to the state government and the National Centre for Disease Control (NCDC). By restricting antibiotic sales without a doctor's prescription, such programs have led to a remarkable Rs 1,400 crore reduction in antibiotic sales, according to state health minister Veena George.

"We have adopted a scientific, strategic approach to fight AMR," George said in a statement, highlighting the state's all-round efforts, including public awareness campaigns at educational institutions and public spaces.

The All Kerala Chemist and Druggist Association reported a sharp decline in antibiotic sales as early as August 2023. "As per our assessment, there is an annual drugs turnover of Rs 15,000 crore, of which antibiotics account for around 25 to 30%. After the government increased awareness, there was a 30% reduction in the 2023-24 fiscal year from the previous year, including sales from private hospital pharmacies," said association state president and national vice-president AN Mohanan.

State action plans

In November 2023, the Family Health Centre (FHC) at Kakkodi in Kozhikode district became the country's first antibiotic-smart hospital. Just two months later, the Ozhalapathi Family Health Care Centre in Palakkad followed suit, becoming the second such facility. Such health centres are recognised for meeting ten key criteria to monitor and control antibiotic use.

While India introduced the H1 rule in 2011 to curb over-the-counter antibiotic sales, it wasn’t until 2013 that the regulation was modified to restrict sales of more powerful antibiotics while allowing the sale of first-line options without a prescription. Kerala is the only state rigorously enforcing the original H1 rule.

Expanding community efforts

In May 2023, Kerala’s Health Department issued a directive to all District Medical Officers to implement Standard Operating Procedures (SOPs) for block-level AMR committees. The committees focus on raising awareness about infection prevention, proper antibiotic use, access to antibiotic-free food and water, and the safe disposal of expired antibiotics. "It was IEC (Information, Education, and Communication) in the first phase of the KARSPA activities. We reached as many people as possible for awareness, conducting workshops and speaking on all platforms. In the second phase, we resorted to punitive action under the Drugs and Cosmetics Act by conducting inspections and taking swift action against unchecked sales. Both measures resulted in a considerable reduction in sales and consumption,” said Shaji M Varghese, state coordinator of One Health and AMR and Assistant Drugs Controller, Kozhikode. The state has over 25,000 wholesale and retail medical shops, he added.

A model for the nation

Kerala’s AMR strategy exemplifies a comprehensive, multi-faceted approach to public health. From community-based initiatives to pioneering healthcare facilities, the state is leading the way in the fight against antimicrobial resistance. By focusing on education, regulation, and innovation, Kerala offers a clear blueprint for other states looking to safeguard the future of antibiotics and preserve their life-saving power.

In the battle against antimicrobial resistance (AMR), Kerala stands out for its innovative and thorough strategy. Dr Divya PK, an ENT specialist, played a pivotal role in transforming the Kakkodi Family Health Centre into an antibiotic-free facility. “I used every opportunity whenever I got a microphone; whether it was a festival at an Anganwadi, a Kudumbashree (State Kudumbashree Mission for Women Empowerment) gathering, or an elderly people’s meeting. Wherever I could get ten people together, I would talk about this. People initially had a reluctance to stop using antibiotics; they had an idea that only antibiotics could cure their disease. Later, people got used to the idea that doctors would prescribe them if needed."

She also reached out to resident associations, Kudumbashree units, and private medical shops, promoting the Go Blue Campaign, which raises awareness about AMR. “Most importantly, the focus was on preventing infection by promoting handwashing, stressing hand hygiene, vaccinating, etc. We distributed pamphlets to all households and informed private medical shops to raise awareness about the Go Blue Campaign (which aims to increase awareness of global AMR and encourage best practices), asking them to sell antibiotics in blue covers. Information was shared with doctors in the private sector through a WhatsApp group. I also spoke at Grama Sabha meetings and to veterinarians,” she added. Divya is now the MO of Koodaranji FHC in the district. 

I used every opportunity whenever I got a microphone; whether it was a festival at an Anganwadi, a Kudumbashree (State Kudumbashree Mission for Women Empowerment) gathering, or an elderly people’s meeting. Wherever I could get ten people together, I would talk about this [AMR].

Antibiotic classification

In 2017, the WHO introduced the AWaRe classification (later revised in 2019 and 2021) to group antibiotics into three categories: Access, Watch, and Reserve. Access antibiotics have a narrow spectrum, fewer side effects, lower resistance risk, and are cost-effective. They are recommended for common infections and should be widely available. Watch antibiotics carry a higher risk of resistance and need careful monitoring to avoid overuse. Reserve antibiotics are the last resort for severe infections caused by multidrug-resistant pathogens.

“Kerala had developed resistance even to the Reserve group–for example, linezolid (used to treat bacterial infections), which resulted in deaths. Ninety-five percent of the total antibiotic usage should be from the Access group, with only 5% from the Watch group. Data from April 2022 to March 2023 showed that Kakkodi hospital used only 5% from the Watch group, despite the usage of antibiotics during the Shigella outbreak in Kozhikode,” Divya said.

Kakkodi FHC and sub-centers set up collection points for unused and expired antibiotics, as discarded medicines can contaminate plants. The PROUD program was launched for safe disposal, training hospital staff and ASHA workers. Monitoring ensured that Kakkodi remained an antibiotic-smart centre, with the entire panchayat also becoming antibiotic-literate.

“As a first step in antibiotic literacy, dairy, poultry, and honeybee farmers were identified with the help of veterinary doctors. We also collected data on the use of antibiotics in animals and found Reserve and Watch antibiotics used among them. The use of antibiotics in animals like cows and poultry transfers to human beings through milk and poultry meat. Antibiotics are even mixed into cattle feed and poultry feed,” she further said adding that veterinarians wholeheartedly supported the campaign.

One Health approach

Kerala’s approach to AMR is rooted in the One Health concept, which encourages collaboration across sectors–public health, veterinary, environmental, and agriculture. This holistic approach recognises that human, animal, and environmental health are interconnected, making it essential to address AMR on all fronts.

In 2023, Kerala made history as the first state in India to establish AMR committees at both district and block levels, covering all 191 health blocks. The committees are composed of representatives from health, animal husbandry, agriculture, and environmental departments. “AMRITH was launched after the formation of the committees, followed by ROAR (Rage on Antimicrobial Resistance by the Drugs Control Department in September 2024). We began groundwork even before 2017; it’s just that coordinated meetings started in 2017, and the declaration came in 2018,” said Dr Aravind, state convener of the KARSAP Working Committee. He is also head of the department of Infectious Diseases Medical College Hospital, Thiruvananthapuram.

The state’s approach also involved creating awareness among doctors, pharmacists, students, and the general public, in that order. “It does not mean that we have achieved 100% success. We have engaged all One Health stakeholders in the process. The most visible example of our success is the increase in media coverage of AMR from 2018 to 2024. The OTC (Over-the-counter) sale of antibiotics can’t be curbed by awareness alone; that’s why AMRITH was launched to provide legislative backup. We’ve also provided a toll-free number for the public to report if antibiotics are dispensed without a prescription, making the public part of enforcement as well,” he said.

A toll-free number lets the public report medical shops selling antibiotics without prescriptions. Complaints lead to licence cancellations after verification. "Kerala’s initiative parallels Sweden’s only. Their motto is 'Antibiotic-aware Sweden,' and ours is 'Antibiotic-literate Kerala.' We can't claim that we have become an antibiotic-literate state, but all process indicators have been instituted. The decentralised, people-centred approach to make each panchayat literate is carried out through block-level AMR committees and antibiotic-smart hospitals. Customised action plans are required for each panchayat based on local AMR challenges. Gap analysis is done, and AMR hotspots in each panchayat are identified before preparing an action plan," he added.

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Direct action

The health minister released the first district-level antibiogram (helps track changes in antimicrobial resistance and guide empirical antimicrobial therapy) to prevent the misuse of antibiotics in Ernakulam district under KARSAP in February 2024.

Kerala’s commitment to AMR awareness also extends to migrant workers, with outreach efforts delivered in their native languages to ensure effective communication. In November, health workers began house-to-house visits as part of a campaign to spread awareness. By then, they had already reached 200,000 homes in Ernakulam, further solidifying the community’s role in combating AMR.

By focusing on education, regulation, and community engagement, the state is taking bold steps to protect the future of antibiotics and ensure their effectiveness for generations to come.

Let’s imagine a scenario where you and your friends are talking about inventions that have changed the course of human life. And you, obviously, are thankful for hundreds of them. Mobile phones? yes. Electricity? Always. The internet? Every waking minute. But what are the chances of one of you bringing up antibiotics? Slim at best. An average person may not count antibiotics among the list of discoveries that they are grateful for. Call it apathy or ignorance, it's one of those things we take for granted. It is as if this miracle drug has been around all along. After all, every time you are down with flu, you are handed a generous dose– prescribed or not. 

But how did this discovery, which revolutionised modern medicine, become so easily accessible? Let’s take a look.

The first antibiotic, the mighty penicillin, was discovered in 1928 (by Scottish microbiologist Alexander Fleming). 

Fun story: While researching Staphylococcus bacteria in his laboratory, Alexander Fleming noticed that a petri dish containing the bacteria had become contaminated with mould. But the area around the mould was free of bacteria. On closer examination, he identified the mould as Penicillium notatum and realised it was producing a substance that killed the bacteria. He named this substance penicillin.

Before this breakthrough, routine surgeries carried life-threatening risks due to fatal infections, organ transplants were unthinkable, and even common infections like UTIs posed a serious risk of death. Everyday activities like gardening or shaving required caution, as a small cut could lead to serious health complications. Simply put, without antibiotics, modern medicine would have been at a standstill.

The magnitude of Fleming’s discovery wasn’t immediately clear even after he published his findings in 1929. At the time, extracting and purifying penicillin in large quantities was challenging, limiting its practical use. The turning point came during World War II, as the need to treat bacterial infections in wounded soldiers became a top priority. Scientists Howard Florey and Ernst Boris Chain developed a method for mass production, and by 1944, penicillin was being manufactured at scale, turning it into a viable antibiotic. As it saved thousands of lives, penicillin quickly gained widespread acclaim. 

Cornerstone of modern medicine

The miracle drug transformed healthcare as it became the standard treatment for various bacterial diseases. But we are not here to thank our stars for Fleming’s accidental discovery, which became one of the greatest breakthroughs in medical history. But to discuss a bigger problem. Antimicrobial Resistance (AMR)— a situation that the World Health Organization has recognised as one of the top 10 global public health threats.

For the uninitiated, AMR is when bacteria, viruses, fungi, and parasites evolve and develop the ability to resist the effects of antimicrobial drugs such as antibiotics, antivirals, and antifungals, which are intended to kill or inhibit them. Their ability to resist would mean that infections caused by these microorganisms become harder to treat, leading to prolonged illnesses, increased mortality, and higher medical costs.

Such a scenario can be dangerous on so many levels. A common infection such as pneumonia, which is now easily treatable may no longer respond to it, leading to prolonged illness or even death. Surgeries could become riskier because of increased chances of untreatable infections. Moreover, resistant infections could mean longer hospital stays, more expensive medications, and multiple treatments.

We were warned

If you are wondering how a lifesaving invention went on to become a threat to mankind in a matter of decades, the answer is simple. Misuse and overuse. The key contributor to AMR development is believed to be the misuse of antibiotics in humans, animals, and even agriculture.

In his 1945 Nobel lecture, Fleming expressed concern about the improper use of penicillin. Specifically how low doses or incomplete treatments could give bacteria a chance to mutate and become resistant.  

He had famously said: "There is the danger that the ignorant man may easily underdose himself and, by exposing his microbes to non-lethal quantities of the drug, make them resistant."

And this is precisely what has been happening since.

Overprescription, failure to complete courses, and the use of antibiotics in livestock for growth promotion have contributed to the rapid development of AMR.

By the ‘60s and ‘70s, scientists began to notice that bacteria were evolving to resist antibiotics like penicillin, leading to the development of newer antibiotics. However, the misuse of these drugs continued, and the development of AMR accelerated.

But it’s hard to keep up with this mutation. Developing newer antibiotics is inherently difficult. As bacteria constantly evolve, finding new compounds that can kill or inhibit them without harming human cells is a complex process. Additionally, developing new antibiotics requires heavy financial investment in research and clinical trials. Besides, the process of bringing a new antibiotic to market involves stringent regulatory hurdles and testing phases, which can take up to a decade or more. This discourages many pharmaceutical companies from investing in antibiotic development. At the same time, antibiotics continue being prescribed for viral infections (where they are ineffective) and are widely used in agriculture to promote animal growth.

As a result of the widespread misuse, superbugs or multidrug resistance organisms (MDROs) have evolved to survive treatment with multiple antibiotics. A few notorious examples include MRSA (Methicillin-resistant Staphylococcus aureus): Resistant to several types of antibiotics, including methicillin; VRE (Vancomycin-resistant Enterococci): Bacteria that have become resistant to vancomycin, often causing infections in hospitals; CRE (Carbapenem-resistant Enterobacteriaceae): Resistant to carbapenems, one of the last lines of defence in treating bacterial infections and Multidrug-resistant Tuberculosis (MDR-TB): A form of tuberculosis resistant to first-line antibiotics like isoniazid and rifampin. These superbugs cause severe infections that are difficult to treat, leading to longer hospital stays, higher medical costs, and increased mortality rates.

Time to act is now

In the last few decades, very few new antibiotics have been approved, with many belonging to existing classes rather than entirely new types of drugs. In fact, between 1980 and 2000, no new major classes of antibiotics were discovered. While there have been a few new drugs approved recently, they are often met with rapid resistance from bacteria.

Efforts to boost antibiotic development have included government incentives, public-private partnerships, and global initiatives like the WHO’s Global Action Plan on AMR. Yet, the number of new antibiotics remains limited, falling short of what’s needed to tackle the AMR crisis.

In short, without new antibiotics, we are at risk of entering a post-antibiotic era where even minor infections or routine surgeries could become life-threatening. The race to develop new antibiotics and alternative treatments such as bacteriophage therapy (treatment for bacterial infections that uses viruses called bacteriophages to target and inactivate bacteria) is critical to avoid this scenario.

The slow pace of antibiotic development, the rapid evolution of resistant bacteria, and the prevalence of superbugs mean that we are running out of effective treatments for infections that were once easily cured. If no urgent action is taken, even routine medical procedures (think surgeries, childbirth, and cancer treatments) could become life-threatening. 

Tackling AMR requires coordinated global efforts—reducing the misuse of antibiotics, promoting responsible use in healthcare and agriculture, funding research for new treatments, and improving infection prevention measures. The cost of inaction is too high, as we risk entering a post-antibiotic era where modern medicine as we know it could be undone.

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Tears rolled down Rakshit’s* cheeks as he talked about losing his 75-year-old father six months ago. In April, his father was rushed to a top hospital after experiencing chest pain. An angiogram showed severe artery blockages, and doctors advised an urgent bypass surgery.

A week after being discharged, his father’s chest wound became infected. He was readmitted to the same hospital and treated with several antibiotics, but the wounds didn’t heal. Lab tests later showed the infection was from a bacteria resistant to most antibiotics, leaving only one or two options. The doctor suggested an expensive treatment plan but warned there were no guarantees.

"The doctor told me everything depended on my father’s response to the medicine," said Rakshit. Already deeply in debt from high-interest loans for his father’s care, Rakshit was conflicted.

Facing mounting hospital bills, Rakshit made the difficult decision to bring his father home against the doctor’s advice. “He passed away two days after we got him home. If I had enough money, I would have agreed to try the expensive medication,” he said.

Rakshit, an air conditioning mechanic, lives with his family of five on Bangalore’s outskirts. His story is not unique. Hospitals nationwide are seeing a rise in critically ill patients being discharged without medical consent, a practice known in medical terms as Discharge Against Medical Advice (DAMA) or Left Against Medical Advice (LAMA).

Experts point to antimicrobial resistance (AMR) as a key driver of this trend.

India is one of the world’s hotspots for antimicrobial resistance, primarily due to the uncontrolled use of antibiotics over the years. The AMR has disproportionately impacted healthcare access for economically and socially vulnerable populations. 

Data collection

Eight years ago, the Indian Council of Medical Research (ICMR) began efforts to collect antimicrobial resistance data from 20 major medical colleges across India. Meanwhile, the National Center for Disease Control (NCDC) collects antimicrobial resistance information from 35 labs across India. A key partner in this initiative is Kasturba Medical College, part of the Manipal Academy of Higher Education (MAHE) in Manipal.

Dr Vandana KE, professor and head of Microbiology at the college and coordinator of the Centre for Antimicrobial Resistance, and Manipal-bioMerieux Centre of Excellence in antimicrobial stewardship, said the soaring medical costs driven by antimicrobial resistance often compel patients' families to opt for discharge against medical advice. Even if they continue to receive hospital care, the health outcome is compromised. “The situation is grave, to say the least,” she said.

The centre of excellence is set up with the support of bioMerieux, a leading French firm focussing on in vitro diagnostics for more than six decades.

The recently released eighth annual antimicrobial resistance report from ICMR has shed light on rising antibiotic resistance and the decreasing effectiveness of standard treatments against common bacteria in India. The report focused on frequently used antibiotics for managing conditions such as upper respiratory infections, fever, diarrhoea, pneumonia, sepsis, community-acquired pneumonia and other bloodstream infections.

Dr Vandana said this data is invaluable for doctors to gauge the resistance levels of specific bacteria. "A few years ago, we had no comprehensive data on antimicrobial resistance. Now, things are slowly but surely improving," she said.

The report, compiled from nearly 10,000 culture-positive isolates across 21 partner hospitals, provides crucial insights. "Each of the partner hospitals collects bacterial samples, analyses their sensitivity patterns, and uploads the information to the national portal," she added.

Limited options

Rising antimicrobial resistance is making many once-common antibiotics less effective. A few decades ago, doctors prescribed antibiotics based on symptoms and physical exams. With the rise of microbiology labs and advanced tests, doctors now send patient samples to labs to identify the specific bacteria and effective antibiotics. This approach helps doctors choose the right treatment, but they’re facing a bigger problem: new antibiotics are scarce, while bacteria are becoming more resistant.

Dr Muralidhar Varma, professor and head of Infectious Diseases at the college and chairman of Antimicrobial Stewardship (AMS) programme, said the number of antibiotics that can be used for treatment has come down drastically. “For example, doctors had seven or eight drugs at their disposal some 25 years ago to treat the common E.coli (Escherichia coli) which causes urinary tract infection,” he said.

“Now, we have only one or two medicines available to treat the same urinary infection. E.coli bacteria has developed resistance to every other antibiotic. This is a huge challenge healthcare professionals are facing now,” he added.

According to experts, antimicrobial stewardship, which encourages the proper and judicious use of antibiotics, is essential in the fight against antimicrobial resistance. The focus is on educating healthcare providers to follow guidelines based on scientific evidence when prescribing and administering antibiotics. 

The Kasturba way

At Kasturba Medical College, a team of pharmacists, physicians, and microbiologists collaborates to ensure that AMS efforts are effective. Under the team’s guidelines, high-end antibiotics can only be administered to patients after receiving approval from the AMS team. “We are not about restricting antibiotic use altogether because patient safety is paramount. If healthcare professionals have a valid reason to prescribe a particular antibiotic, we authorise it,” said Dr Varma. “Similarly, hospital pharmacies must seek AMS team approval before dispensing any new antibiotic.”

We aim to have open conversations with doctors, explaining why certain antibiotics may not be ideal. They understand our reasoning, and we can move forward collaboratively.

The biggest challenge in implementing antimicrobial stewardship is gaining the trust of senior doctors who are accustomed to having autonomy in prescribing antibiotics.

Dr Vandana emphasised that strict mandates are unlikely to work with experienced doctors. “There are two global approaches to stewardship: restrictive and handshake. With a restrictive model, doctors must justify their rationale for using certain antibiotics, but this approach can feel intrusive and harm the programme’s success,” she said.

Dr Vandana’s team primarily relies on the handshake approach. “We aim to have open conversations with doctors, explaining why certain antibiotics may not be ideal. They understand our reasoning, and we can move forward collaboratively,” she said. “The handshake approach fosters shared responsibility.”

Diagnostics is key

“Without proper diagnosis, effective infection management is impossible. That’s why we also focus on diagnostic stewardship. Diagnostic stewardship means applying the right test for the right patient at the right time, along with accurate interpretation and effective communication between the diagnostician and prescriber,” said Dr Vandana. 

However, accurate diagnostics remain a distant dream for much of India’s population, as microbiology labs are scarce or nonexistent in rural areas.

“The lack of access deprives people in these regions of the benefits of both antimicrobial and diagnostic stewardship,” said Dr Varma. “Until we establish robust facilities, a vast majority will be left out of efforts to reduce antimicrobial resistance.”

(*Name changed to protect identity)

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In 2020, antimicrobial resistance (AMR) was linked to 700,000 deaths worldwide, a figure that continues each year. AMR causes severe infections in approximately 2.8 million people annually. In India alone, AMR was associated with 1,042,500 deaths in 2019, a number projected to more than double by 2050.

“While the term antibiotic resistance (ABR) is loosely used interchangeably with antimicrobial resistance (AMR), antibiotics as a group of medicines only work on pathogens that are bacterial and those that are semi-bacterial in nature. They don’t work on viruses or fungi. There are multiple types of bacteria, different ones in different living beings and different groups of antibiotics that will work on them, causing a wide variety of medicines to be circulating in our environment,” says Dr Samita Moolani Katara, an ophthalmologist from Pune.

Several studies have established the link between meat and antimicrobial resistance, and the potential risks are alarming. Resistant bacteria can travel from animals to humans through raw and cooked food, or even directly from animals on farms. 

Despite the challenge of feeding its large population, India boasts a strong agricultural sector, with a significant focus on animal husbandry. The country stands tall as the world leader in milk production, ranks third globally in egg production, and holds the eighth position in meat production. 

Moreover, the country caters to the growing international demand for meat, poultry, and agricultural products, with buffalo meat being a key export.

AMR and meat

AMR is a complex and growing crisis that connects our food, our health, and the environment. Microbial strains found in food, particularly Staphylococcus spp., extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae, and vancomycin-resistant Enterococcus spp., highlight the spread of AMR. Today, the threat comes from multidrug-resistant (MDR) bacteria that can withstand multiple antibiotic classes, affecting both humans and animals.

“What’s so scary about this situation is that currently no new antibiotics are being developed globally. The same top-of-the-line antibiotics that were developed a couple of decades ago are in use today so when patients develop a resistance to these, there aren’t many other courses of action that us doctors are left with,” says Dr Samita who is seeing a lot of antibiotic resistance in her patients because even patients with a simple case of viral pink eye are being prescribed broad-spectrum antibiotics. 

Antimicrobials, particularly antibiotics, are commonly used in the meat industry globally and in India, both for growth promotion in animals slated for meat consumption and to protect animals from disease. These antimicrobials, such as antibiotics, antivirals, antifungals, and antiprotozoals, are effective at killing or inhibiting the growth of harmful microorganisms. When humans consume meat that contains antimicrobial-resistant bacteria, these bacteria can transfer to the human gut, potentially resulting in infections that are resistant to treatment. 

The same top-of-the-line antibiotics that were developed a couple of decades ago are in use today so when patients develop a resistance to these, there aren’t many other courses of action that us doctors are left with.

“Often, human and animal health professionals over-prescribe antibiotics or advise people to use them even when they’re not required,’ says Dr Geeta Kumar, a gynaecologist from Rae Bareilly, Uttar Pradesh. 

Many antibiotics given to farm animals are excreted in their waste, which is frequently used as manure in agriculture. This practice introduces antibiotics into the soil and water, contaminating food crops as well. This contamination allows resistant bacteria in animals to reach humans directly or indirectly through food, water, soil and manure.

 “The unhygienic conditions and high number of animals packed into a small space make them even more susceptible to infections, which is why meat farms introduce various antibiotics as preventives, not curatives,” says Dr Samita.

Some types of meat are riskier than others. Salmon, often eaten raw, is one such example. “Salmon is one of the worst meats to have without cooking because their breeding conditions are quite bad. There is so much sickness in the water they’re farmed in that they are pumped with antibiotics. Salmon is often eaten without cooking, which results in a high transfer of antibiotics to the consumers,” she adds.

Policies and regulation

In 2010, India ranked as the fourth-largest user of antibiotics in animal food production, following China, Brazil, and the United States, and accounted for 3% of the global antibiotic use in this sector. Despite oversight from international regulatory bodies like the Food and Drug Administration (FDA), World Health Organization (WHO), World Organisation for Animal Health (WOAH), and Food and Agriculture Organization (FAO), the widespread use of antibiotics in healthy animals persists, partly due to the predominantly non-vegetarian diets in Western countries.

In India, regulatory bodies such as the Central Drugs Standard Control Organization (CDSCO) and the Food Safety and Standards Authority of India (FSSAI) have made some efforts - while they have made policies and a list of drugs to watch out for, the implementation of these policies has not been very stringent. There has been some tightening of regulations around the use of antibiotics in food production as recently as last week. The FSSAI lowered the permissible residue levels in foods and also put more antimicrobial drugs on its watchlist. 

Practical precautions

The UN’s One Health campaign advocates for a unified approach to treating animals, humans, and the environment with equal care in the fight against AMR.

Holistic nutritionist Aashti Sindhu points to lab-grown meat as a hopeful alternative. “Every time we eat meat that’s been pumped full of drugs, we’re adding to the problem. Lab-grown meat could be a game-changer—it doesn’t need antibiotics, so it’s cleaner, better for our health, and kinder to the planet. It’s a win-win solution that could really make a difference.”

Several organisations are now working to counter AMR in India’s National Action Plan, with initiatives focused on awareness, enhanced surveillance, infection control, and research. Although antibiotic-free poultry options exist, there is often limited verification of their claims, leaving consumers in a tricky position.

Veterinarians, too, play a critical role. “I’m personally aware of a number of times I have been prescribed antibiotics for very minor ailments. If the government increased the prices of antibiotics, I’m sure vets would reduce use of them,” says Goa-based veterinarian Dr Suvarnaraj Gaonkar. As individuals, we must take responsibility by staying informed and reducing our own antibiotic reliance.

Beyond reducing meat consumption, small actions can make a difference. “Washing hands is key. It might sound simple, but it’s a highly effective tool in preventing infection spread,” says Dr Kumar.

For those who choose to eat meat, opting for certified organic and humane sources is best. However, sourcing verification can be challenging in India. Ensure meat is thoroughly washed and fully cooked. Other precautions include using separate cutting boards for meat, washing hands between handling meat and other foods, and storing food properly to minimise infection and AMR risks.

By being mindful of the choices we make–from what we eat to how we approach hygiene–we can all play a part in slowing the AMR crisis.

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Between April 2023 and March 2024, Tamil Nadu issued corrective actions to 517 pharmacies and suspended 283 licences for violations including unsupervised drug sales, failure to maintain prescription registers, and dispensing drugs without prescriptions from registered medical practitioners, according to data we accessed from the Drug Control (DC) Department.

The department has ramped up pharmacy inspections across the state, raising awareness on restricted antibiotic use to curb antimicrobial resistance. “We are invoking the provisions of the Drugs and Cosmetics Act, 1945, to suspend the licence of pharmacies that sell antibiotics without a prescription. We find this approach more effective than court prosecution, as closing the shop brings about a behavioural change,” said MN Sridhar, joint director, Drugs Control cum Controlling Authority.

The assistant director of drugs control conducts annual awareness sessions for pharmacies across the state’s 26 zones. “We have WhatsApp groups for each zone to regularly discuss AMR (antimicrobial resistance) and stress the importance of not giving antibiotics without a prescription,” said Swaminathan Elangovan, treasurer of the Tamil Nadu Chemists and Druggists Association, which has 30,000 members across the state.

Meanwhile, the health department is streamlining infection control committees in major private and public hospitals to monitor antimicrobial susceptibility, provide guidelines, and restrict the excessive use of antibiotics. Headed by microbiologists in medical college and teaching hospitals, these committees work to control infections and encourage judicious antibiotic use.

Ground reality

India launched its National Action Plan on antimicrobial resistance in 2017. But seven years later, Tamil Nadu still hasn’t developed a state-level action plan. “Even without a plan, we’ve been consistently working to keep antibiotic use in check,” said MN Sridhar, Joint Director of Drugs Control.

Yet, the situation on the ground remains concerning. “Creating a state action plan involves coordination with various departments beyond health, such as agriculture and environment. It took us some time to bring them all under a singular umbrella to work on the plan,” said an official from the Directorate of Public Health and Preventive Medicine (DPH), who requested anonymity.

Patients who buy antibiotics over the counter often cite time constraints, avoidance of doctor fees, and a perception that the same drug is always prescribed.

Out of seven pharmacies visited by this reporter and her team to ask about Amoxicillin, one of the most commonly overused antibiotics, four were willing to sell it without a prescription. The pharmacies are located in rural areas of Trichy, Nagapattinam, Thanjavur and Thiruvallur.

A 2022 study published in the National Library of Medicine, which looked at 15 independent pharmacies in a major city and a smaller city, found that antibiotics like Amoxicillin, co-amoxiclav, azithromycin, levofloxacin, and metronidazole were often bought without prescriptions. “Patients who buy antibiotics over the counter often cite time constraints, avoidance of doctor fees, and a perception that the same drug is always prescribed,” the study noted.

“Azithromycin is one of the most abused antibiotics, especially since COVID-19 when restrictions were mild and whatsapp forwards encouraged people to use the drug if they face any symptoms of respiratory distress,” said Nanda Kumar, pharmacist, Sekar Medicals, Thiruvottiyur. “We don’t sell antibiotics without a prescription. We issue sinarest for cold and Dolo 650 for fever,” he added. 

Antibiotic resistance in hospitals

Doctors are witnessing an increase in drug resistance within hospitals, signalling a serious health threat. “For example, some Fluoroquinolones, a type of antibiotics used to treat Typhoid, have become resistant due to inappropriate usage. Thus, we are going for new antibiotics, but they are sold at higher cost. This is a dangerous pattern,” said Dr Keerthy Varman, general secretary of the Tamil Nadu Resident Doctors Association.

Antimicrobial resistance poses a significant challenge for the medical community. “For patients who are at a higher risk of infection, we rely on blood cultures and organism identification to determine appropriate treatment. A drug sensitivity test is performed in the lab, and I’ve often seen reports where the infection shows resistance to all standard antibiotics, particularly in critically ill ICU patients. In such cases, we have to resort to different classes of drugs, but the success rate is unfortunately lower,” Varman added. 

According to the 2023 annual report by the National AMR Surveillance Network (NARS-Net), certain antibiotics, like methicillin and, to a lesser extent, linezolid, show significant resistance, especially in ICU environments. Research from 41 hospitals across the country, including two in Tamil Nadu, highlights resistance to many drugs.

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Status quo

State Action Plans on AMR align with India's National Action Plan and adopt a One Health approach that encompasses animal health, agriculture, and the environment for a comprehensive fight against AMR. “Health is a state subject with major decisions happening at the state level. A state action plan on AMR will provide a clear direction to tackle AMR for all stakeholders,” said Dr S S Lal, director of ReAct Asia Pacific, a global network dedicated to the problem of AMR. 

Tamil Nadu hospitals analyse resistance patterns from their patients and periodically submit data to the WHO. The state is working to create a plan, following the examples of other Indian states like Kerala and Delhi, to limit antibiotic use across all sectors.

“There is a desperate need for local antibiotic usage/consumption and antibiotic resistance data from both human and animal sectors. While resistance data among patients are available in major tertiary care hospitals, the same is limited at the secondary care and community levels. Adopting a State Action plan should be seen as a starting point to fill these gaps, to promote awareness among different stakeholders, and to allocate health resources in a better manner,” said Dr Jaya Ranjalkar, former deputy director, ReAct Asia Pacific, who has been working on this issue for over six years.

A model state

Kerala serves as an inspiring model among states with action plans. Through initiatives like the Kerala Antimicrobial Resistance Surveillance Network (KARS-NET), the state collects drug resistance data from public and private hospitals. Awareness of AMR is being raised not only in major medical college hospitals but also in primary care centres.

Earlier, ReAct Asia Pacific had developed and piloted the ‘Antibiotic Smart Communities’ model in Kerala to empower residents and key stakeholders within local government organisations. The model identifies local drivers of AMR and gaps within the community to design context-specific interventions. “A 15-point indicator framework is used to assess the antibiotic smartness of a community,” Dr Jaya said, adding that community engagement is essential to address complex One Health challenges such as AMR besides identifying synergies with other health plans across sectors, engaging private entities and civil societies.   

Although Tamil Nadu is taking steps to combat AMR, a unified approach and intersectoral coordination among departments such as health, agriculture, animal welfare, environment, and veterinary services are vital. Adopting a well-funded state action plan on AMR will enhance effectiveness in addressing this issue.

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