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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“If we use antibiotics when not needed, we may not have them when they are most needed,” Dr Tom Frieden, former director of the US CDC.

Antimicrobial resistance is knocking at humanity’s door, and the warnings have been ringing loud and clear. Since the advent of antimicrobial medicines in the 1920s, these drugs have increased our average lifespan by 23 years and saved countless lives. However, the overuse and misuse of antibiotics, antifungals, antivirals, and antiparasitics have created a vicious cycle of resistant pathogens, rendering these life-saving medicines increasingly ineffective.

We now stand at the brink of a post-antibiotic era, where common diseases are no longer treatable by these drugs.

Global health crisis

But what happens when bacteria adapt, and our bodies stop responding to these medicines? That’s when antimicrobial resistance (AMR) sets in. “Common diseases are becoming untreatable.” That’s the blunt warning issued on page one of a 2019 United Nations report on drug resistance.

When antibiotics and other antimicrobials lose effectiveness, infections become harder—or even impossible—to treat, raising the risk of disease spread, severe illness, and death. Misuse, such as taking antibiotics when they’re not needed or failing to follow prescriptions, enables bacteria to adapt and become resistant, complicating future treatments.

As antibiotics lose their effectiveness, experts have warned for years of a ‘silent’ global health crisis. Some argue that the rise in AMR cases could make the COVID-19 crisis pale in comparison.

“Antimicrobial resistance could unwind 100 years of medical progress, making infections that are easily treatable today a death sentence,” said Tedros Adhanom Ghebreyesus, the World Health Organization director-general, at a news conference in September. “No country is immune to this threat, but low- and middle-income countries bear the greatest burden.”

Indian picture

One out of every eight people worldwide lives in India, and with that concentration of humanity comes an equally concentrated problem of antimicrobial resistance. India’s struggle with AMR is paradoxical, with people suffering both from a lack of access to antibiotics and from fatal AMR infections.

According to a analysis, between 300,000 to 1.1 million Indians lost their lives to AMR in 2019. The superbug crisis has taken a toll on India's healthcare system. 

The three most common antibiotic-resistant pathogens here are E. coli, causing gut infections; Klebsiella pneumoniae, which leads to pneumonia and urinary tract infections; and Acinetobacter baumannii, associated mainly with hospital-acquired infections.

A concerning number of children in India are born with infections resistant to most antibiotics, resulting in over 58,000 infant deaths within a year. Just five years ago, the situation wasn’t this severe. The rapid rise of AMR in India stems from multiple factors: lack of clean water, harmful bacteria prevalent from soil to sewage, and widespread environmental contamination.

With a population of 1.5 billion, India is well aware of the urgency of addressing Antimicrobial Resistance (AMR). The Indian government has already created a national action plan to tackle the issue, which recognizes the importance of tackling all four key drivers of AMR: humans, animals, food, and environment.

Recognizing the country-specific challenges like untreated water waste, improper discard of livestock, and use of sludge in agriculture, the plan takes a comprehensive approach to address the issue from multiple angles.

While similar factors drive AMR in other countries, India lacks adequate data and research on AMR trends. Researchers, scientists, and doctors are charting new territory in the fight against AMR, with experts calling for a unified data system and standard operating procedures to monitor AMR effectively. Planning, monitoring progress, and reassessing the approach are critical steps to ensure India can manage this growing crisis effectively.

Unschooled 

AMR has always been an integral part of our everyday lives, but it's been largely ignored in the pages of our science textbooks and in public discourse. However, after spending nearly two years cooped up in our homes during the pandemic, AMR has suddenly been thrust into the spotlight.

With a newfound focus on health, food, and medicine, people have become increasingly aware of the importance of AMR and the urgent need to address it. The global COVID-19 lockdown has served as a wake-up call, making AMR one of the hottest topics in health and science today.

Every year since 2015, the World Health Organization has designated November 18-24 as World AMR Awareness Week (WAAW) to draw attention to the alarming problem of antimicrobial resistance, which is affecting the health of humans, animals, plants, and the environment alike. In 2024, the theme for WAAW is “Educate. Advocate. Act Now.”, chosen after receiving valuable input from around 200 stakeholders from diverse areas of health.

Silent threat

Year after year, medical journals and publications report on this “invisible killer,” often referred to as the “silent pandemic” or even “evolution in action.” Beyond human health, antibiotics are used heavily in agriculture, livestock farming, and aquaculture, further fueling their spread across our environment.

Throughout November, the Good Food Movement will cover these topics and more as part of the World Health Organization’s AMR awareness week.

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The apple harvest in Himachal Pradesh's famed orchards has come up short this season, as the state’s collection centres have received only 3.61 lakh metric tonnes (LMT) of apples, a big drop from last year's 3.84 LMT. The dip has been attributed to several factors, according to Rakesh Thakur, an apple orchard owner in Shimla. “This year, the season, which typically runs from June 27 to October 25, started late. Ageing orchards are being replaced, and some farmers are shifting to other crops for year-round income. We’ve also faced setbacks from fungal infections.”

While the old adage about an apple a day keeping the doctor away may still hold some truth, the stakes are higher. According to a 2022 mBio study, 13% of sampled apples from northern India were found to harbour the drug-resistant fungus Candida auris, which has been linked to severe infections and carries a mortality rate of 34%, according to the Centres for Disease Control and Prevention (CDC) data.

With such high risks associated with this potentially deadly pathogen, the message is loud and clear: keep your apple safe by thoroughly washing it before taking a bite.

The presence of drug-resistant fungus on fruits like apples is just the tip of the iceberg. The broader, underlying issue is antimicrobial resistance (AMR) in our food systems, where once-healthy soil has become a breeding ground for antibiotic-resistant bacteria.

The increasing use of antimicrobials in agriculture, often used to boost crop yield and protect plants from diseases, is contaminating the soil with these substances. “Increasing use of antimicrobials in agriculture is contaminating the soil, leading to the emergence and selection of resistant strains,” said Rajesh Bhatia, former director of communicable diseases for WHO's South-East Asia regional office.

How AMR enters our soil

As global food demand rises, so too does the use of antibiotics to speed up livestock growth and protect crops from disease. While these practices may offer short-term gains, they also inadvertently create a long-term problem: antibiotic-resistant bacteria in soil. 

These resistant bacteria can spread and survive in soil through multiple routes, including seeds, soil additives, irrigation water, and especially animal manure used as fertiliser. Antibiotics given to livestock often remain in their manure, and when this manure is applied to fields, it releases antibiotic residues and resistance genes into the environment.

AMR bacteria can contaminate crops, get into water supplies, and pass resistance to bacteria that infect people. As a result, common infections could become harder to treat, causing longer illnesses and more deaths. “The food we eat plays a critical role in the dynamics of AMR, largely due to the overuse of antibiotics. Intensive farming practices often involve giving animals antibiotics to promote growth and prevent disease, leading to resistant bacteria that can enter the human food chain,” said Dr Akhlesh Tandekar, head consultant of critical care at Wockhardt Hospitals Mira Road.

A recent study confirmed that animal manure often contains antibiotics like tetracyclines, sulfonamides, and fluoroquinolones, all of which contribute to the growth of AMR in soil. These resistant microbes can easily find their way onto nearby crops.

The food we eat plays a critical role in the dynamics of AMR, largely due to the overuse of antibiotics. Intensive farming practices often involve giving animals antibiotics to promote growth and prevent disease.

“Antimicrobials and bacteria from these sources also adapt and exchange genetic material, creating more resistant strains. Through the food chain, humans and animals can become exposed to these resistant pathogens,” said Bhatia. 

In a 2021 study, researchers at the University of Nebraska-Lincoln found that over 60% of the antimicrobial resistance (AMR) genes found on lettuce leaves were traced back to soil that had been fertilised with animal manure.

Moreover, antibiotics are sometimes applied directly to plants, enhancing crop health and yields. However, this practice also fuels the spread of resistant bacteria in the soil. "For instance, tetracyclines are injected into tree trunks to combat citrus diseases like huanglongbing (HLB) and sprayed on pears and apples to prevent fire blight. Although effective, such practices add to the growing issue of resistance in soils, posing risks across the food chain," said Vidyut Singh, a pear farmer in Kullu.

Climate change then compounds the issue. "Rising temperatures create favourable conditions for bacteria to multiply, while excessive rains and water accumulation create an ideal environment for pathogens," said Bhatia.

Why it matters to you

In 2023, the WHO identified AMR as one of the top global public health threats. And the alarming part? These bacteria don’t respond to common antibiotics. "If they cause infections, doctors have fewer treatment options, turning a mild infection into a serious, potentially life-threatening condition. When people consume foods carrying antibiotic-resistant bacteria, they face the risk of infections that require longer hospital stays and can increase mortality rates," said Dr Tandekar.

According to the WHO, bacterial AMR caused an estimated 1.27 million deaths and contributed to an additional 4.95 million in 2019 alone. If left unchecked, the impact of AMR is predicted to be catastrophic, with an estimated 10 million deaths worldwide by 2050. India, with its vast population, carries a disproportionate burden of drug-resistant pathogens, highlighting the urgent need for action and interventions to mitigate this crisis.

For farmers, the impact is even more immediate. "Resistant bacteria degrade soil health, reducing crop yields. This forces farmers to rely on even more chemicals, creating a vicious cycle that is hard to break. Addressing AMR is crucial not just for our health, but for the sustainability of agriculture and food security," said Thakur.

Solutions for AMR-free farming

The challenge is significant. “India’s National Action Plan on AMR (2017-2021) highlighted the importance of a One Health approach, integrating efforts across human, animal, and environmental health. However, implementation faltered due to the pandemic and limited engagement from the environmental sector,” said Bhatia.

Despite setbacks, experts believe India's farming sector can still turn the tide. Here are their recommendations:

But India’s farming sector can still turn the tide. Here’s what the experts recommended:

• Go organic: Organic farming avoids antibiotics and synthetic pesticides, fostering healthier soil microbes that combat resistant bacteria. India has 2.6 million hectares under organic farming, fifth largest in the world, supported by the GOI’s Paramparagat Krishi Vikas Yojana, but broader adoption is needed.
• Integrated pest management (IPM): By using natural pest predators, crop rotation, and habitat modifications, IPM reduces reliance on chemicals, limiting resistant bacteria in the soil.
• Stricter regulation & awareness: Stronger enforcement of antibiotic regulations and educating farmers about AMR risks are essential. Public health campaigns should target rural areas to ensure greater awareness.
• Monitoring soil health: Focus on Soil Health Management (SHM) under the National Mission for Sustainable Agriculture (NMSA), by combining chemical fertilisers with organic manures and bio-fertilisers to improve soil health and productivity.

Protecting our soil from resistant bacteria means safeguarding our crops, health, and the future of Indian agriculture. That future depends on the choices we make today–in the fields, in research labs, and at our dinner tables.

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Antimicrobial resistance, or AMR, is a fast-evolving threat to global health systems. According to the World Health Organization (WHO), AMR occurs when bacteria, viruses, fungi, and parasites no longer respond to antimicrobial medicines as they develop drug resistance.

In many wealthy countries, doctors frequently prescribe antimicrobials even when they aren't necessary, according to a paper published in the United States National Center for Biotechnology Information. Meanwhile, in developing nations like India, these drugs are often readily available over the counter, leading to rampant misuse.

A study in The Lancet Regional Health — Southeast Asia highlighted India's high consumption of broad-spectrum antibiotics, which should be used sparingly due to their wide-ranging effects. The journal JAC—Antimicrobial Resistance reported that antibiotic misuse varies significantly across India, with poorer states showing lower rates of consumption, likely due to limited access rather than prudent use. This misuse breeds superbugs—pathogens armed with resistance genes that render treatments ineffective. As a result, common infections become increasingly difficult, if not impossible, to treat.

According to a report published by the Indian Council of Medical Research, a big chunk of patients in India may no longer benefit from carbapenem, a powerful antibiotic used in critical care settings to treat pneumonia and septicemia. The resistance isn't limited to bacteria. Fungal pathogens like C. parapsilosis and C. glabrata are showing increasing resistance to common antifungal medicines such as fluconazole.

Unfolding catastrophe

In 2019 alone, drug-resistant infections claimed 1.27 million lives globally. The United Nations warns that by 2050, this number could soar to a staggering 10 million annual deaths. 

According to an article in the United States Centers for Disease Control and Prevention (CDC), antimicrobial-resistant infections that require the use of second- and third-line treatments can harm patients by causing serious side effects, such as organ failure, and prolonged care and recovery, sometimes for months.

The article further says that resistance also comes in the way of a person’s ability to fight infections using antibiotics during treatments/procedures, including joint replacements, organ transplants, cancer therapy, and chronic diseases like diabetes, asthma, and rheumatoid arthritis. 

According to the United Nations Environment Programme (UNEP), AMR could shave off USD 3.4 trillion from global annual GDP and push 24 million more people into extreme poverty in the next decade. The UNEP also warns that by 2050, up to 10 million deaths could occur annually due to drug-resistant infections globally. 

Beyond human health

The misuse of antimicrobials extends beyond humans, affecting food-producing animals and aquaculture. The widespread use of these drugs to promote growth and prevent disease has led to resistant bacterial strains that can spread to humans through direct contact, consumption, or the environment.

While AMR drivers are universal, its impact is disproportionately severe in low- and middle-income countries, as noted by the WHO. Here, the overuse of non-prescribed drugs is more prevalent, exacerbating existing inequalities as healthcare costs rise and agricultural productivity falls.

Charting a new course

Recognising the gravity of AMR, scientists and policymakers advocate for a multi-faceted approach. Improved surveillance is crucial, as highlighted by the United States Library of Medicine. Gaps in data on key microbes hinder our understanding of AMR trends, making it essential to establish standardised methods and definitions for tracking resistance.

Hospitals must improve infection control measures, while public education campaigns can help curb antimicrobial misuse. The Federation of European Microbiological Societies (FEMS) suggests that effective public awareness campaigns could cut antimicrobial prescriptions by 36%.

In agriculture, reducing antimicrobial use in livestock and developing new drugs to combat superbugs is imperative. The UNEP emphasises the environment's role in AMR's evolution and spread, advocating for a 'One Health' approach that recognises the interconnectedness of humans, animals, plants, and ecosystems.

A call to action

For the 'One Health' strategy to succeed, global organisations and governments must prioritise AMR as an international concern. The time has come to place this threat at the forefront of the global political agenda, acknowledging that addressing AMR is not just a scientific or medical issue but a societal imperative that demands coordinated action from all sectors. Only by acting decisively can we hope to avert the looming health crisis and safeguard future generations from the devastating impact of drug-resistant infections.