India, the world’s largest producer of milk, contributing 25% to global production, is facing a serious challenge with antimicrobial resistance (AMR). The widespread use of antibiotics to treat cattle infections in the dairy industry is a major driver of this crisis.

“AMR severely hampers the effective treatment of infectious diseases, leading to higher mortality rates, longer hospital stays, and increased healthcare costs,” says Amit Khurana, director of the Sustainable Food Systems Programme at the Centre for Science and Environment (CSE) in New Delhi.

Milk matters

Over the last decade, India's milk production has grown by about six percent annually, reaching an impressive 231 million metric tonnes (MMT) in 2022-23. The growth highlights the importance of dairy farming to India’s economy, with 18 million dairy farmers spread across 230,000 villages, many of whom are women. The National Dairy Development Board (NDDB) aims to boost productivity so the country accounts for one-third of global milk production by 2030.

However, this achievement comes at a cost. The industry heavily relies on antibiotics to manage cattle diseases such as mastitis, a bacterial infection of the mammary glands prevalent in high-yielding crossbred cows. While crossbreeding has boosted milk production, it has also made cattle more susceptible to disease.

“Cross-breeding with exotic breeds was introduced to India mainly to enhance production of milk. This led to the loss of local breeds which have resistance to many diseases. High incidence of diseases in cross-bred animals and the indiscriminate use of antibiotics in dairy animals caused high antibiotic residues in animal products like milk and meat,” states a chapter in the book, Medicinal Agroecology.

Mastitis not only threatens public health but also imposes heavy financial burdens on dairy farmers. While mastitis prevalence was below 30% in the 1960s, it now exceeds 60%. A report by the National Dairy Research Institute estimated that in 2012, mastitis caused annual economic losses of Rs 71,655 million, increasing farmers’ reliance on antibiotics as a quick fix.

Studies have found a positive link between this rise in demand for mild, a high yield and mastitis.

“Antibiotics are also eliminated in the milk till seven days post-treatment. However, there is an absence of compliance to milk withdrawal periods following antibiotic administration, which leads to antibiotic residues in milk. Hence, improper use of antibiotic therapy in milch animals poses a threat to the public, especially if milk is consumed unpasteurized,” the study states.

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Antibiotics overload

By 2030, the livestock industry is expected to account for 70% of global antimicrobial use. In India, antibiotic use in animal husbandry is predicted to double by the same period. India ranks fourth globally in antibiotic usage in livestock, but enforcement of regulations on antibiotic use in both human and animal medicine remains weak.

Researchers from CSE have pointed towards an inadequate focus on testing for antibiotic residues in the milk collected by some state milk federations, which process it and sell packaged milk and dairy products under popular brands.

“Farmers often sell milk while the animal is under treatment, which increases the chances of antibiotic residues in the milk,” says Amit Khurana of CSE. “While milk sold directly to consumers is not tested, contrary to what one would expect, processed milk sold in packets is also largely unchecked for antibiotic residues.”

The Food Safety and Standards Authority of India’s (FSSAI) 2018 milk quality survey found antibiotic residues in packed milk samples, revealing gaps in testing and regulation.  

While milk sold directly to consumers is not tested, contrary to what one would expect, processed milk sold in packets is also largely unchecked for antibiotic residues.

Despite efforts, several challenges sustain antibiotic misuse in India’s dairy farming. Weak regulations and limited enforcement allow over-the-counter sales of antibiotics, often without veterinary prescriptions. Inadequate veterinary services leave farmers to self-administer antibiotics, often incorrectly.

The implications of antibiotic misuse in dairy farming extend beyond cattle. Residues in milk and dairy products can introduce resistant bacteria into the human food chain through consumption of milk or dairy products, posing serious health risks to the public. Pathogens such as Staphylococcus aureus and Escherichia coli, common in mastitis cases, are among the resistant strains that threaten public health.

Also read: What’s lurking in your chicken dinner?

No quick fixes

Dr Nabanita Medhi, a microbiologist at Arya Hospital in Guwahati, highlights the gravity of the situation. “The number of pan and multi-drug resistance cases we encounter regularly is astounding. A matter of concern is that no new antibiotics are currently being developed globally. When patients develop resistance to the existing drugs, doctors are left with very few alternative treatment options.”

To combat AMR, experts advocate for systemic changes in the dairy industry, including the adoption of herbal remedies. Katrien van ’t Hooft, a Dutch veterinarian and livestock development expert, and founder of the Dutch Farm Experience and Natural Livestock Farming Foundation, has worked extensively with Indian dairy farmers to promote the potential of ethno-veterinary practices (EVP). These traditional, culturally-rooted methods leverage local knowledge to manage animal health and treat livestock diseases. For example, a formulation combining Aloe vera, turmeric and calcium hydroxide has proven effective against mastitis.

“Revitalise traditional knowledge on herbal medicine, train veterinarians and farmers, and develop scientific substantiation on remedies and practices concerning herbal medicine in dairy farming, gradually replacing antibiotics and other agro-chemicals with herbal products,” Katrien suggests in a co-authored study.

The fight against antimicrobial resistance in dairy farms is not solely the responsibility of farmers but requires a collaborative effort across various stakeholders.

“EVP can go a long way in replacing antibiotics in this sector and reducing antibiotic resistance. But most importantly, it is a low-cost, farmer-friendly option. It can be a game-changer in how diseases are managed without toxic chemicals in the dairy sector,” says CSE director general Sunita Narain.

To tackle AMR, experts recommend a multi-pronged approach. Strengthening farm biosecurity–by isolating sick animals, ensuring clean feeding systems, and maintaining hygiene during milking–can reduce infections and the need for antibiotics.

"The positive impact of ethno-veterinary medicine as an alternative to antimicrobial and chemical veterinary drugs is often overlooked. These remedies are primarily preventive and also curative. We have been able to reduce the incidence of mastitis by over 83% and other infectious diseases significantly. With over 1 million treated cases and an 80% cure rate, the results are undeniable. Of course, the problem is vast, but we need to take positive action" says Dr M N Balakrishnan Nair, Emeritus Professor, University of Transdisciplinary Health science and Technology, Ethnoveterinary science and practice group, Bengaluru.

Educating farmers about alternatives like vaccination and probiotics, along with the importance of veterinary-supervised antibiotic use, is crucial.

“India will need a roadmap to scale up preventive approaches related to animal housing, antibiotic alternatives, vaccines, biosecurity and resilient breeds that help reduce the occurrence of disease in food-animal farms and the need for antibiotics at its first place,” says Rajeshwari Sinha, programme manager, sustainable food systems.

“It also needs a long-term approach to reduce dependence on intensive industrial systems and promote local, decentralised food systems supported by backyard farming,” she adds.

Despite challenges, the country has made progress. In October 2024, FSSAI banned certain antibiotics in food animal production, following an earlier ban on colistin—a critically important antibiotic for human medicine. Under the Muscat Manifesto (2022), India has committed to reducing antimicrobial use in the agri-food sector by 30-50% by 2030.

(Photo credit: https://www.flickr.com/photos/cgiarclimate)

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In 2019, the World Health Organization (WHO) estimated that bacterial antimicrobial resistance (AMR) directly caused 1.27 million deaths and contributed to a total of 4.95 million. Experts across health organisations, medicine, and academia agree that the overuse and misuse of antimicrobials in humans, animals, and plants are the main drivers behind the rise of drug-resistant pathogens.
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In response to this growing threat, Andhra Pradesh became the fourth state in India to introduce its own State Action Plan on AMR in June 2022. The plan, titled the Andhra Pradesh Action Plan for the Containment of Antimicrobial Resistance, outlined various strategies to tackle AMR.

One key initiative was the adoption of a culture-free diagnostic tool powered by artificial intelligence (AI) and machine learning (ML). The tool, called AMRx®, was developed in collaboration with SCIINV Biosciences Private Limited and the Sathya Sai Institute of Higher Learning in Puttaparthi. It aims to help doctors predict bacterial infections and prescribe antibiotics more accurately, promoting the rational use of these medicines. 

The tool is being integrated into Andhra Pradesh's government healthcare system, Dr Care, for use in public hospitals (APAP CAR report 2022, p. 53) “Integrating both these softwares takes time. We are doing multiple tests on compatibility,” said Dr Ratnakar Palakodeti, co-founder and director of SCIINV Biosciences Private Limited.

How AMRx® works

Normally, a patient tells the doctor their symptoms, and the doctor decides whether a culture test is needed. If they go ahead with the test, it identifies the cause and checks for antibiotic resistance. The doctor then prescribes the appropriate medication, but this process usually takes over 24 hours. To avoid delays, the doctor often starts the patient on antibiotics based on an educated guess, without waiting for the test results.

AMRx® changes all of that. It supports the doctor’s judgment, boosts their confidence, and often removes the need for a culture test altogether. With AMRx®, the entire process is much quicker and more efficient.

A conventional culture test costs Rs 800, but this machine learning model, trained on over 100 parameters across different demographics, provides rapid insights. It validates the doctor’s judgment, flags resistant antibiotics, and serves as a clinical decision support tool.

 "The patient consults the physician, who uses the app. If the patient had visited earlier, all records are readily available on the application. Otherwise, the physician inputs clinical symptoms–such as the history of antibiotics and current symptoms–into the app. Within two minutes, the app processes the data, even in resource-limited facilities without diagnostic centers, and predicts bacterial infections and antibiotic resistance patterns instantly."

This approach supports physicians’ decisions, reduces reliance on culture tests, and offers cost-effective insights. “A conventional culture test costs Rs 800, but this machine learning model, trained on over 100 parameters across different demographics, provides rapid insights. It validates the doctor’s judgment, flags resistant antibiotics, and serves as a clinical decision support tool,” Dr Palakodeti added.

The tool won the Startup India Grant, the Federation of Asian Biotech Associations’ Best Startup Award, and the Economic Times Award for Industry Healthcare Solution of the Year. 

Antibiotic stewardship

Antibiotic stewardship involves using antibiotics responsibly and only when needed. This includes selecting the right antibiotic, determining the correct dose, prescribing for the appropriate duration, and ensuring antibiotics are used exclusively for bacterial infections. The app has the potential to drastically cut down on antibiotic usage. 

“The tool significantly reduces the diagnostic workload. If the app determines a negative case, antibiotics don’t need to be prescribed, thus avoiding unnecessary treatment. For example, 50 percent of cultures show negative results, yet 16 percent of such patients received empirical antibiotics which were unnecessary—something this tool can help prevent," said Dr BE Pradeep, the head of Antimicrobial Resistance Laboratory at the Satya Sai Institute of Higher Learning and the principal investigator who co-developed and clinically validated the tool.

"Between 2021 and 2023, we studied multiple hospitals across India and evaluated 15 different antibiotics for susceptibility. This tool is critical in controlling the emergence of AMR. It can integrate seamlessly with any hospital's Electronic Medical Information System (EMIS), capture essential data, and support antibiotic stewardship programs with instant updates,” he added

‍Implementation delays‍

Integrating AMRx® with the Dr Care platform, designed to create digital health records for patients visiting government health facilities in Andhra Pradesh, is a mammoth task. “Dr Care and AMRx® operate on different platforms, making integration necessary. Additionally, the data feeding process is time-consuming,”  Dr Palakodeti said. 

The tool's primary users are general physicians, and ensuring their adoption is crucial. In government hospitals, a general physician typically spends less than five minutes with each patient, juggling long hours and a heavy workload. AMRx® is designed to ease this burden, but many doctors may not be familiar with using technology. 

"Some of the doctors are hesitant as they are not familiar with using technology," said Prof Rangineni Jayaprada, a microbiologist at Sri Venkateswara Institute of Medical Sciences (SVIMS) and co-principal investigator on the project. To address this, the team has been running intensive training sessions for two to three months, involving two doctors and two healthcare professionals from each government hospital across 30 medical colleges and hospitals.

The challenge is not just about rolling out a tool; it’s about ensuring it’s used effectively by those who need it most. This is where the project’s true potential lies: it’s not just a step forward for Andhra Pradesh—it’s a model that could scale across India, tackling antimicrobial resistance on a national level. The app’s success hinges on both technological integration and on-the-ground training, making it a critical experiment in how health tech can shift the entire ecosystem of healthcare in India. If it works here, it could change the way we think about tackling AMR everywhere.

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Humanity has been warned. First, by Sir Alexander Fleming, and now, decades later, by the World Health Organization: if Antimicrobial Resistance (AMR) isn’t addressed, it could cause millions of preventable deaths each year.

It’s a scary thought. But do people truly understand the threat?

While researchers understood AMR through lab studies and clinical data, communicating its urgency to the public needed something more powerful. So scientists at Harvard Medical School and Technion-Israel Institute of Technology devised a powerful way to display bacterial evolution in response to antibiotics in a strikingly visual way.

Evolution on display

Famously known as the MEGA-Plate Petri dish experiment, or Microbial Evolution and Growth Arena plate, this study showed how bacteria evolve resistance over time. To capture bacterial mutations as they occurred, researchers designed a large petri dish filled with a nutrient-rich agar medium. At 2-feet long and 4-feet wide, the dish was divided into zones with increasing antibiotic concentrations, from none on the outer edges to extremely high levels at the centre.

E. coli bacteria were introduced to the outer edges, and as they multiplied, they began to spread toward the next zone with a low dose of antibiotics. In each antibiotic zone, some bacteria mutated to develop resistance, allowing them to survive and move inward. As the bacteria approached the highest concentration zones, only the most resistant strains continued to thrive.

The experiment illustrated natural selection in action, as viewers watched bacteria evolve from lower to higher antibiotic zones over two weeks. Time-lapse images captured the bacterial waves as they mutated and advanced inward. 

When bacteria fight back

The MEGA-plate experiment demonstrated how bacterial resistance develops gradually, underscoring the dangers of using low or sub-lethal doses of antibiotics, reinforcing the critical need for appropriate antibiotic use to prevent the rise of superbugs.

As bacteria progressed across the petri dish, even small populations adapted to survive, showing just how difficult it is to contain resistance, highlighting the urgency of developing alternative treatments and improving antibiotic stewardship to avoid a future where even routine infections become untreatable.

World as a petri dish

The MEGA-plate experiment is a powerful analogy for how our world acts as a breeding ground for microbial evolution, and, by extension, antibiotic resistance. Just as bacteria evolved within the controlled petri dish, microbes mutate and adapt in various ecosystems, such as soil, water, and even within our bodies, often at an accelerated pace due to human activity.

Let’s look up close.

Soil, one of the richest microbial habitats, is home to a vast diversity of bacteria and fungi, many of which naturally produce antibiotics. These microbes develop resistance genes as a survival mechanism, spreading them to other bacteria through horizontal gene transfer. Agriculture further accelerates this process by introducing antibiotics in livestock farming, creating an environment where resistant strains thrive.

Waterways face a similar threat. Antibiotic residues and resistant bacteria from sewage, agricultural runoff, and industrial waste enter rivers, lakes and oceans. The water bodies act as conduits, enabling bacteria to transfer genes across diverse species, driving global antibiotic resistance.

Our bodies are not exempt; our gut microbiomes host trillions of microbes, some of which can mutate or acquire resistance genes when exposed to antibiotics. This makes our microbiomes potential incubators for antibiotic resistance, especially with improper or excessive antibiotic use.

All of these encourage the survival of only the most resistant strains, creating superbugs that withstand multiple drugs. Our actions–through antibiotic overuse, improper waste disposal, and agricultural practices–are speeding up microbial evolution and resistance.

Wake-up call

The MEGA-plate experiment is a stark wake-up call, vividly illustrating that AMR is not just a scientific concern but a global threat. The rapid spread of AMR highlights how our world has become a vast breeding ground for resistant microbes. With certain infections already becoming untreatable, AMR poses a serious threat to global health, endangering surgeries, cancer treatments, and routine medical care. The thought of a post-antibiotic era–a future where minor injuries or common infections could be fatal–is daunting.

Combating this looming crisis requires a unified response, advancing antibiotic stewardship, investing in new treatments, and adopting practices that limit the spread of resistant bacteria across healthcare, agriculture, and communities. Acting now is the only way to ensure the future of modern medicine and protect generations to come.

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In West Midnapore, West Bengal, Joymalya Halder manages a one-acre poultry farm, raising 14,000 broiler chickens five times a year. Each flock matures in just 38 to 42 days under tightly controlled conditions. The process involves three rounds of vaccinations and strict temperature regulation to ensure the birds grow optimally.

“Poultry birds are very susceptible to temperature changes. If they catch the flu—signalled by specific noises—an antibiotic is administered to prevent mortality,” said Halder.

But there’s a catch. “While antibiotics reduce mortality, they impact weight gain. Birds don’t eat as much after receiving antibiotics, which leads to losses,” he added.

Halder recalled a particularly challenging episode with a batch of 3,000 birds. “If one bird falls sick, the disease can spread rapidly, affecting the entire flock. Even a small change in the Feed Conversion Ratio (FCR) can cause big losses.”

An ideal FCR, Halder said, is 1.5. This means a bird should weigh 1 kg after consuming 1.5 kg of feed. But fluctuations in market prices can make or break a farmer’s bottom line. “Right now, raising a bird costs Rs 95 per kg. If the market price is between Rs 100 and Rs 110, we’re safe. But if it drops to Rs 88, we incur a loss of Rs 7 per kg. For 14,000 birds, that’s Rs 98,000 gone,” he said.

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Boon or bane?

Since the 1940s, antibiotics have been used as growth promoters (AGPs) in animal farming to meet rising global meat demand. While the Bureau of Indian Standards (BIS) recommends avoiding AGPs in poultry feed, they remain readily available and widely used.

The implications are alarming. A joint study by Toxic Links and World Animal Protection uncovered high levels of antimicrobial resistance genes (ARGs) in poultry farms in Tamil Nadu and Andhra Pradesh. Samples revealed ARGs against 15 critical antibiotics in 11 out of 14 groundwater and poultry litter tests.

PK Patil, principal scientist at the Central Institute of Brackishwater Aquaculture, underscored the problem’s complexity. “The unscientific use of antibiotics accelerates antimicrobial resistance (AMR) in animals. To effectively address AMR, we need to tackle its root causes,” he says.

Patil’s research focuses on how antibiotics degrade in the environment, particularly in soil and water. He has observed a stark contrast between India and Northern Europe. “In Europe, antibiotics persist longer in the environment. But here, high temperatures and intense sunlight speed up their degradation,” he said.

Correct usage involves knowing which antibiotics to use, their dosages, duration, and administration methods. Education on the types, concentrations, and doses of antibiotics is crucial in India.

Still, the risks remain high. Misuse of antibiotics–especially those critical for human health–blurs the line between animal and human medicine. “Some antibiotics are important for humans, while others are meant for animals. It’s crucial not to mix them, as animal-specific antibiotics should not be used in humans and vice versa. However, this distinction is often overlooked, leading to potential misuse,” he added.

Patil also stressed the importance of understanding global and Indian antibiotic usage patterns. He called for a coordinated, national-level programme to establish clear guidelines for antibiotic use and monitor AMR trends continuously.

"Correct usage involves knowing which antibiotics to use, their dosages, duration, and administration methods. Education on the types, concentrations, and doses of antibiotics is crucial in India," he said.

Mapping AMR

A recent study by the Drug Safety Division of the Indian Council of Medical Research-National Institute of Nutrition (ICMR-NIN) in Hyderabad has revealed critical insights into antimicrobial resistance (AMR) in poultry. Researchers analysed AMR gene profiles from chicken farms in Kerala and Telangana, uncovering distinct resistance patterns.

Southern Kerala emerged as a hotspot, showing the highest concentration of AMR genes. The study collected chicken faeces samples from farms across Central and Southern India. Genetic material from these samples underwent whole genome sequencing, uncovering significant levels of gram-negative and anaerobic bacteria.

The findings highlighted regional differences. Southern India showed a greater abundance of AMR genes compared to Central India, with E. coli more commonly detected in the southernmost areas. Interestingly, the AMR profiles from these farms resembled patterns seen in poultry farms in the European Union (EU). However, researchers found no evidence of the mcr-1 gene in E. coli—a gene associated with resistance to colistin, a last-resort antibiotic for severe infections.

Also read: How our meat industry is feeding antibiotic resistance

Growing concerns

India is the world’s third-largest egg producer and fourth-largest chicken meat producer, with broiler production concentrated in Tamil Nadu, Andhra Pradesh, Maharashtra, Uttar Pradesh, and Telangana. This scale of production raises concerns about antibiotic residues in poultry products.

When laying hens receive antibiotics, traces of the drugs can build up in their eggs. After administration, antibiotics are absorbed in the chicken’s intestines and travel through the bloodstream to the ovaries and oviducts. Since the ovaries create the egg’s contents, residues are more likely to appear in the yolk and albumen.

Cooking methods such as boiling, steaming, frying, or microwaving can break down some antibiotic residues. However, research shows that boiling affects only certain drugs. This means that even when residues are undetectable, they may still pose health risks, making eggs potentially unsafe to eat.

By 2030, antimicrobial usage in India is expected to exceed the global average by 40%. In 2021 alone, the country administered 2,160 tonnes of antimicrobials to livestock. Vijay Pal Singh, principal technical officer (Veterinary) at CSIR-Institute of Genomics and Integrative Biology, emphasised the need to prioritise human-critical antibiotics.

“These are antibiotics that are considered ‘last-resort’--highly effective and essential for human health. We should ensure these antibiotics are reserved exclusively for human use,” he said.

The PM effect

Shivaji Bhattacharya, a wildlife expert and former deputy director of Animal Resource Development at the Government of West Bengal, noted that antimicrobial resistance would continue to develop even without antibiotic use.

“One cause of AMR is PM2.5, and another is the pharmaceutical industry. Untreated effluents released during antibiotic production pollute air and water, worsening the problem. As the antibiotics industry grows, so does this issue,” he said.

Research conducted across 116 countries between 2000 and 2018 revealed strong links between PM2.5 pollution and antibiotic resistance. These links have strengthened over time. According to The Lancet, PM2.5-related AMR caused an estimated 0.48 million premature deaths in 2018, resulting in 18.2 million years of life lost and an economic impact of USD 395 billion annually.

As the poultry industry continues to grow, striking a balance between productivity and sustainability is crucial. The cost of inaction may prove too high for both farmers and public health.

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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.