Around mid-October 2025, when the World Health Organization (WHO) released its Global antibiotic resistance surveillance report 2025 (GLASS), there was hardly any surprise in the quarters in which antimicrobial resistance usually gets a rise. No one was surprised that antimicrobial resistance (AMR) in India “is a serious and escalating threat, with resistance rates among the highest in the world.”
The report, which draws on data from over 100 countries, noted: In 2023, approximately one in three bacterial infections in India were resistant to commonly used antibiotics, mirroring severe trends across South-East Asia. Globally, the report said, one in six confirmed infections were resistant, with India disproportionately affected due to factors including high infectious disease burden, overuse and misuse of antibiotics, and gaps in surveillance and healthcare infrastructure.
For India, the report underlined the following aspects: High resistance rates to major antibiotics, especially in serious infections such as those caused by E.coli, Klebsiella pneumoniae, and Staphylococcus aureus, particularly in hospital ICUs; the challenging factors that aggravate AMR are widespread over-the-counter antibiotic access, self-medication, incomplete courses, environmental contamination (from pharmaceutical manufacturing and hospital waste), and uneven enforcement of regulations.
The report also provided a hat tip to national initiatives such as the National Programme on AMR Containment and the growing lab network in India, in trying to stem the tide, but concluded that several significant issues remain to be addressed, including insufficient funding and limited coordination between human, animal, and environmental health.
While India participates actively in GLASS, most surveillance data comes from tertiary hospitals, not fully representing the community or rural areas. Notably, India enrolled in the WHO’s GLASS in 2017.
Incomplete data
Abdul Ghafur, senior consultant, infectious diseases, and one of the architects of the Chennai Declaration, among the early actors against microbial resistance says: “The AMR levels in India are among the highest globally, particularly for gram-negative pathogens. This is entirely consistent with the national surveillance data from ICMR’s AMRSN / i-AMRSS and NCDC’s NARS-Net.” These are two complementary surveillance networks for AMR in India.
“There are high rates of carbapenem resistance, and worrisome resistance trends in acinetobacter and pseudomonas. But there are no surprises here — much of India’s GLASS submission is in fact drawn from these same networks that collect and curate resistance data from sentinel hospital laboratories,” he explains
Dr. Ghafur says, these datasets are valuable, and yet, they have a fundamental limitation in that they largely originate from top tertiary care hospitals (medical colleges or referral centres) where severe, complicated infections and high antibiotic pressure are common. “This does not incorporate bacterial susceptibility data from the vast network of secondary or primary care hospitals, which see very different patient populations, antibiotic usage patterns, and microbiological ecologies. The result is that the national “resistance rates” we cite are likely a biased overestimate of the country-wide average — reflecting the more extreme end of the spectrum rather than the full distribution of resistance.”
He hastens to add that this skew is not to minimise the seriousness of AMR in India — “Clearly, our burden is high. But it does mean that our national estimates are incomplete and not fully representative. To correct this, we need to transform the surveillance network from a limited sentinel model into a true national network covering all levels of care.”
V. Ramasubramanian, senior infectious diseases specialist, also touches upon the issue of inconsistent representation. “This is a vast nation with huge diversity, we need to have [AMR surveillance] centres spread across the country. Unless we correctly interpret susceptibility patterns, we may be drawing erroneous conclusions.” In his opinion, the GLASS report may not be a true representative of what exists at the ground level, and needs to be taken with a ‘lot of salt’, though there is no doubt that antibiotics stewardship is necessary for the country.
The WHO too urges for more complete nationwide surveillance, rational antibiotic use, and stronger regulation, warning that without urgent improvements, routine infections in India may increasingly become untreatable, leading to higher mortality and pressure on the healthcare system.
Kerala model
A key factor for the worsening situation is attributed to snail’s pace progress on implementation of India’s National Action Plan on Antimicrobial Resistance (NAP-AMR). “While the national framework set a strong vision in 2017, only a few States have formally launched or operationalised their State Action Plans on AMR; even among these, most remain in the very early stages of execution,” Dr. Ghafur explains.
Apart from Kerala, no other State has done anything significant in terms of AMR, adds Dr. Ramasubramanian. The Kerala Antimicrobial Resistance Strategic Action Plan was rolled out in 2018 and took the path of inter-sectoral collaborations and One Health to handle AMR. The State went on to launch “AMRITH” (Antimicrobial Resistance Intervention for Total Health) in January 2024 to stop the over-the-counter (OTC) sale of antibiotics. Since then, the government has conducted surprise inspections of pharmacies to ensure antibiotics are only sold with a doctor’s prescription, with penalties for non-compliance. The public is encouraged to report violations to help curb antibiotic misuse and combat the growing problem of AMR. In the latest antibiogram released by the State government, a slight dip has been noticed in AMR levels.
AMR literacy
Kerala also aims to become antibiotic-literate by December 2025 through awareness programmes and proper antibiotic use initiatives, realising the significance of building awareness in the transformation process. Yewande Alimi, One Health Unit Lead, Africa CDC, says the key now is for the world to have a basic understanding of the role of bacteria. “We need to spread information very early about the importance of the bacterial world in our life,” she said during a recent webinar on Antimicrobial Resistance — A Global Health Security Crisis organised by the AIDS Healthcare Foundation (AHF), in collaboration with the University of Miami Public Health Policy Lab.
Ella Balasa, patient advocate and consultant, also fleshed out the same theme. “Awareness is really valuable. I would suggest we bring together large non profit groups, bring a face to the crisis and problem. That is the way by which we can get the general population to relate to the issue more easily. That is currently where we have the disconnect: AMR to the general population is abstract. We must humanise it, and bring it into their lives, that’s how we are going to bring solutions.”
Dr. Alimi points out that we must seize the moment and the opportunity that a recent adversity provided us. “Several sectors came together during COVID and the One Health approach had come into its own. Global approaches including the pandemic agreement have helped advanced one health,” she said, advising that this must guide the movement against AMR.
Colistin ban
One significant intervention that has benefitted the country is the 2019 ban on colistin — being widely used as a growth agent in animal husbandry in India until then. Dr. Ramasubramanian says: “Intuitively, we know it will help, but quantification of how much it has helped will only be possible after long-term studies”. Simply and consistently implementing State and national policies on AMR will go a long way in ameliorating the situation, he adds.
There is little doubt that but for pockets of progress, India’s antibiotics stewardship is all but flailing and needs resuscitation. The thing is we do know what to do, experts say. For a first, it is essential to bring in more centres reporting resistance, Dr. Ghafur insists: “To obtain truly representative national estimates, India must adopt a full-network model: draw in the 500+ NABL labs that already exist, and invest in building microbiology capacity in peripheral and primary care tiers.” Only then will our national AMR metrics reflect the real microbial ecology of the entire country — not just its referral apex,” he explains.
Newer antibiotics
Tackling the problem from the other side would be to develop newer antibiotic models. Vasan Sambandamurthy, Senior Vice President at Bugworks Research Inc., a clinical stage biopharmaceutical company that is developing a novel class of broad-spectrum antibacterial agents and immunotherapies, points out that several antibiotics have been launched in the last two years. In India, the approval of the CDSCO has been granted to four new antibiotic candidates (Nafithromycin, Plazomicin, cefepime/enmetazobactam, Tedizolid phosphate) while six other candidates have received approval for use globally.
He adds: “What is encouraging is that the 2024 WHO report on the antibiotic development pipeline shows a modest increase in antibacterial agents, with 97 candidates in clinical and preclinical stages in 2023 versus just 80 in 2021. Unfortunately, the pipeline remains thin in terms of truly innovative antibiotics. Only 12 of the 32 traditional antibiotics in development meet WHO innovation criteria (new class, new mode of action, no cross-resistance), and just four target WHO’s highest priority critical pathogens, particularly MDR Gram-negative bacteria.”
Dr. Sambandamurthy says the availability of newer antibiotics in India does have the potential to significantly alter the AMR landscape. But, despite this sliver of hope, the current clinical pipeline and recently-approved antibiotics are insufficient to tackle the global AMR challenge given the significant gaps in their spectrum, and availability across Low and Middle Income Countries (LMIC).
He says “new antibiotics should possess novel mechanisms of action or belong to new classes that bypass existing resistance pathways. They must target WHO’s highest priority MDR pathogens, including carbapenem-resistant Enterobacterales and Acinetobacter baumannii. In addition, demonstrating broad efficacy against MDR strains, offering both oral and intravenous formulations, and having a strong safety profile are essential. Furthermore, these antibiotics should suppress further resistance development, be accessible and affordable globally, especially in LMICs, and align with antimicrobial stewardship principles.”
Global efforts and funding
It’s important to understand the role of the AMR Industry Alliance in countering AMR globally. Dr. Sambandamurthy who sits on the board of this alliance says the organisation aims at accelerating discovery and development of new antibiotics and diagnostic tools, with member progress tracked via regular reports and strengthening equitable access to antibiotics, especially in LMICs, and implementing responsible antibiotic manufacturing standards.
Ultimately, funding shortages need to be tackled head on, Dr. Ghafur stresses: “Beyond the modest surveillance funding and a few innovation grants, there has been very little sustained financial or policy investment. Industry engagement, public awareness, and innovation funding are sporadic and small in scale.” This needs to change. He also articulates his belief that the energy and attention that once surrounded AMR policy a few years ago have noticeably slowed. “If India is to retain its leadership in this area, we must rejuvenate the AMR agenda — by expanding the implementation of state action plans, strengthening data-driven surveillance, incentivising innovation, and integrating AMR priorities into mainstream public health programmes.”
Just around the corner, this year’s World AMR Awareness Week (18–24 November) urges the world to “Act Now: Protect Our Present, Secure Our Future.” For India, it means embracing the staggering breadth of the problem and employing multi-pronged strategies that will improve its stewardship, resulting in reducing the rates of AMR in the community. If one State has managed to do that, then it is proof that what seems like a tide can indeed be stemmed.