Around mid-October 2025, when the World Health Organization (WHO) released its Global Antibiotic Resistance Surveillance Report 2025 (GLASS), there were hardly any surprises in the quarters in which antimicrobial resistance typically increases. To no one’s surprise, antimicrobial resistance (AMR) in India is “a serious and growing threat, with resistance rates among the highest in the world.”
The report, which is based on data from more than 100 countries, said: In 2023, nearly one in three bacterial infections in India was resistant to commonly used antibiotics, reflecting serious trends across Southeast Asia. Globally, the report said, one in six confirmed infections was resistant, with India disproportionately affected due to factors including high infectious disease burden, overuse and misuse of antibiotics, and gaps in surveillance and health care infrastructure.
For India, the report highlights the following aspects: high resistance rates to major antibiotics, especially in serious infections caused by E.coli, Klebsiella pneumoniae and Staphylococcus aureus, especially in hospital ICUs; Challenging factors increasing AMR are widespread over-the-counter antibiotic access, self-medication, incomplete courses, environmental pollution (from pharmaceutical manufacturing and hospital waste), and uneven enforcement of regulations.
The report also advised national initiatives such as the National Program on AMR Prevention and increasing lab networks in India in an attempt to stem the tide, but concluded that several critical issues remain to be addressed, including inadequate funding and limited coordination between human, animal and environmental health.
While India actively participates in GLASS, most of the surveillance data comes from tertiary hospitals, which does not fully represent the community or rural areas. Notably, India enrolled in WHO’s GLASS in 2017.
incomplete data
Abdul Ghafoor, Senior Advisor, Infectious Diseases, and one of the architects of the Chennai Declaration, one of the early actors against microbial resistance, says: “The level of AMR in India is among the highest globally, especially for Gram-negative pathogens. This is completely in line with 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 worrying resistance trends in Acinetobacter and Pseudomonas. But no surprise here – most of India’s glass submissions are actually drawn from these very networks that collect and curate resistance data from sentinel hospital laboratories,” he explains.
These datasets are valuable, says Dr. Ghafoor, and yet, they have a fundamental limitation in that they largely originate from top tertiary care hospitals (medical colleges or referral centers) where serious, complex infections and high antibiotic pressures are common. “It does not include bacterial susceptibility data from the vast networks of secondary or primary care hospitals, which see very different patient populations, antibiotic use patterns, and microbiological ecologies. The result is that the national “resistance rate” we cite is likely a biased estimate of the country-wide average – reflecting the more extreme end of the spectrum rather than the full distribution of resistance.”
He also said that this disparity is not meant to understate the severity of AMR in India – “Clearly, our burden is higher. But it does mean that our national estimates are incomplete and not fully representative. To fix this, we need to transform the surveillance network from a limited sentinel model to a true national network that covers all levels of care.”
Senior infectious disease expert V. Ramasubramaniam also speaks on the issue of disproportionate representation. “This is a huge country with huge diversity, we need (AMR surveillance) centers spread across the country. Unless we interpret the susceptibility patterns correctly, we may draw wrong conclusions.” In his opinion, the Glass report may not be a true representative of what is happening on the ground, and needs to be taken with a ‘very high grain of salt’, although there is no doubt that antibiotics stewardship is essential for the country.
WHO also urges more thorough nationwide surveillance, rational antibiotic use and stronger regulation, warning that without urgent improvements, routine infections in India could become increasingly untreatable, leading to higher mortality rates and increased pressure on the health care system.
Kerala model
A major reason for the worsening situation is considered to be the slow progress on the implementation of India’s National Action Plan on Antimicrobial Resistance (NAP-AMR). “While the national framework established a strong approach in 2017, only a few states have formally launched or operationalized their state action plans on AMR; even among these, most are in the early stages of implementation,” explains Dr Ghafoor.
Apart from Kerala, no other state has done anything significant on AMR, says Dr Ramasubramaniam. The Kerala Antimicrobial Resistance Strategic Action Plan was launched in 2018 and adopted the path of inter-sectoral collaboration and One Health to handle AMR. The state launched “AMRUT” (Antimicrobial Resistance Intervention for Total Health) in January 2024 to stop over-the-counter (OTC) sale of antibiotics. Since then, the government has carried out surprise inspections of pharmacies to ensure that antibiotics are only sold with a doctor’s prescription, with penalties for non-compliance. The public is encouraged to report violations to help prevent antibiotic misuse and combat the growing problem of AMR. The latest antibiogram released by the state government has shown a slight decline in AMR levels.
amr literacy
Understanding the importance of creating awareness in the change process, Kerala aims to become antibiotic-literate by December 2025 through awareness programs and appropriate antibiotic use initiatives. Yewande Alimi, Africa CDC’s One Health Unit Lead, says it is important for the world now to have a basic understanding of the role of bacteria. “We need to spread awareness much earlier about the importance of the bacterial world in our lives,” he said during a recent webinar on Antimicrobial Resistance – A Global Health Security Crisis organized by the AIDS Healthcare Foundation (AHF) in collaboration with the University of Miami Public Health Policy Lab.
Patient advocate and consultant Ella Balassa also shed light on the same topic. “Awareness is really valuable. I suggest we bring large non-profit groups together, confronting the crisis and the problem head on. That’s the way we can more easily connect the general population to the issue. Currently we have a disconnect: AMR is abstract to the general population. We must humanize it, and bring it into our lives, that’s how we’re going to bring solutions.”
Dr. Alimi explains that we must take advantage of the moment and opportunity that the recent adversity has provided us. “During COVID, many sectors came together and the One Health approach came into its own. The global approach, including the pandemic agreement, has helped drive One Health forward,” he said. He advised that this should guide the movement against AMR.
ban on colistin
One important intervention that has benefited the country is the 2019 ban on colistin – which until then was widely used as a growth agent in animal husbandry in India. Dr Ramasubramaniam says: “Intuitively, we know it will help, but quantification of how much it has helped will be possible only after long-term studies”. He said simple and consistent implementation of state and national policies on AMR would go a long way in improving the situation.
There is no doubt that for some of the progress made, India’s antibiotics management as a whole is flailing and in need of revamping. The point is that we know what to do, experts say. First, it is necessary to get more centers reporting resistance, Dr Ghafoor insists: “To get a truly representative national estimate, India must adopt a full-network model: drawing on the 500+ NABL laboratories that already exist, and investing in building microbiology capacity in the peripheral and primary care levels.” Only then will our national AMR metrics reflect the true microbial ecology of the entire country – not just its referral top,” he explains.
new antibiotics
On the other hand, to deal with the problem, new antibiotic models will have to be developed. Vasan Sambandamurthy, senior vice president at Bugworks Research Inc., a clinical-stage biopharmaceutical company that is developing a new class of broad-spectrum antibacterial agents and immunotherapy, points out that several antibiotics have been launched in the past two years. In India, four new antibiotic candidates (napithromycin, plazomicin, cefepime/enmetazobactam, tedizolid phosphate) have been granted CDSCO approval, while six other candidates have received approval for use globally.
He adds: “Encouragingly, 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, compared to 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 only four target WHO’s highest priority critical pathogens, particularly MDR gram-negative bacteria.”
Dr. Sambandamurthy says the availability of new antibiotics in India has the potential to significantly change the AMR landscape. But, despite this ray of hope, the current clinical pipeline and recently approved antibiotics are inadequate to address the global AMR challenge, due to significant differences in their spectrum and availability across low- and middle-income countries (LMICs).
He says, “New antibiotics must have 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 Enterobacterella and Acinetobacter baumannii. In addition, they must demonstrate broad efficacy against MDR strains, offer both oral and intravenous formulations, and have a strong safety profile. Furthermore, these antibiotics must prevent further resistance development, be globally accessible and affordable, particularly in LMICs, and align with antimicrobial stewardship principles.”
Global efforts and funding
It is important to understand the role of the AMR Industry Coalition in combating AMR globally. Dr. Sambandamurthy, who is on the board of the alliance, says the organization aims to accelerate the discovery and development of new antibiotics and diagnostic tools, with members’ progress tracked through regular reports, and to strengthen equitable access to antibiotics and enforce responsible antibiotic manufacturing standards, particularly in LMICs.
Ultimately, the lack of funding needs to be tackled head-on, Dr Ghafoor emphasizes: “Apart from modest monitoring funding and a few innovation grants, there has been little sustained financial or policy investment. Industry involvement, public awareness and innovation funding are sporadic and small-scale.” This needs to change. He also explained his belief that the energy and focus around AMR policy a few years ago has diminished significantly. “If India is to retain its leadership in this field, we must reinvigorate the AMR agenda – by expanding the implementation of state action plans, strengthening data-driven surveillance, encouraging innovation, and integrating AMR priorities into mainstream public health programmes.”
Nearby, this year’s World AMR Awareness Week (18-24 November) urges the world to “Act Now: Protect Our Present, Secure Our Future”. For India, this means acknowledging the enormity of the problem and employing multi-pronged strategies that will improve its management, resulting in reduced rates of AMR in the community. If one state has managed to do this, it is proof that what seems like a tide can actually be stemmed.
