INTRODUCTION Older adults represent a growing proportion of India’s population, with a concomitant rise in hospitalizations due to infections. Age-related changes in immunity, along with multimorbidity, frailty, and polypharmacy, predispose older patients to infections that are more severe and difficult to manage. Common clinical presentations include urinary tract infections (UTIs), respiratory tract infections (RTIs, including community-acquired and hospital-acquired pneumonia), skin and soft-tissue infections, influenza-related complications, postsurgical infections, and device-associated infections, such as those associated with urinary catheters or central lines. In India, tertiary hospital reports a high prevalence of resistant pathogens such as Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas, particularly among the older population (>40%).1,2 Empirical antimicrobial therapy is frequently initiated due to diagnostic uncertainty, leading to prolonged and inappropriate courses, especially in community-onset infections. Inadequate diagnostic stewardship, such as delayed cultures, poor specimen quality, or misinterpretation of colonization versus infection, further compounds antimicrobial resistance (AMR). The World Health Organization has repeatedly highlighted AMR as a global crisis, emphasizing the need for integrated antimicrobial stewardship (IAS) interventions in older adults.3 The 42 practice points proposed by the Society of Antimicrobial Stewardship PractIces (SASPI) for Indian hospitals provide a structured roadmap to implement IAS, covering administrative, diagnostic, preventive, and therapeutic domains.4 For geriatricians, stewardship must become a clinical reflex, extending from bedside diagnosis to prescription, prophylaxis, and follow-up care. GERIATRIC INFECTIONS CONTRIBUTING TO ANTIMICROBIAL RESISTANCE UTIs remain the most common bacterial infection in older adults. The overuse of broad-spectrum cephalosporins, fluoroquinolones, and carbapenems, often initiated empirically in catheterized or frail elderly patients, drives resistance among E. coli, Klebsiella, and Enterococcus species.5 Complicated UTIs in older adults frequently require culture guidance, but preemptive broad-spectrum therapy is still common in India due to delayed laboratory support. Community-acquired pneumonia, aspiration pneumonia, and influenza-related complications are also prevalent in older adults. Empirical coverage with third-generation cephalosporins, fluoroquinolones, or combinations is often prolonged, resulting in selection pressure for resistant pneumococci and Gram-negative bacilli. Polypharmacy and comorbidities increase the risk of drug interactions and suboptimal therapy.6 Cellulitis, diabetic foot infections, and pressure sores are frequent in the elderly. Empirical treatment without culture or debridement promotes resistance in Staphylococcus aureus and Gram-negative organisms. Indwelling catheters, urinary stents, pacemakers, and postoperative wounds are significant sources of nosocomial infections because of their higher uses among olders. Failure to remove or appropriately manage devices leads to prolonged empirical therapy, contributing to AMR and higher mortality.7 Postoperative infections in Indian geriatric surgical wards are often underreported, further complicating stewardship. They often present atypically with sepsis, delaying diagnosis and empirical therapy. Multidrug-resistant Gram-negative infections are common in Indian tertiary centers, necessitating careful stewardship to balance timely intervention with resistance prevention.1 Influenza, respiratory syncytial virus (RSV), and other viral respiratory pathogens often prompt unnecessary antibacterial therapy. Collectively, these infections perpetuate a vicious cycle: high prevalence, empirical broad-spectrum therapy, AMR, treatment failure, escalation to last-line antimicrobials, and again AMR in continuum. STEWARDSHIP: GERIATRICIANS AS PROBLEM-SOLVERS Geriatricians occupy a pivotal role at the intersection of complex comorbidities, polypharmacy, and infection susceptibility. Stewardship for this group must move beyond antibiotic selection: it must integrate diagnostic prudence, therapeutic optimization, infection prevention, education, and institutional accountability in line with the SASPI’s 42-point framework.4 Accurate diagnosis and pathogen identification form the foundation of stewardship. In complicated infections such as pneumonia, catheter-associated UTI, and diabetic foot infections, blood, urine, respiratory, or wound cultures should be obtained before initiating therapy. However, cultures from colonized sites (e.g. urinary catheters, tracheal aspirates, or chronic ulcers) should not automatically trigger antimicrobial use. Clinical correlation, host response, and sample quality are vital in distinguishing pathogen from nonpathogen, as emphasized by Panda et al.8 In India, improper specimen collection, delayed transport, and underresourced microbiology facilities often lead to contamination or false results. Geriatricians must collaborate with microbiologists to ensure diagnostic accuracy and adopt rapid molecular assays judiciously where available. Empirical therapy must be guided by local antibiograms, infection site, and kidney–liver function. Culture results should prompt de-escalation or discontinuation when infection is unproven. Duration must be rational: 1–5 days for uncomplicated UTI, 5–7 days for community-acquired pneumonia, or shorter where clinical recovery occurs.9 Geriatricians should engage in source control: drainage, debridement, or removal of infected prostheses, before resorting to prolonged therapy. Early intravenous-to-oral switch and dose optimization based on kidney function form key SASPI indicators of good stewardship.4 Prevention remains the most effective stewardship strategy in elderly care. Vaccination (influenza, pneumococcal, coronavirus disease 2019, Tdap, and herpes zoster) when indicated, strict catheter-care bundles, hand hygiene, and aspiration–prevention protocols significantly reduce healthcare-associated infections.10,11 These are especially vital in long-term care and rehabilitation settings. Patient and caregiver counseling on adherence, antibiotic avoidance in viral illnesses, and infection–prevention practices are essential. Nursing and resident teams must be trained in correct specimen collection, catheter maintenance, and isolation precautions, an area often neglected due to staffing constraints. Embedding geriatricians in institutional AMS committees strengthens clinical-laboratory collaboration. Audit–feedback cycles, antimicrobial indication documentation, and rational outpatient parenteral antimicrobial therapy monitoring ensure compliance with stewardship policies.4 Elderly patients often act as reservoirs and amplifiers for resistant organisms due to repeated hospital exposure and often antimicrobial uses. While dealing with them, HCWs must discuss about One Health aspects 'how humman, animal, and environmental antimicrobial use is increasing AMR in our society. Geriatricians can contribute to national AMR surveillance by sharing infection and resistance data through hospital AMS programs, aligning with India’s National Action Plan on AMR and National Centre for Disease Control (NCDC)-led initiatives.12 PRACTICE POINTS BY THE SOCIETY OF ANTIMICROBIAL STEWARDSHIP PRACTICES FOR GERIATRICIANS Aligned with the SASPI 42-point model, as recently declared as “Mangalagiri Declaration,”13 geriatric stewardship translates into 10 focused, measurable priorities, can be memorized easily, and practice with a mnemonic Box 1.Box 1: The 10 core elements of the integrated antimicrobial stewardship framework - the “OLD AGE AMSP” modelTogether, these SASPI-linked practices redefine geriatric medicine as a cornerstone of antimicrobial stewardship, bridging diagnostic acumen and clinical judgment. CONCLUSION Older adults face a disproportionate burden of infections, often complicated by comorbidities, frailty, and polypharmacy. Empirical antimicrobial use without culture guidance, prolonged therapy, underreporting of device or postsurgical infections, and inadequate infection-prevention practices are major contributors to AMR in India. Geriatricians occupy a central role in stewardship, bridging pathogen identification, bedside management, and hospital-wide AMS efforts. Implementing SASPI-aligned integrated stewardship, such as diagnostic, therapeutic, preventive, and administrative, can reduce AMR, improve clinical outcomes, and preserve antimicrobial effectiveness for future generations through this OLD AGE AMSP model; in truth, this is a call for action. Embedding stewardship in geriatric practice is both an ethical obligation and a practical necessity, with measurable impacts from pathogen to patient, hospital, and the broader One Health ecosystem. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Dhar et al. (Thu,) studied this question.