Background Antimicrobial resistance (AMR) is a significant global public health hazard. The latest Global Research on Antimicrobial Resistance study predicted that, if recent trends continue, bacterial AMR could lead to 8.22 million deaths each year by 2050, with 1.91 million of those deaths directly caused by resistance. These numbers should be seen as estimates of what will happen in the future, not as definite outcomes. They should not be confused with older worst-case scenarios, like the earlier “10 million deaths by 2050” estimate, which was based on a different modeling framework. In Bangladesh in 2021, about 23 500 people died because of AMR. This means that these deaths probably would not have happened if the organisms that caused the infections had still been treatable. There were 96 900 deaths linked to AMR in the same year. This means that there were resistant infections, but they were not always the direct cause of death. Bangladesh had a total of 914 988 deaths in 2021. This means that deaths caused by AMR made up about 2.6% of all deaths, or about 1 in every 39 deaths in the country1. Colonization is also considered a useful metric for understanding the burden of AMR. Recent data highlight the severity of the problem. In Dhaka, a study found that 78% of community participants and 82% of hospitalized individuals were colonized with bacteria resistant to extended-spectrum cephalosporins. Not only that, colonization with carbapenem-resistant Enterobacterales was markedly higher among hospitalized patients – that is, 37% compared with community individuals, where it is only 9%2. Among urinary tract infection pathogens, resistance to first-line antibiotics is increasing rapidly. It is driven by empiric prescribing and the use of over-the-counter (OTC) antibiotics3. During the COVID-19 pandemic in Bangladesh, 100% of hospitalized patients received at least one antibiotic. Even up to 88% of the general population practiced self-medication. A study revealed that they commonly used azithromycin and ivermectin. These trends have markedly accelerated AMR. They have also heightened the risk of a future AMR crisis4. In Bangladesh, antibiotics are widely accessible through both formal and informal retail channels, frequently serving as the initial point of care due to their geographical availability, low cost, and quicker access compared to qualified physicians. In this environment, market incentives, patient demand, and weak regulatory enforcement work together to sustain non-prescription sales and repeated exposure to broad-spectrum antibiotics going5. Poor diagnostic ability and slow laboratory confirmation make doctors more likely to prescribe antibiotics without testing them first. Additionally, the lack of full implementation of antimicrobial stewardship makes it harder to monitor the duration and types of antibiotics being used. The pharmaceutical supply system has facilitated easier access to antibiotics, but the regulations governing their use have not kept pace with this accessibility. The outcome is a self-perpetuating cycle characterized by easy access, commercial motivations, inadequate enforcement, and limited diagnostic capabilities6. This article is compliant with the TITAN Guidelines 2025 – governing the declaration and use of AI7. In Bangladesh, AMR is not just a biomedical issue of increasing pathogen resistance but also a crisis in governance and regulation. Its persistence is influenced by inadequate enforcement of prescription-only antibiotic sales, illogical dispensing and self-medication practices, constrained diagnostic and surveillance capabilities, inconsistent implementation of stewardship, and disjointed coordination among the human, animal, and environmental sectors8. This editorial contends that the AMR crisis in Bangladesh necessitates examination through the perspectives of governance and health systems, as resistant infections are exacerbated not only by microbial evolution but also by institutional, regulatory, and service delivery shortcomings. AMR in Bangladesh is caused by many factors, but current evidence suggests that three of these should be given more attention. First, the ability to obtain antibiotics without a prescription and the practice of self-medication at retail pharmacies are the most immediate and widespread causes. This is because antibiotics are still easily accessible in the community, and a large number of the drugs dispensed belong to the WHO Watch group instead of the preferred Access group. Second, wrong prescriptions in clinical settings, often exacerbated by a lack of diagnostic tools and poor antimicrobial stewardship, are a major reason why people in formal healthcare settings continue to receive unnecessary broad-spectrum antibiotics. Third, the use of antibiotics in livestock and aquaculture is a major One Health amplifier of resistance. However, its effect on human clinical AMR is often less direct, occurring through food, environmental contamination, and cross-sector transmission pathways. As a result, all three drivers need to be addressed. Nevertheless, Bangladesh’s most important policy goals right now should be stricter regulations for the sale of antibiotics in communities and improved management of prescribing practices in human healthcare, along with longer-term One Health control measures in animal production9,10. Challenges and current situations The WHO has recognized AMR as 1 of the top 10 global health threats; however, it continues to receive limited public attention in Bangladesh. The Bangladesh National Antimicrobial Resistance Surveillance program launched by the Institute of Epidemiology, Disease Control hence, they dispatch antibiotics without any prescription from a registered physician. It is also an alarming problem that drug sellers often operate pharmacies without any formal training and with minimal knowledge of pharmacotherapy and medicine management12. For tackling this problem during the World Antimicrobial Awareness Week 2022, DGDA and WHO Bangladesh launched the “Red Label” campaign in order to control the misuse of antibiotics13 Bangladesh has come up with several policy responses to AMR, but they are not always put into action or shown to be effective. The red-label initiative is an important step in regulation and communication, but the official reports that are currently available mostly discuss its purpose, the baseline pharmacy survey, the feasibility assessment, the legal approval, and the packaging rollout. They do not address how it has led to fewer sales of non-prescription antibiotics, reduced use of antimicrobials, or better resistance outcomes. Through IEDCR and other similar programs, surveillance capacity has also grown. However, published studies indicate that surveillance sites are still mostly found in urban and higher-level laboratories, and that data completeness, laboratory quality, and electronic record-keeping vary widely from site to site. Also, a qualitative evaluation of Bangladesh’s National Action Plan has identified deeper problems within the country’s institutions, such as poor coordination between sectors, the absence of a national monitoring and evaluation framework, a shortage of trained workers, insufficient funding, and delays in implementation exacerbated by the COVID-19 pandemic6. These findings highlight that the main problem with governance in Bangladesh is not merely a lack of policies; it is also weak enforcement, insufficient capacity to implement policies, and a lack of evaluation to determine whether existing interventions actually change how doctors prescribe and dispense drugs. AMR in Bangladesh is not just a technical concern with standard drugs. Carbapenem resistance, which was once rare, is now gradually rising and has been confirmed in ICUs14. This indicates the loss of antibiotics that were once considered the last line. It ultimately narrows treatment options, prolongs hospital stays, increases treatment costs, and raises mortality in diseases that could previously be treated very easily with cost-effective drugs. Hospitals have reported frustrations over delays when first-line treatments fail, requiring them to wait for days to receive culture/sensitivity reports, which are often unavailable in many primary health care settings. Beyond hospitals, apparently healthy individuals are found to be silent carriers of resistant bacteria in their gut, serving as an unnoticed reservoir for spreading resistance. According to another study in 2021, Bangladesh has a high rate (98%) of local antibiotics production, making it more accessible to the general population. There is no structured antimicrobial supply chain to regulate production limits, drug quality, limited distribution, and access to the general public15. Moreover, various marketing strategies by pharmaceutical companies encourage people to take antibiotics more often, fueling AMR. The lack of awareness and proper knowledge is another contributing factor to AMR. According to a recent KAP (Knowledge, Attitude, and Practice) study in Bangladesh, 82.23% of respondents believe that antibiotics can accelerate the recovery process after fever, and 81.1% of respondents admit that they will consult another physician if antibiotics are not prescribed during the initial visit. Nearly half of the respondents (42%) still hold misconceptions about how antibiotic misuse can speed up resistance, and a similar percentage of people were unaware that increased antibiotic usage could accelerate the risk of resistance 16. While many people reported a positive attitude toward appropriate antibiotic usage, their actual practice often did not match this. These findings highlight the importance of educating the general population about AMR, irrespective of their age, gender, occupation, social status, and income16. In many hospitals, even large tertiary care centers, proper infection control measures are often not strictly followed. This increases the risk of hospital-acquired infections and often encourages doctors to prescribe antibiotics unnecessarily, adding to the burden of AMR in our country. In addition, the absence of a blood culture facility in many hospitals leads the doctors to prescribe antibiotics empirically. As a result, commonly used antibiotics such as cephalosporins are becoming increasingly resistant, which may compromise the effectiveness of treatment and pose a future threat to surgical procedures. Factors such as weak infection control practices, overcrowded wards, and limited laboratory support worsen the problem in our country. Recommendations The three key factors, i.e., human, animal, and environment, have directly influenced AMR in Bangladesh. These factors are complex and interlinked, so to adequately address AMR in Bangladesh, a comprehensive strategy along with a multifaceted empirical approach is essential. IEDCR has expanded the national AMR surveillance network in recent years, but these efforts are confined to sentinel sites, often in tertiary hospitals, with under-representation of private labs and rural areas. Therefore, only by ensuring geographic representativeness across all districts and including both public and private sector laboratories can Bangladesh reinforce its nationwide standardized AMR surveillance and data system. Further, internationally recognized standards like CLSI/EUCAST should be implemented as standardized protocols in laboratories nationwide, along with the establishment of a centralized data-sharing platform like WHONET and a structured format for data collection. Furthermore, to ensure data management quality, current paper-based practices should be transformed into electronic platforms. These can also address the need for an integrated hospital information system in Bangladesh. Moreover, enhancing diagnostic support through the expansion of rapid diagnostic facilities and the advancement of molecular diagnostics capabilities across healthcare centers can ultimately help achieve more precise surveillance. This can also facilitate the early detection of resistant strains and improve patient outcomes. Antimicrobial Stewardship Programs should be mandatory in both primary health care and hospitals (both public and private), together with sustained training of healthcare workers on updated empirical treatment guidelines. Also, the WHO AWaRe classification (Access, Watch, Reserve) should be followed as a guideline when using antibiotics. This can optimize the use of antimicrobial medicines and reduce AMR and health care-associated infections, leading to better clinical outcomes17. There is widespread and easy availability of OTC antimicrobials, leading to their irrational use without any regulation. Therefore, policies should be strictly enforced to regulate the OTC sales of antibiotics without a prescription. Although WHO Bangladesh has initiated the red label antibiotic packaging and the message “Do not use without a prescription of a registered physician” on every packaging of antibiotics to reduce misuse, this requires stronger inspection of pharmacies and penalties for non-compliance18. Recent studies have shown significant gaps and misconceptions regarding antibiotic use and AMR in Bangladesh, so community-level activities like public awareness and educational campaigns, incorporation of AMR in school curricula, mass media campaigns, and appropriate patient counseling at clinics can help in reducing the AMR burden of the country by promoting positive KAP regarding antibiotic use and AMR, as well as the importance of hygiene, vaccination, and infection prevention. Integration of One Health policies across human, animal, and environmental sectors, as recommended by WHO, involving multiple stakeholders from relevant sectors and proper coordination between them, can help tackle the emergence and spread of resistant bacteria in Bangladesh. Additionally, addressing problems such as the shortage of trained health workforce, limited financial resources, inadequate infrastructure, lack of awareness among healthcare providers, farmers, and the general population, and insufficient enforcement of regulations regarding the responsible use of antimicrobial drugs across human, aquatic, and animal health sectors can help the country reduce its burden of AMR19–21. Enhancement in research and innovation, with the collaboration of governments, pharmaceutical companies, and research institutions, as well as interdisciplinary cooperation among microbiologists, pharmacologists, epidemiologists, social scientists, and policymakers, can encourage the development of new antibiotics and vaccines, the improvement of existing treatments, and the exploration of alternatives such as bacteriophage therapy, immunomodulation, and antivirulence approaches, which can ultimately become a crucial aspect in combating antibiotic resistance, alongside surveillance and diagnostic research. Conclusion Addressing AMR in Bangladesh requires a multi-pronged approach that involves strengthening surveillance, regulating antibiotic use, and enhancing public awareness. By integrating efforts across the human, animal, and environmental sectors, and fostering collaboration among healthcare professionals, policymakers, and the general public, Bangladesh can mitigate the growing threat of AMR and safeguard public health for future generations.
Kalam et al. (2026) studied this question.