Combating antimicrobial resistance in India: Challenges, progress, and the path forward with a One Health approach

Antimicrobial resistance (AMR) poses an urgent public health threat worldwide, and India is no exception, with an estimated 290,000 deaths annually attributed to AMR-related infections.[1,2] This crisis is exacerbated by the rapid rise in antimicrobial resistance across human, animal, and environmental health sectors.[3,4] Key pathogens, such as Escherichia coli, Klebsiella pneumoniae, Acinetobacter, and Staphylococcus aureus, have developed resistance to multiple affordable antibiotics, including carbapenems and extended-spectrum beta-lactamase-producing strains, which limit treatment options and contribute to escalating healthcare costs.[5] The AMR situation in India is driven by several interconnected factors.[6] The overuse and misuse of antibiotics in human medicine and agriculture, coupled with inadequate infection prevention and control (IPC) measures, have facilitated the proliferation of resistant pathogens.[6] In informal and rural sectors, weak regulatory enforcement allows antibiotics to be sold over the counter without prescriptions, contributing to irrational drug use.[6] The use of antibiotics as growth promoters in livestock farming further exacerbates the spread of resistance, creating a cross-sectoral challenge.[6] Moreover, India’s surveillance systems for monitoring AMR are fragmented, making it difficult to track resistance trends comprehensively.[7] In response to the growing AMR threat, India launched the National Action Plan on AMR (NAP-AMR) in 2017–2021, which aligned with the World Health Organization’s (WHO) Global Action Plan.[8] The NAP-AMR aimed to address AMR through a comprehensive framework that spans human, animal, and environmental health sectors, focusing on key areas such as awareness, surveillance, infection prevention, rational antimicrobial use, research, and international collaboration.[4] Several initiatives have been implemented, including the establishment of the AMR Surveillance Research Network (AMRSN) by the Indian Council of Medical Research as well as the National Antimicrobial Resistance Network coordinated by the National Centre for Disease Control to track resistance patterns and promote data-sharing.[9] Public awareness campaigns like the “Red Line Campaign” and “Superheroes Against Superbugs” have raised awareness about the dangers of antibiotic misuse.[9] Additionally, Kerala’s Antimicrobial Resistance Strategic Action Plan (KARSAP) has successfully integrated AMR management within the healthcare system through a One Health approach.[9] AMR poses significant challenges across various strategic priorities outlined in the NAP-AMR. These include weak regulatory enforcement, inadequate infection control measures, insufficient funding, and limited political commitment, compounded by fragmented surveillance systems that primarily focus on human health.[10,11] Weak oversight of pharmaceutical marketing and financial incentives for overprescription further exacerbate the problem.[10] Surveillance systems lack integration with data from animal and environmental sectors, whereas limited laboratory capacity and inadequate data-sharing mechanisms hinder effective monitoring.[12] IPC measures in public healthcare facilities are often insufficient, and poor water, sanitation, and hygiene infrastructure in community settings further elevates infection risks.[12] The over-the-counter availability of antibiotics, combined with weak regulatory enforcement and the absence of comprehensive antimicrobial stewardship programs, contributes to irrational antibiotic use.[13] Moreover, low economic incentives have led to limited investment in research and development for new antibiotics, diagnostics, and alternative therapies.[11] Inconsistent implementation of AMR policies across states and inadequate capacity of subnational governments to enforce them impede progress.[12] Finally, insufficient international collaboration limits India’s ability to effectively address AMR on a global scale.[8] Despite these challenges, there are numerous opportunities to address AMR effectively. Enhancing awareness through existing communication frameworks and integrating AMR education into school curricula and professional training can promote responsible antibiotic use.[14] Community-based initiatives, such as “Superheroes Against Superbugs,” can foster behavior change.[14] Expanding the AMRSN to include a One Health approach and leveraging artificial intelligence and big data analytics can improve tracking and predictive modeling of resistance patterns.[9] Strengthening laboratory infrastructure and fostering integrated data-sharing mechanisms will enable timely interventions.[15] Evidence-based IPC practices, expanded vaccination coverage, and regulated antibiotic disposal can reduce infections and mitigate environmental contamination.[13] Digital tools like e-prescription systems and robust antimicrobial stewardship programs can optimize antibiotic use, whereas restricting antibiotics as growth promoters in animal husbandry will address misuse in agriculture.[8] Public-private partnerships, increased government funding, and collaborations with organizations like WHO and the Global Antibiotic Research & Development Partnership can drive innovation in AMR-related research.[9] State-specific action plans, such as the KARSAP, can serve as models for tailored local responses.[14] Strengthening subnational capacities and leveraging India’s role in global forums, such as the Global Health Security Agenda, can enhance international collaboration and ensure consistent policy implementation across the country.[14] AMR is a critical public health issue in India, impacting healthcare, agriculture, and the environment sectors. While initiatives like the NAP-AMR and KARSAP have made progress, challenges remain, particularly in regulatory enforcement, surveillance, and antimicrobial stewardship. To combat AMR, India needs a comprehensive approach addressing root causes and gaps in surveillance, antimicrobial use, public awareness, infection control, and research. Strengthening enforcement, optimizing antimicrobial use, and fostering innovation in antibiotics and diagnostics are key priorities. Despite the existence of the National One Health Mission, the implementation of a One Health approach, integrating human, animal, and environmental health sectors, remains a significant challenge. A robust One Health approach will be crucial for the long-term success of AMR containment. By aligning with the NAP-AMR and focusing on these priorities, India can build a sustainable framework to reduce AMR’s public health burden and ensure lasting progress. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.