Antibiotic Resistance in India Over a Decade: A Systematic Review and Meta-analysis of Clinical and Molecular Evidence (2015-2025)

Antibiotic resistance is a major global public health threat that compromises the effectiveness of antibiotic agents and increases morbidity, mortality, and health care costs. India faces a substantial AMR burden driven by high infectious disease prevalence, widespread antibiotic use, and variable surveillance capacity. This systematic review and meta-analysis aimed to synthesize evidence on antibiotic resistance patterns in India from 2015 to 2025, estimate the prevalence of resistance among major bacterial pathogens, evaluate molecular resistance determinants, and assess mortality associated with resistant infections. A systematic search of PubMed/MEDLINE, Scopus, Web of Science, Google Scholar, surveillance reports, and grey literature was conducted following PRISMA 2020 guidelines. Studies reporting antibiotic resistance data from India between January 2015 and December 2025 were included. Data extraction and quality assessment were performed independently by 2 reviewers. A random-effects meta-analysis was used to estimate the pooled prevalence of antibiotic resistance, molecular determinants of resistance, and mortality outcomes, and heterogeneity was assessed using the Cochrane Q and I 2 statistics. Forty-six studies met the inclusion criteria. The pooled prevalence of antibiotic resistance was 55.7% (95% CI: 47.4%-63.9%; I 2 =98.6%). High resistance rates were reported among major gram-negative pathogens, particularly Klebsiella pneumoniae, Escherichia coli, Acinetobacter baumannii , and Pseudomonas aeruginosa . Molecular meta-analysis demonstrated a pooled prevalence of resistance-associated genes of 64.5% (95% CI: 46.0%-83.0%), with blaNDM, blaOXA-48-like, and blaKPC being the most frequently reported determinants. Mortality associated with resistant infections was 31.0% (95% CI: 18.2%-43.8%). Substantial heterogeneity was observed across all analyses. Available evidence indicates that antibiotic resistance remains a significant health care challenge in India. High levels of multidrug resistance, widespread dissemination of carbapenemase genes, and considerable mortality associated with resistant infections underscore the need for strengthened antibiotic stewardship, standardized surveillance, expanded molecular diagnostics, and coordinated public health interventions. However, the findings should be interpreted cautiously because of substantial heterogeneity and the predominance of studies from tertiary-care settings. This review was registered with PROSPERO (CRD420261406324).