Antibiotic use for medically attended febrile illnesses in an urban cohort in South India

Antimicrobial resistance (AMR) is a significant global health threat, driven by increasing antibiotic use, particularly in low- and middle-income countries (LMICs). In India, febrile illnesses are often treated empirically with antibiotics; however, community-level data on prescribing patterns are limited. We analysed data collected from January to December 2024 from a prospective, community-based surveillance conducted as part of the Vellore Typhoid Vaccine Impact Trial, which followed 72,076 individuals aged 1–30 years across 30 urban wards in Vellore, South India. Febrile episodes were identified through a stimulated passive surveillance system integrated with the cluster-randomized vaccine trial. Information related to healthcare visits, prescriptions, laboratory investigations, and physician-confirmed diagnoses was documented. Antibiotics were classified using the Anatomical Therapeutic Chemical (ATC) Classification for systemic use (ATC code J01) and WHO AWaRe framework. Incidence rates of antibiotic-treated medically attended febrile illnesses (MAFI) and prescribing patterns were analysed by age, gender, diagnosis, facility type, and admission status. Among 17,487 MAFI episodes (incidence: 248.10; 95% CI: 244.45–251.80 per 1,000 person-years), 8,490 (48.55%; 95% CI: 47.81–49.29) received antibiotics (incidence: 120.45; 95% CI: 117.91–123.04 per 1,000 person-years). Antibiotic use was higher in private facilities (51.55%; 95% CI: 50.70–52.40) than in public facilities (38.76%; 95% CI: 37.27–40.27), and in inpatients (84.53%; 95% CI: 82.01–86.76) compared to outpatients (46.53%; 95% CI: 45.77–47.29). The most prescribed classes were penicillins (34.22%), third-generation cephalosporins (26.08%) and macrolides and lincosamides (22.05%). Overall, 55.47% of antibiotics were from the Watch group, 44.46% from Access, and < 1% from Reserve. Nearly half of MAFI episodes were treated with antibiotics, predominantly broad-spectrum agents from the WHO Watch category. These findings highlight the urgent need to strengthen point-of-care diagnostics to mitigate the growing threat of antimicrobial resistance in urban India. Not applicable.