OPINION | India's Antibiotic 'Chaos': Why The Country Needs An Integrated Roadmap

By: Samriddhi S Gupte and Amanjeet Singh

A leading private hospital in Hyderabad took a pioneering step a few years ago to combat the growing threat of antibiotic resistance. Every prescription for this last-resort antibiotic designed to fight the most dangerous bacterial infections required approval from the hospital's antimicrobial stewardship committee. Pharmacists audited every request. Data was tracked in real-time. This controlled approach worked well to prevent antimicrobial resistance while ensuring effective patient care. 

Eventually, the patent of this life-saving antibiotic expired, generics flooded the market, and suddenly this precious weapon against drug-resistant bacteria was available at any pharmacy across India. No prescription audits. No coordinated monitoring. The predictable happened: resistance rates began climbing, and another antibiotic started losing its effectiveness.

This alarming trend has caught the attention of many stakeholders. In a recent letter to the Drugs Controller General of India, the AMR Declaration Trust warned that "one of the most potent antibiotics currently available in our armamentarium is rapidly losing its efficacy due to extensive, irrational, and uncontrolled use." The urgent plea highlights a flaw: while regulatory authorities license these life-saving drugs, they provide no clear pathways to prevent their misuse.

This story isn’t just about a single drug. It captures the core problem with India’s approach to antibiotic stewardship: fragmented systems, lack of coordination, and minimal regulation around how these crucial medicines are introduced and used.

Recent work by the Max Institute of Healthcare Management at the Indian School of Business highlights a troubling reality: India lacks a coherent national framework for introducing new antibiotics. While states like Kerala have developed sophisticated antimicrobial resistance action plans, many other states are just beginning to draft theirs. The result? A patchwork system where life-saving drugs may be meticulously managed in one state while being misused in another.

The contrast couldn't be starker. When Bedaquiline—a tuberculosis drug—was introduced in 2016, it was done through India's well-established National TB Elimination Program. Every prescription was tracked, every patient monitored, resistance rates stayed below 5%. The program worked because it had central coordination, dedicated resources, and clear accountability structures.

On the other hand, when another critical last-resort antibiotic entered the market, it was left to individual hospitals and market forces to determine how it would be used. As noted in a letter to DCGI, "While DCGI has licensed the drug, it has only provided indications for use. There are no clear-cut pathways laid out, and there is nothing to deter mis-prescriptions." 

Recent consultations by the Indian School of Business across Kerala, Telangana, and Punjab reveal how different states are grappling with this challenge in isolation. Kerala, with its ‘Antibiotic Smart Hospitals’ initiative, wants to restrict new antibiotics to government facilities only. Telangana prefers a hybrid model involving select private hospitals. Punjab advocates for a hub-and-spoke system where larger hospitals mentor smaller ones.

The Price of Inaction

The stakes couldn't be higher. Antimicrobial resistance already kills 300,000 Indians annually, more than many diseases that receive far greater attention and resources. Between 1999 and 2014, only 12 of 25 new antibiotics developed globally were made available in more than ten low- and middle-income countries. Pharmaceutical companies are reluctant to introduce new drugs in markets like India, fearing that misuse will quickly render them ineffective.

This creates a vicious cycle: the countries that need new antibiotics most are the least likely to get them, precisely because they lack the systems to use them responsibly.

Our TANDEM-ABX research points toward a solution: a phased, coordinated approach that links access to stewardship from day one. This isn't just about managing drugs—it's about building the institutional capacity to responsibly handle the medical breakthroughs of the future.

(Samriddhi S Gupte is senior researcher and Amanjeet Singh is senior manager at the Max Institute of Healthcare Management at the Indian School of Business. This analysis is based on the TANDEM-ABX research project, a collaboration between the Max Institute of Healthcare Management and the International Centre for Antimicrobial Resistance Solutions, which conducted comprehensive consultations across Kerala, Telangana, and Punjab to develop sustainable antibiotic introduction frameworks)

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