Antibiotic-resistant infections: Risks, costs

Why in the News

Infections caused by antibiotic resistant bacteria are more likely to kill hospitalised patients in India and cost more to treat than infections caused by drug susceptible strains. A surveillance study by the Indian Council of Medical Research (ICMR) records higher mortality, longer hospital stays and higher antibiotic costs where the bacteria resist carbapenems, the broad spectrum antibiotics doctors hold in reserve for serious infections. The study links laboratory resistance results to what then happened to the patient, which Indian resistance surveillance had not previously done at this scale. Most of the severe infections it recorded began inside the hospital rather than in the community. The tension it sets up is between the search for the next antibiotic and the routine work of preventing infection in the first place.

What is antimicrobial resistance?

1. Bacteria survive the drugs meant to kill them: Resistant bacteria continue to grow and reproduce in the presence of antibiotics designed to stop them. Treatment narrows to whatever the organism still responds to.
2. Resistance spreads sideways, not only down generations: Resistant bacteria pass resistance genes to their offspring. They also transfer those genes to unrelated bacteria through the exchange of DNA.
3. Carbapenem resistance closes the reserve line: Carbapenems are held back for serious infections where other antibiotics have already failed. Resistance to them leaves few effective options behind.

What did the ICMR surveillance study cover?

1. Scale and period: The ICMR antimicrobial resistance (AMR) surveillance network studied 159,336 hospitalised patients across 20 tertiary care hospitals between April 2022 and April 2025.
2. Two of the four bacteria tracked: Escherichia coli causes urinary tract infections. Klebsiella pneumoniae triggers both urinary and lung infections.
3. The other two: Acinetobacter baumannii causes ventilator associated pneumonia, bloodstream infections, wound and surgical site infections, urinary tract infections and sometimes meningitis. Pseudomonas aeruginosa causes bloodstream, eye and ear infections.
4. Resistance was the majority finding: Almost 61.1 percent of the patients studied carried infections resistant to carbapenem antibiotics.

How much does carbapenem resistance raise the risk of death?

1. Escherichia coli: 24.4 percent of patients with carbapenem resistant infections died, against 17.3 percent of those with susceptible infections. That is a 41 percent higher relative risk of death.
2. Klebsiella pneumoniae: Mortality was 31.2 percent in the resistant group against 23.5 percent in the susceptible group, a 33 percent higher relative risk.
3. Acinetobacter baumannii: Mortality was 37.9 percent against 32.8 percent, a 16 percent higher relative risk.
4. Pseudomonas aeruginosa: Mortality was 28.9 percent against 20.2 percent, a 43 percent higher relative risk.
5. Bloodstream infections carry the heaviest toll: Among patients with carbapenem resistant bloodstream infections, mortality ran from 39.3 percent for E. coli to 50.8 percent for A. baumannii. It was 44.8 percent for K. pneumoniae and 46.4 percent for P. aeruginosa.

What does resistance add to the cost of treatment?

1. Escherichia coli: Antibiotic cost averaged about Rs 39,846 per patient for resistant infections against Rs 20,034 for susceptible ones.
2. Klebsiella pneumoniae: The corresponding figures were about Rs 55,688 and Rs 47,918.
3. Acinetobacter baumannii: Treatment cost about Rs 62,150 for resistant infections against Rs 41,372 for susceptible ones.
4. Pseudomonas aeruginosa: Treatment cost about Rs 66,599 for resistant infections against Rs 48,392 for susceptible ones.
5. The costing is deliberately conservative: Only antibiotics priced under the Jan Aushadhi scheme were counted. Intensive care, bed and room charges, diagnostic investigations, procedures, supportive care and consultation were all left out, so the real burden on patients and the health system is larger.

Why does the study point to infection control rather than antibiotic overuse?

1. The severe infections began in the hospital: More than 85 percent of bloodstream infections across the four bacteria were classified as healthcare associated.
2. The named failure points are procedural: Healthcare associated transmission, invasive devices, recent surgery and gaps in infection prevention and timely diagnosis are what the study identifies. Reducing the problem to antibiotic overuse alone misplaces it.
3. Antibiotics cannot substitute for prevention: The measures named are hand hygiene, device associated infection prevention, appropriate insertion and early removal of invasive devices, environmental cleaning, surgical infection prevention and surveillance of healthcare associated infections. Prevention stops the reserve antibiotics from being needed at all.
4. Diagnostics decide whether prescribing is targeted: Timely diagnostics let a doctor identify the resistant organism and select a narrow, appropriate antibiotic. Without them, broad spectrum drugs are used by default.
5. Surveillance has to reach the patient, not stop at the isolate: Integrated surveillance connecting laboratory results with mortality and treatment outcomes is what produced these findings. Prescribing data alone would not have shown them.

What the study could not establish

1. A tertiary hospital population is not a national average: These hospitals manage referred and often critically ill patients, so the level of resistance found there cannot be read as the level in the country.
2. Key clinical variables were absent: The data carried no patient level information on how sick each patient was, how quickly appropriate treatment began, the source of the infection or the specific resistance mechanism involved.
3. The findings describe practice, not drug superiority: The results reflect real world treatment patterns in India. They do not prove that one drug is universally better than another.

Challenges to containing antimicrobial resistance in India

1. Antibiotics move without a prescription: Schedule H1 of the Drugs and Cosmetics Rules, 1945 requires a prescription and a separate sales register for named antibiotics, and compliance at the retail counter is weak. Eg. The Red Line campaign marks such medicines with a red stripe on the pack precisely because the schedule alone was not restricting sales.
   The Fix: Link Schedule H1 sales to an electronic prescription record, so the register is generated by the transaction instead of written up after it.
2. Non human antibiotic use applies constant selection pressure: Antibiotics used for growth promotion and disease prevention in poultry and aquaculture select for resistant bacteria outside any clinical setting. Eg. India banned colistin, a last resort human antibiotic, in food producing animals in 2019 after its use in poultry farming was documented.
   The Fix: Replace single drug bans with a positive list of permitted veterinary antibiotics, enforced through residue testing at the point of procurement.
3. Manufacturing effluent breeds resistance in the environment: Antibiotic residues discharged from pharmaceutical plants expose environmental bacteria to sub lethal drug concentrations, which is the condition in which resistance develops. Eg. Water bodies receiving effluent from the pharmaceutical cluster at Patancheru near Hyderabad have recorded high antibiotic concentrations.
   The Fix: Notify enforceable antibiotic residue limits for pharmaceutical effluent and make compliance a condition of the plant’s consent to operate.
4. Infection prevention has no staffing floor: Most Indian hospitals run no dedicated infection control team to conduct hand hygiene and device audits, so prevention has no one accountable for it. Eg. National Accreditation Board for Hospitals and Healthcare Providers (NABH) accreditation requires an infection control programme, and it covers a small share of India’s hospitals.
   The Fix: Make a minimum infection prevention and control staffing norm a condition of hospital empanelment under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana.
5. Diagnostic delay forces empirical prescribing: Culture and sensitivity testing capacity sits mainly in large hospitals, and results take days, so smaller facilities start broad spectrum therapy blind. Eg. Rapid molecular testing is routine for drug resistant tuberculosis under the National Tuberculosis Elimination Programme, with no equivalent programme for bacterial bloodstream infections.
   The Fix: Fund rapid molecular resistance testing at district hospital level and tie its use to the hospital’s antibiotic prescribing audit.

Conclusion

India’s resistance response has been organised around what is prescribed, because prescribing is what the system can already count. This study relocates the problem to where the infection is acquired, which is a different task with a different owner inside the hospital. The unresolved part is that prevention carries no staffing norm, no dedicated budget line and no measurable output of its own, while prescribing has a surveillance network behind it. The marker to watch is whether prevention starts being counted the way prescribing already is.

Back2Basics: Jan Aushadhi scheme

1. What it is: The Pradhan Mantri Bhartiya Janaushadhi Pariyojana supplies quality generic medicines at prices well below their branded equivalents.
2. Who runs it: It is implemented by the Department of Pharmaceuticals under the Ministry of Chemicals and Fertilizers, through the Pharmaceuticals and Medical Devices Bureau of India.
3. How it reaches patients: Medicines are sold through dedicated Janaushadhi Kendras rather than through ordinary retail pharmacies.

[2019] Which of the following are the reasons for the occurrence of multi-drug resistance in microbial pathogens in India?

1. Genetic predisposition of some people

2. Taking incorrect doses of antibiotics to cure diseases

3. Using antibiotics in livestock farming

4. Multiple chronic diseases in some people

Select the correct answer using the code given below.

(a) 1 and 2

(b) 2 and 3 only

(c) 1, 3 and 4

(d) 2, 3 and 4