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Antimicrobial resistance (AMR) is becoming an increasingly serious challenge for healthcare in India. Infections that were once straightforward to treat can become difficult to manage when bacteria no longer respond to commonly used antibiotics. This can lead to longer hospital stays, higher treatment costs and fewer effective treatment options.
For general physicians, hospital doctors and critical care teams, antimicrobial resistance and antibiotic stewardship in India are therefore essential clinical concerns. Every prescription matters, from deciding whether an antibiotic is necessary to selecting the appropriate drug, dose and duration.
Antibiotic stewardship does not mean withholding treatment from patients who need it. It means using antibiotics rationally, protecting their effectiveness and reducing avoidable harm.
Antimicrobial resistance occurs when microorganisms develop the ability to survive medicines that would previously have controlled or eliminated them. Although resistance can affect bacteria, viruses, fungi and parasites, antibiotic stewardship specifically focuses on the responsible use of antibacterial medicines.
India faces a substantial AMR burden, particularly from resistant Gram-negative bacteria. Carbapenem resistance is a major concern because carbapenems are important antibiotics used for selected serious bacterial infections.
A multicentre study using ICMR surveillance network data from April 2022 to April 2025 examined resistant Gram-negative infections across 20 tertiary hospitals. The findings associated carbapenem-resistant infections with higher mortality and treatment costs than infections caused by susceptible organisms. These hospital-based findings should not be interpreted as national prevalence estimates, but they illustrate the clinical consequences of resistance.
India’s National Action Plan on Antimicrobial Resistance 2.0 for 2025–2029 also reinforces the importance of surveillance, infection prevention, awareness and appropriate antimicrobial use.
In January 2026, the government published draft rules proposing a conspicuous blue vertical strip on antimicrobial drug labels. The proposal was intended to improve identification and support efforts against inappropriate use. Doctors and pharmacists should check the latest official notifications to establish the current legal status of this labelling requirement.
For clinicians, the practical priority is clear: avoid unnecessary antibiotic exposure and make every indicated prescription defensible.
Antibiotic resistance develops through several mechanisms, but unnecessary and inappropriate antibiotic use creates additional selection pressure that favours resistant organisms.
Most common colds and many uncomplicated upper respiratory tract infections are viral. Antibiotics do not treat viruses and should not be prescribed simply because a patient has a sore throat, cough or fever.
The decision should be based on the likely diagnosis, clinical findings, severity and risk factors. Some respiratory presentations do require antibiotics, so clinicians must assess patients carefully rather than applying a blanket rule.
The WHO antibiotic guidance emphasises symptomatic care and avoiding antibiotics when they are not indicated.
Broad-spectrum antibiotics may be necessary for selected severe infections, but routine use when a narrower agent is appropriate can increase unnecessary exposure.
The choice should reflect the suspected infection, likely organisms, local resistance patterns, patient history and severity. A more expensive or broader-spectrum medicine is not automatically a better choice.
Fever alone does not establish a bacterial infection. Depending on the presentation, clinicians may need to consider viral illness, inflammatory conditions, malaria, dengue or other causes.
A documented working diagnosis helps explain why an antibiotic is being prescribed and what evidence would support continuing it.
Inappropriate dosing may compromise treatment or increase toxicity. Unnecessarily prolonged courses expose patients to additional risks, including adverse effects and selection for resistant organisms.
Prescriptions should follow applicable guidelines, with adjustments for factors such as renal function, age, infection severity and relevant patient characteristics.
Rational antibiotic use begins with selecting a medicine that is appropriate for the suspected infection while avoiding unnecessary antimicrobial coverage.
For common infections, clinicians should consult current national or institutional guidance. India’s ICMR resources include treatment guidelines for antimicrobial use in common syndromes and guidance on carbapenem-resistant Gram-negative infections.
Selection should account for:
For serious infections, collect appropriate microbiological samples before starting antibiotics when feasible, provided this does not delay urgent treatment.
The WHO AWaRe classification groups antibiotics into Access, Watch and Reserve categories.
Access antibiotics are preferred for many common infections when clinically appropriate. Watch antibiotics require more careful use because of their resistance potential, while Reserve antibiotics should generally be protected for selected situations involving difficult-to-treat infections.
The classification is a stewardship tool, not a substitute for clinical judgement. A Watch or Reserve antibiotic may be justified in a seriously ill patient when the clinical circumstances support its use. Conversely, an Access antibiotic is not automatically appropriate for every infection.
The objective is to choose the most suitable effective treatment, using the narrowest reasonable spectrum without compromising patient safety.
Starting antibiotics is only one part of prescribing responsibly. Clinicians should also decide when treatment needs review and what findings would justify changing or stopping it.
For hospitalised patients receiving empirical antibiotics, a review within approximately 48–72 hours is a useful stewardship checkpoint, adjusted to clinical urgency and the infection involved.
Review the working diagnosis, clinical response, microbiology results, inflammatory markers where useful and any evidence of an alternative diagnosis.
This review should answer four questions: Is a bacterial infection still likely? Is the patient improving? Do test results support the current antibiotic? Can the treatment be narrowed, changed or stopped?
De-escalation means reducing unnecessary antimicrobial coverage once more information becomes available.
For example, if a culture identifies a susceptible organism and the patient is improving, treatment may be narrowed to a more targeted antibiotic. If investigations and the clinical course make a bacterial infection unlikely, stopping empirical antibiotics may be appropriate.
De-escalation should not be automatic. Consider sample quality, infection site, clinical stability, possible mixed infections and whether the available results adequately explain the patient’s condition.
Antibiotic duration depends on the infection, drug, response to treatment and patient-specific factors. Some infections require short courses, while others need longer treatment because of complications or particular anatomical sites.
Avoid extending treatment solely because symptoms have not disappeared completely. Equally, do not shorten treatment below an evidence-supported duration without a clinical rationale.
Document the intended duration and review point when prescribing, particularly in hospital settings.
Antibiotic stewardship is possible even in clinics without a dedicated infectious disease team. A few consistent practices can improve prescribing quality.
Before prescribing, document the suspected diagnosis, whether antibiotics are indicated, the chosen medicine, dose, route and planned duration. Record relevant allergies and consider whether cultures or other investigations are needed.
Patients may expect antibiotics for every fever or respiratory infection. Explain when antibiotics are unlikely to help, what symptom-relief measures are appropriate and which warning signs require reassessment.
Clear communication can reduce pressure to prescribe unnecessarily while maintaining patient confidence.
Hand hygiene, appropriate cleaning, safe injection practices, sterilisation where indicated and infection-control procedures reduce the spread of resistant organisms.
Vaccination, timely diagnosis and appropriate isolation precautions also contribute to reducing infections and the need for antibiotics.
Clinics and hospitals can periodically review antibiotic prescriptions, common diagnoses, treatment duration and use of broad-spectrum agents. Larger facilities may develop formal antimicrobial stewardship teams involving clinicians, microbiologists, pharmacists and infection-control professionals.
Even a small audit followed by feedback can identify repeated prescribing problems and opportunities for improvement.
Antibiotic stewardship is the coordinated effort to improve antibiotic use by selecting appropriate treatment, dose, route and duration while reducing unnecessary exposure and avoidable harm.
Assess the likely diagnosis, avoid antibiotics for uncomplicated viral illnesses, follow current prescribing guidance, use cultures when indicated, explain decisions to patients and review treatment when new information becomes available.
Resistance patterns vary by organism, infection and location. Carbapenem resistance among Gram-negative bacteria, including organisms such as Klebsiella pneumoniae and Acinetobacter baumannii, is a major concern in Indian hospital settings. Local surveillance should guide treatment decisions.
A draft notification published in January 2026 proposed a blue vertical strip on antimicrobial drug labels. Clinicians and dispensers should check the latest official notification to confirm whether the proposal has been finalised and what requirements currently apply.
Review the diagnosis, clinical response and microbiology results. If evidence supports a narrower effective antibiotic, change treatment accordingly. If bacterial infection becomes unlikely, consider stopping treatment when clinically justified.
Antimicrobial resistance is a serious challenge for Indian healthcare, but rational prescribing, infection prevention and consistent treatment review can help reduce avoidable antibiotic exposure.
Every clinician has a role in antibiotic stewardship: prescribe only when indicated, choose an appropriate agent, use evidence-based durations and reassess treatment as new information emerges.
Doctors seeking additional knowledge in infection management may explore the Fellowship and Certificate in Infectious Diseases and the Fellowship and Certificate in Critical Care Medicine offered by Virtued Academy International. Review each programme’s curriculum, eligibility and clinical training details to determine its relevance to your professional goals.
