A Review on Current Antibiotic Resistance Trends of Uropathogens in India, A Survey from Urology Department 2020 – 2025

Abstract

A urinary tract infection is a bacterial infection in any part of the urinary system. UTIs range from uncomplicated lower urinary tract infections to complicated infections-which include pyelonephritis and urosepsis-and catheter-associated UTIs. It affects all ages and sex, though distribution varies by population subgroup including venerable population, for example, pregnant women, paediatrics, elderly. AMR heightens the treatment failure rate, recurrence, hospital length of stay, cost, and mortality, especially when first-line agents fail and reserve drugs are necessitated. WHO and Lancet analyses have documented that globally, AMR in UTIs is a critical concern; in high-burden LMICs, India also depicts a high prevalence of resistant Gram-negative Uropathogens and considerable inter-regional variability. Empiric oral therapy for uncomplicated cystitis should favour nitrofurantoin or fosfomycin where local susceptibility supports this. Fluoroquinolones should be de-emphasized for empiric community UTI in many regions. Increase in CRKP increases dependence on combination/last-line agents in severe infection; provides additional support for stewardship, infection control, and routine molecular epidemiology in tertiary settings. We anticipate a further?increase in the production of ESBLs, continued rise of carbapenem resistance in Enterobacterales, increase in fluoroquinone resistance and significant regional variation all stressing the urgency for coordinated national efforts to support surveillance systems, promote antimicrobial stewardship, expand rapid diagnostic testing and reinforce infection control measures.

Keywords

Introduction

Multidrug-Resistant (MDR), Extensively Drug-Resistant (XDR), and Pan-Drug-Resistant (PDR) Uropathogens

Definition and Clinical Importance:

MDR is defined as the resistance of an isolate to at least one antimicrobial agent in three or more antimicrobial categories. XDR strains are those that are non-susceptible to all but one or two antimicrobial categories, leaving clinicians with very limited therapeutic options. The most extreme end of the spectrum is represented by pan-drug-resistant (PDR) pathogens, which are non-susceptible to all available antimicrobial classes, including the last-resort drugs, leaving treatment virtually ineffective.

MDR, XDR, and PDR organisms that cause UTIs have also become a significant clinical and public health concern. These pathogens contribute to higher rates of treatment failure due to the scarcity of effective empiric therapies and are associated with increased morbidity, lengthened stays in hospitals, and greater healthcare utilisation-particularly in an ICU and catheter-associated environment. Management often requires the use of last-line agents such as colistin and tigecycline, which carry risks of nephrotoxicity and other side effects. The lack of reliable oral treatment options further complicates outpatient care and increases the risk of recurrence, pyelonephritis, sepsis, and urosepsis. Given the high burden of UTIs in India, the spread of MDR and XDR strains points to an imperative need for enhanced surveillance, antimicrobial stewardship, and infection-control practices. (2)

Recent Indian Surveillance Data:

The consistent upward trend in MDR prevalence among uropathogens has been highlighted by the different Indian surveillance networks, including the ICMR-AMRSN and several other multicentre tertiary-care studies. The major urinary isolates like Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii showed an increasing resistance pattern in many regions. Hospital and ICU isolates had very high rates of MDR, with prevalence rates as high as 50–70% in some centres among gram-negative Uropathogens.

The emergence of XDR clusters, including carbapenem-resistant Enterobacterales such as carbapenem-resistant K. pneumoniae, confers additional complexity to the therapeutic decisions. Though uncommon, PDR organisms have been recognized in high-risk units like ICUs and transplant wards and settings associated with long-term catheterisation. Clinicians are increasingly forced to consider last-line agents like colistin, polymyxin B, fosfomycin, and tigecycline despite their limitations in pharmacokinetics and toxicities. Overall, these trends suggest a transition from community-acquired, generally susceptible strains to hospital-driven reservoirs of extremely resistant MDR/XDR organisms. These call for continuous surveillance at the national level. (5) (18)

Hospital vs Community Isolates:

A clear difference exists between community-acquired versus hospital-acquired urinary isolates. Community strains-particularly E. coli-have traditionally exhibited lower rates of MDR, with many still susceptible to agents such as nitrofurantoin, fosfomycin, and pivmecillinam. Community resistance is slowly rising, however, owing to factors such as irrational outpatient antibiotic consumption, over-the-counter availability of antibiotics, and non-compliance. In contrast, hospital and particularly ICU isolates exhibit much higher rates of MDR and XDR, especially among those who are catheterised or critically ill. This pattern is promoted by prolonged hospital stay, prior exposure to antibiotics, indwelling catheters, immunocompromised states, and biofilm formation related to various devices. Common hospital organisms include ESBL-producing Enterobacterales, carbapenem-resistant strains, and highly resistant Pseudomonas and Acinetobacter species. These differences have important implications for empirical therapy. While community-acquired UTIs can often be managed with narrower-spectrum oral antibiotics, hospital-acquired infections typically require broader empirical coverage informed by local antibiograms. Distinguishing between community and hospital onset is thus of utmost importance to avoid under-treatment and unnecessary broad-spectrum antibiotic use. (10) (13)

RISK FACTORS CONTRIBUTING TO RESISTANCE:

Empirical and Inappropriate Antibiotic Use:

High outpatient antibiotic consumption, especially excessive or inappropriate use of broad-spectrum agents such as fluoroquinolones and third-generation cephalosporins, significantly contributes to AMR in both the community and hospital settings. In many regions, antibiotics are initiated empirically without microbiological testing because of diagnostic uncertainty, lack of access to rapid culture facilities, or pressure to provide immediate symptom relief. Once initiated, therapy is often not adjusted ("no de-escalation") even after culture results become available, thereby prolonging exposure to broad-spectrum agents.

Indeed, local prescribing patterns are repeatedly linked to resistance trends: fluoroquinolone use and fluoroquinolone-resistant E. coli are higher in those communities, while carbapenem use is associated with rising carbapenem-resistant Enterobacterales (CRE) in hospitals. Additional contributing factors include the virtual lack of Antimicrobial Stewardship Programs (ASPs), grossly inadequate clinician training on rational prescribing, and time constraints in busy outpatient departments. Together, these practices create selective pressure driving the proliferation of MDR pathogens. (28) (29)

Self-Medication and OTC Sales:

Self-medication is prevalent in parts of India and other LMICs. The patients frequently buy antibiotics without prescription for symptoms such as fever, dysuria, or upper respiratory infections, which are often viral or self-limiting. Easy OTC availability, low cost, and perception of antibiotics as “quick cures” fuel this behaviour.

Incomplete or incorrect dosing means taking antibiotics for a period considered too short, using leftover tablets, or sharing medications. All these create subtherapeutic exposure, which accelerates the selection of resistance. While national regulations such as Schedule H1 attempt to restrict over-the-counter sales of critical antibiotics, the enforcement is not uniform. Variability in pharmacy oversight, economic dependency on antibiotic sales, and uneven state-level monitoring result in continued access in many areas without restriction. Consequently, self-medication remains one of the key yet preventable drivers of AMR. (30) (31)

Hospital-Acquired Infections and Catheter Use:

Healthcare settings, especially tertiary-care hospitals and ICUs, represent high-risk environments for the emergence and transmission of MDR organisms. An indwelling urinary catheter is one of the major risk factors for CAUTIs. The formation of biofilms on the surface of catheters protects bacteria from both antibiotics and the host immune responses, thus promoting resistance development.

Prolonged hospitalization, mechanical ventilation, immunosuppression, and invasive procedures further increase exposure to hospital-acquired pathogens such as ESBL-producing E. coli, Klebsiella spp., and CRE. In particular, patients in the ICU are often exposed to multiple courses of broad-spectrum antibiotics, enhancing the selective pressure.

A catheter care bundle that includes sterile insertion techniques, daily review of the necessity of catheters and closed drainage systems, and early removal reduces rates of CAUTIs significantly. Hand hygiene adherence and robust infection prevention and control programs are required to disrupt the chain of transmission. (2)

Environmental and Socioeconomic Influences:

Environmental factors also play a critical role in the amplification and spread of AMR. Antibiotic residues from pharmaceutical manufacturing, hospital effluents, and agricultural runoff contaminate water bodies and soil, creating “hotspots” where resistant strains and resistance genes proliferate. Poor sanitation infrastructure facilitates fecal–oral transmission of resistant pathogens, particularly in densely populated urban settlements.

Socioeconomic disparities influence health-seeking behavior: a lack of access to trained practitioners means that communities rely on informal providers who often prescribe antibiotics inappropriately. Overcrowding, inadequate waste disposal, and irregular clean water supply further facilitate the spread of MDR organisms. With the interconnectedness of human, animal, and environmental health, a strategy toward controlling AMR should include integrated surveillance, policy, and intervention in the three domains. This encompasses enhancing wastewater management, regulation of antibiotic use in livestock, improving sanitation, and raising public awareness.  (2) (30)

IMPACT ON CLINICAL OUTCOMES AND HEALTHCARE BURDEN:

Treatment Failures and Recurrence:

Antimicrobial resistance greatly reduces the efficacy of standard therapies for UTIs. In cases of failure of first-line empirical regimens—mostly because of ESBL–producing Enterobacterales or carbapenem-resistant strains—patients need to be escalated to second-line or parenteral antibiotics. This not only complicates the treatment but also delays clinical recovery and increases the risk of drug toxicities and nosocomial infections.

Recurrent UTIs are more common in the face of resistant pathogens. Persistent colonization, inadequate eradication of the organism, and the formation of biofilms contribute to multiple relapse episodes. These repeated infections create a cyclical burden leading to repeated antibiotic exposure, which further fuels the development and spread of resistance.

Adverse outcomes are disproportionately worse for certain populations. Pregnant women are at increased risk for pyelonephritis and adverse maternal-foetal complications; paediatric patients may experience impaired growth and renal scarring; while elderly patients—particularly those with catheters or co-morbidities—have higher rates of bacteraemia and non-response to treatment. Overall, resistance changes what is generally an easily treatable infection into a persistent, often recurrent clinical problem. (32)

Duration Of Hospital Stay and Costs:

MDR UTIs directly translate to prolonged hospitalization and increased healthcare resource utilization. Patients infected with resistant pathogens often require admission for intravenous therapy, intensive monitoring, and additional diagnostic procedures. Higher rates of intensive care unit (ICU) transfer are observed, particularly when infections progress to complicated pyelonephritis or urosepsis.

The financial consequences are significant: increased direct medical costs through extended inpatient care, expensive broad-spectrum antibiotics, laboratory monitoring, and specialist consultations. The indirect costs of lost productivity, caregiver burden, and long-term complications further increase the societal impact.

Evidence from Indian cost-of-illness studies shows that MDR UTIs incur significantly higher per-patient costs than susceptible infections, a trend mirrored worldwide. These economic burdens not only stress tertiary care hospitals but also impact public health systems already struggling with high infectious disease loads. (6)

Data On Morbidity and Mortality:

The morbidity associated with resistant UTIs extends well beyond lower tract symptoms. As resistance limits effective antimicrobial therapy, the same infections tend to progress more readily into severe forms such as acute pyelonephritis, emphysematous UTI, and urosepsis. These clinical conditions are linked to substantial organ dysfunction, such as acute kidney injury, septic shock, and multi-organ failure.

Mortality rates sharply rise in cases caused by MDR Gram-negative organisms, especially Klebsiella pneumoniae, Escherichia coli, and Pseudomonas aeruginosa. Global AMR burden estimates rank UTIs among the leading contributors to resistance-associated mortality, with Gram-negative pathogens responsible for a significant proportion of deaths. Of particular concern is the rising prevalence of carbapenem resistance, which leaves clinicians with limited and often toxic last-resort treatment options. Poor access to advanced diagnostics or timely care in low- and middle-income countries further elevates mortality risk. Thus, resistant UTIs are a critical public health threat, impacting morbidity, quality of life, and survival outcomes. (6) (2)

Current Guidelines and Stewardship Practices In India:

India’s response to antimicrobial resistance is now anchored in a mix of national policy instruments, surveillance platforms, and hospital-level stewardship initiatives. The evolution from the first National Action Plan on AMR (2017–2021) to the recently launched NAP-AMR 2.0 has gradually strengthened the policy–practice continuum, with explicit links to state action plans, national surveillance networks (ICMR-AMRSN, NCDC), and hospital Antibiotic Stewardship Programmes (ASPs). (30) (33)

National Antimicrobial Resistance Action Plan (NAP-AMR) and Updates:

India’s first National Action Plan on Antimicrobial Resistance (NAP-AMR 2017–2021) provided the overarching policy framework for tackling AMR in line with the WHO Global Action Plan. It articulated six strategic priorities: improving awareness and understanding of AMR; strengthening knowledge and evidence through surveillance; reducing infection incidence via effective infection prevention and control (IPC); optimising antimicrobial use in human and animal health; promoting research and innovation; and ensuring strong leadership, intersectoral coordination and funding. (33) (34) (35) A key feature was its explicit One-Health orientation, linking human health, veterinary and food sectors, environment, and agriculture through a multi-stakeholder governance mechanism under the Ministry of Health and Family Welfare.

Operationalisation of the national plan has been driven through State Action Plans for Containment of Antimicrobial Resistance (SAPCARs). States such as Kerala (KARSAP), Madhya Pradesh (MP-SAPCAR) and Delhi (SAP-CARD) have developed their own AMR strategic plans and surveillance networks, which serve as sub-national platforms for stewardship interventions, statutory regulation (e.g. Schedule H1 enforcement), and integration of antibiogram data into clinical decision-making and essential drug lists. (36)(37) These state-level initiatives are particularly important for urinary tract infections, as they influence empirical prescribing norms in public hospitals and guide procurement policies for key UTI antibiotics.

Building on the experience and gaps identified during the first plan, the Government has now adopted NAP-AMR 2.0 (2025–2029). The second plan emphasises consolidation and scale-up rather than de-novo pilot initiatives: expanding functional microbiology and AMR surveillance capacity beyond tertiary centres to district and sub-district hospitals; strengthening ASPs and IPC programmes; standardising methodologies for knowledge, attitude and practice (KAP) assessments; and improving data sharing between human, animal and environmental sectors.  For common community infections like UTIs, NAP-AMR 2.0 underlines rational outpatient prescribing, restricted OTC antibiotic sales, and wider dissemination of context-specific treatment guidelines as key levers to curb resistance. (30)(38)(39)

Hospital Antibiotic Stewardship Programmes (ASPs):

At the hospital level, Antibiotic Stewardship Programmes (ASPs) have emerged as the principal implementation arm of national AMR policy. Many tertiary-care hospitals, especially those that are part of the ICMR Antimicrobial Resistance Surveillance and Research Network (AMRSN) or the National AMR surveillance network coordinated by NCDC, have established formal ASPs. These typically involve multidisciplinary teams comprising microbiologists, infectious disease physicians (where available), clinical pharmacists, nursing staff and hospital administrators. Their core activities include development of hospital-specific antibiotic policies informed by local antibiograms, formulary restriction and pre-authorisation for reserve drugs (e.g. carbapenems, colistin), prospective audit and feedback on prescriptions, dose optimisation including renal dose adjustments, IV-to-oral switch policies, and regular clinician education.

Nevertheless, ASP coverage and intensity remain highly variable across the country. Many secondary-level and smaller private hospitals lack on-site microbiology laboratories, infectious disease specialists, or clinical pharmacists, resulting in empirical and often broad-spectrum antibiotic use for UTIs without reference to local resistance data. Resource constraints, competing clinical workloads, limited electronic health record systems, and inadequate administrative prioritisation further hinder systematic stewardship implementation. Recognising these gaps, ICMR has initiated efforts to extend ASP and infection prevention and control (IPC) interventions to secondary-care settings through hub-and-spoke models, capacity-building initiatives, and targeted calls for implementation research.  In the context of urology and nephrology services, ASPs that integrate catheter-associated UTI (CAUTI) bundles, stringent indications for urine cultures, and step-down or de-escalation guided by culture reports are particularly critical to reducing the selection pressure that drives MDR Uropathogens.(9) (40)

Rational prescribing and surveillance networks (ICMR-AMRSN, NCDC):

Rational antibiotic prescribing in India is increasingly being supported by robust national surveillance platforms. The ICMR-AMRSN, initiated in 2013, now includes a network of tertiary-care hospitals generating standardised data on resistance trends in priority pathogens from key specimen types, including urine.  Annual AMRSN reports and hospital antibiograms derived from this network are used to update empirical treatment recommendations, inform national and institutional antibiotic policies, and identify “hot-spot” organisms such as ESBL-producing Enterobacterales and carbapenem-resistant Gram-negative bacilli that complicate UTI management.

In parallel, the National Centre for Disease Control (NCDC) coordinates the National Programme on AMR Containment and serves as India’s national coordinating centre for the WHO Global Antimicrobial Resistance Surveillance System (GLASS). India enrolled in GLASS in 2017–2018, and since then NCDC has been compiling and uploading national AMR data—largely derived from a sentinel network of public sector laboratories—onto the GLASS platform each year.  These surveillance systems use tools such as WHONET for data management and incorporate external quality assurance mechanisms, thereby enhancing the reliability and comparability of resistance data across regions.

Together, ICMR-AMRSN and the NCDC-led national network provide the empirical foundation for data-driven prescribing in UTIs. Their outputs support the revision of standard treatment guidelines, state and hospital-level antibiotic policies, and essential medicines lists, while also feeding into global assessments of AMR burden and trends. For clinicians, access to regularly updated antibiograms allows more nuanced empirical choices (for example, avoiding fluoroquinolones or third-generation cephalosporins in regions with high resistance and preferring nitrofurantoin or fosfomycin for uncomplicated cystitis where susceptibility remains preserved), thereby aligning individual patient care with national stewardship priorities. (8) (9)

Emerging Therapeutic Options and Preventive Strategies:

Newer antimicrobials and combination therapies:

Novel combinations of BL/BLI and optimized aminoglycoside regimens have expanded the therapeutic options against MDR Gram-negative uropathogens, especially ESBL- and certain carbapenemase-producing strains. Agents such as ceftazidime–avibactam, ceftolozane–tazobactam, and meropenem–vaborbactam show improved activity against resistant Enterobacterales and Pseudomonas aeruginosa due to the inhibition of key β-lactamases and restoration of the activity of the partner β-lactams. In turn, novel dosing strategies for aminoglycosides (for example, extended-interval or once-daily high-dose regimen driven by pharmacokinetic/pharmacodynamic considerations) maximize bacterial kill while limiting nephrotoxicity, particularly when used as part of combination regimens.

Combination therapies, such as a carbapenem plus an aminoglycoside or a BL/BLI plus colistin or fosfomycin, are often used in severe infections caused by XDR or carbapenem-resistant organisms, with a view to achieving synergy and preventing further emergence of resistance. However, the high cost of these newer molecules and limited availability outside tertiary centers, coupled with the need for stewardship, severely restrict their widespread use in low- and middle-income settings like India. (41)

Phage Therapy and Non-Antibiotic Approaches:

Phage therapy has re-emerged as a possible adjuvant or alternative to antibiotics for MDR urinary pathogens. Bacteriophages are viruses that infect only bacteria and can be prepared either as single phage’s or cocktails acting on Uropathogens like MDR E. coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Their ability to lyse bacteria, including those embedded in biofilms on catheters or in the uroepithelium, makes them appealing for complicated and recurrent UTIs where conventional agents fail. Early-phase clinical experiences and case series have been described, many published via platforms such as ScienceDirect, indicating clinical benefit in selected, but often compassionate-use, scenarios, though standardized dosing, regulatory pathways, and large randomized trials remain highly lacking.

Parallel to this, bacteriocins and AMPs are being explored as novel non-traditional antibacterials. These bacteria-derived or synthetically engineered molecules interfere with bacterial cell membrane integrity, inhibit cell wall synthesis, or modulate host immune response. Their broad mechanistic diversity and lower cross-resistance with conventional antibiotics raise their potential against MDR uropathogens. However, instability in biological fluids, toxicity, delivery of active compounds into the urinary tract, and high cost of production remain key translational challenges. These novel non-antibiotic strategies presently represent promising but largely investigational adjuncts rather than established standard therapy. (42)

Probiotics, vaccines, and preventive measures:

Modulation of genitourinary and gut microbiota using probiotics is a potentially complementary preventive strategy against recurrent UTIs, especially in women. Probiotic preparations that include Lactobacillus strains aim at reconstituting protective vaginal and intestinal flora, thereby reducing the uropathogenic E. coli colonization and risk of ascending infection. Several clinical trials have reported reductions in recurrence, but heterogeneity in strains, formulations, and designs means that these studies are not yet definitive and standardized recommendations are still evolving. Vaccine approaches, such as oral immunostimulants derived from bacterial lysates of uropathogenic E. coli and parenteral vaccines tested in experimental settings, targeting key virulence factors of E. coli, have shown promise in reducing recurrence rates but need large, good-quality randomized, controlled trials to definitively establish efficacy, optimal schedules, and long-term safety.

While these biologic strategies continue to evolve, timely and inexpensive prevention interventions are necessary. Stringent catheter care bundles—aseptic insertion, closed drainage systems, maintenance protocols, and prompt removal of unnecessary catheters—are critical in preventing catheter-associated UTIs and the selection of MDR organisms. Hand hygiene promotion, adequate hydration, appropriate perineal hygiene, and avoidance of unnecessary antibiotic prescriptions are paramount in hospital and community settings. Public and patient education is critical in this respect through the emphasis on the risks of self-prescribing of antibiotics, incomplete antibiotic courses, and over-the-counter antibiotic use, both to reduce the incidences of infection and slow the emergence of resistance, especially in high-burden countries. (2)

Role of rapid diagnostics in resistance control:

RDTs for pathogen identification and AST are the key to better management of MDR UTIs. Standard culture-based techniques require 24 to 72 hours, a time in which patients are commonly treated empirically with broad-spectrum agents. New technologies, from automated microfluidic AST platforms to nucleic-acid amplification tests, MALDI-TOF mass spectrometry-based identification, and multiplex PCR panels, can significantly shorten turnaround times. A few point-of-care systems have the ability to yield organism identification along with targeted susceptibility information in about 45 to 60 minutes, thus allowing clinicians to tailor therapy much earlier in illness. By reducing diagnostic uncertainty, rapid tests can reduce inappropriate empirical therapy, promote early de-escalation from broad-spectrum to narrow-spectrum agents, and identify those patients for whom non-antibiotic management is appropriate. At a population level, this can lead to less selection pressure for resistance and more rational use of antibiotics. However, high upfront costs, the need for laboratory infrastructure and trained personnel, integration with electronic prescribing systems, and reimbursement issues all limit widespread implementation, particularly in resource-constrained settings. Building laboratory capacity, integrating rapid diagnostics into antimicrobial stewardship programs, and ensuring contextually appropriate adoption will be important for maximizing the role these technologies can play in combating MDR Uropathogens. (43)

Challenges and Future Perspectives:

Gaps In Surveillance and Data Integration:

Surveillance for antimicrobial resistance in India is still fragmented, with marked geographic inequities, limited representation from the private sector (where a large proportion of care is delivered), and considerable variability in laboratory capacity and quality. Many microbiology laboratories do not consistently follow standardized operating procedures, susceptibility testing guidelines, or external quality assurance schemes, which undermines comparability of data across sites. In addition, microbiological findings are rarely linked with granular clinical information such as comorbidities, prior antibiotic exposure, treatment regimens, and outcomes, making it difficult to generate actionable evidence for guideline development and impact evaluation. These weaknesses delay recognition of emerging resistance patterns and limit timely, data-driven policy responses. Consolidating and expanding the ICMR-AMRSN network, investing in interoperable national data repositories, and strengthening India’s contribution to global platforms such as GLASS are therefore critical steps toward a more responsive, integrated AMR surveillance ecosystem. (5) (8)

Need For Policy Strengthening and Public Awareness:

Despite the existence of regulatory frameworks, enforcement remains inconsistent, particularly with respect to over-the-counter sales of antibiotics, informal prescribing, and inadequate documentation of antimicrobial use. Stronger policy implementation must be accompanied by sustained investment in hospital- and community-based antimicrobial stewardship programs, including staffing, decision-support tools, audit-and-feedback mechanisms, and access to diagnostics. At the population level, large-scale, culturally tailored public awareness campaigns are needed to address widespread practices such as self-medication, sharing of leftover antibiotics, and premature discontinuation of therapy, which collectively accelerate resistance. Experiences from state-level SAPCAR initiatives demonstrate that coordinated, multisectoral models—combining regulation, capacity building, and behavior-change communication—can be scaled and adapted across diverse health system settings in India. (30)

Research Priorities for The Next Decade:

Over the coming decade, research on AMR in India must prioritize robust regional surveillance platforms that systematically integrate microbiological data with clinical, pharmacological, and outcome indicators, enabling more precise risk stratification and context-appropriate empiric therapy. There is a pressing need for pharmacokinetic and pharmacodynamic studies of key antimicrobials in Indian populations, including vulnerable groups, to optimize dosing and reduce toxicity while preserving efficacy. Clinical trials and implementation studies evaluating non-antibiotic preventive strategies—such as vaccines, bacteriophage therapy, probiotics, and infection-prevention bundles—are equally important, particularly in high-burden settings. In parallel, implementation research should focus on designing, testing, and scaling antibiotic stewardship interventions that are feasible in low-resource hospitals and primary care facilities. Finally, systematic environmental surveillance for antibiotic residues, resistance genes, and resistant organisms in water, soil, and effluents is essential to fully operationalize a One Health approach and inform regulatory action on pharmaceutical and agricultural waste. (2) (40)

CONCLUSION:

We anticipate a further increase in the production of ESBLs, continued rise of carbapenem resistance in Enterobacterales, increase in fluoroquinone resistance and significant regional variation all stressing the urgency for coordinated national efforts to support surveillance systems, promote antimicrobial stewardship, expand rapid diagnostic testing and reinforce infection control measures. Practitioners will need to depend on pertinent local antibiograms and stewardship principles in order to direct empirical therapy, and those in leadership positions should prioritize One-Health initiatives and the promotion of new anti-infective therapeutics which confront this rapidly advancing resistance challenge.

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