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Analysis Antimicrobial Resistance in South East Asia

Antibiotic resistance and its containment in India

BMJ 2017; 358 doi: (Published 05 September 2017) Cite this as: BMJ 2017;358:j2687

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  1. Manish Kakkar, senior public health specialist1,
  2. Kamini Walia, scientist2,
  3. Sirenda Vong, regional technical lead, antimicrobial resistance3,
  4. Pranab Chatterjee, senior research associate1,
  5. Anuj Sharma, technical officer, antimicrobial resistance4
  1. 1Public Health Foundation of India
  2. 2Indian Council of Medical Research, New Delhi, India
  3. 3World Health Organization Regional Office for South-East Asia, New Delhi, India
  4. 4World Health Organization Country Office for India, New Delhi, India
  1. Correspondence to: A Sharma sharmaan{at}

Manish Kakkar and colleagues discuss factors contributing to antibiotic resistance in India, and examine policy initiatives to address it

Antibiotic resistance is a major public health threat in India. A high burden of infectious diseases, unregulated sale of antibiotics, financial incentives for healthcare providers to prescribe antibiotics, patient expectations, rising incomes, and limited public health response have helped drive the emergence of resistance.1 Resistance patterns in India in human samples are shown in box 1. Resistance to commonly used antibiotics is increasing. This complicates clinical management, and newer, more expensive antibiotics need to be used. Resistance to newer, broad spectrum drugs such as carbapenems, which are the antibiotics of last resort, has been seen in parallel with their increased use.4

Box 1: Patterns of antimicrobial resistance in isolates from humans23

  • High resistance (>50%) to nalidixic acid, norfloxacin, and ampicillin

  • Presence of the blaCTX-M-15 gene with a risk of spreading cephalosporin resistance to Enterobacteriaceae

Salmonella typhi
  • High resistance to fluoroquinolones, and cephalosporins

  • Decreased multidrug resistance, and resistance to ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole

Pseudomonas spp
  • Low resistance to imipenem (15%), amikacin (20%), and ciprofloxacin (20%)

  • High resistance to piperacillin-tazobactam (42%), and meropenem (50%)

  • 12% of samples carry the gene for New Delhi metallo-beta-lactamase-1 (NDM-1), the enzyme that confers resistance

Acinetobacter spp
  • Maximum susceptibility to colistin (99%), followed by imipenem, and meropenem (53%)

  • 13% of samples carry the NDM-1 gene

Rising trends
  • Rise in meticillin resistant Staphylococcus aureus from 29% in 2008 to 47% in 2015

  • Carbapenem resistant isolates of Escherichia coli increased from 10% in 2008 to 13% in 2013

  • Carbapenem resistant isolates of Klebsiella pneumoniae increased from 29% in 2008 to 57% in 2014

  • In S typhi isolates, resistance to fluoroquinolones has increased from 8% in 2008 to 28% in 2014. Resistance to antimicrobials that are not used commonly (trimethoprim-sulfamethoxazole, aminopenicillin) is decreasing

In April 2017, the government of India finalised the National Action Plan on …

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