India may be using too many powerful ‘watch’ antibiotics — medicines that should be reserved for specific infections when simpler antibiotics are unlikely to work — while underusing both first-line ‘access’ antibiotics and last-resort ‘reserve’ drugs, according to a major international study published in The Lancet Public Health.Researchers estimate that India’s antibiotic use is skewed towards broader-spectrum drugs, suggesting that some patients are being exposed unnecessarily to ‘watch’ antibiotics even as others may not receive the most appropriate medicines for their infections. The findings come from the first global framework that estimates how much of each category of antibiotics countries actually need based on their infection burden and antimicrobial resistance patterns.The India findings are part of a wider global picture that shows nearly three-fourths of countries are using more antibiotics overall than needed, while almost every country is overusing the antibiotics that contribute most to antimicrobial resistance. At the same time, millions of people worldwide still lack access to the antibiotics they need.“Our study found that in India some patients were exposed unnecessarily to antibiotics while others did not have access to the right antibiotics to treat their infections,” Prof Ramanan Laxminarayan, founder and president of One Health Trust, senior research scholar at Princeton University and one of the study’s authors, told The Indian Express. “Strategies to improve antibiotic use will focus on ensuring populations have access to the right antibiotics at the right time while reducing unnecessary use.”What is antibiotic classification all about?The World Health Organisation (WHO) groups antibiotics into three categories:Access: First-choice antibiotics for common infections that have a lower risk of driving resistance.Watch: Broad-spectrum antibiotics that should be used only for specific infections because they carry a higher risk of promoting antimicrobial resistance.Reserve: Last-resort antibiotics reserved for treating multidrug-resistant infections.How the India map looksThe study estimates India would ideally require 14.7 defined daily doses (DID) of antibiotics per 1,000 people per day, comprising 7.8 DID of ‘access’ antibiotics, 6 DID of ‘watch’ antibiotics and 0.99 DID of ‘reserve’ antibiotics. Actual consumption, however, paints a different picture. India currently uses 18.3 DID overall, comprising 4.5 DID of ‘access’ antibiotics, 9.3 DID of ‘watch’ antibiotics and 0.19 DID of ‘reserve’ antibiotics. Only 27 per cent of antibiotic use currently comes from the ‘access category,’ against an estimated requirement of 52.3 per cent.“This suggests that in India some ‘watch’ antibiotics are potentially being used unnecessarily and some of this use could be replaced with ‘access’ antibiotics instead,” Prof Laxminarayan says, adding India’s higher burden of infectious diseases and antimicrobial resistance means the country will legitimately require more ‘watch’ antibiotics than many other countries. However, the study also suggests ‘reserve’ antibiotics are being underused despite the country’s resistance burden, while antibiotics that are no longer recommended continue to be prescribed more than expected.Story continues below this adGlobal pictureResearchers analysed antibiotic use across 186 countries and territories, representing 99.8 per cent of the world’s population. They found that 72 per cent of countries used more antibiotics overall than estimated to be necessary. Ninety-nine per cent prescribed excessive quantities of antibiotics that contribute most to antimicrobial resistance. Sixty per cent continued to use antibiotics the World Health Organisation (WHO) considers should no longer be routinely prescribed.The study estimates that around 43 billion antibiotic treatment days were needed globally in 2019 — roughly one antibiotic course per person per year — to appropriately treat bacterial infections. It also found that 77 per cent of global antibiotic use should come from the WHO’s access group, suggesting the United Nations target of 70 per cent ‘access’ antibiotic use by 2030 is reasonable.Lead author Aislinn Cook, Senior Research Fellow in Infectious Diseases Epidemiology at City St George’s, University of London, feels the findings point to a double challenge. “While some antibiotics are being overused, millions of people may still lack access to the medicines they need to treat their infections,” she says.How the study workedThe researchers grouped countries with similar infection burdens, antimicrobial resistance patterns, healthcare access and socioeconomic characteristics into peer groups.Story continues below this adWithin each group, countries with the lowest antibiotic use and the fewest infection-related deaths served as benchmarks for estimating optimal antibiotic consumption.The analysis found that while high-income countries currently consume the most ‘watch’ and ‘reserve’ antibiotics, more than 80 per cent of the world’s estimated need for these medicines lies in lower-income countries, where infectious disease and antimicrobial resistance burdens are highest. At the same time, 42 per cent of countries were using fewer Access antibiotics than estimated to be necessary, while 52 per cent were using fewer ‘reserve’ antibiotics than required, potentially leaving patients with drug-resistant infections without the treatments they need.India’s prescribing pattern already raises concernsThe findings mirror earlier evidence from India. The National Centre for Disease Control’s First Multicentric Point Prevalence Survey of Antibiotic Use (2021-22), conducted across 20 tertiary care hospitals in 15 states and two Union Territories, found that nearly three out of every four hospitalised patients were receiving antibiotics. The survey showed 57 per cent of prescriptions were for ‘watch’ antibiotics, 38 per cent were ‘access’ antibiotics and 2 per cent were ‘reserve’ antibiotics. About 3 per cent were fixed-dose combinations not recommended by WHO.Only 6 per cent of antibiotic prescriptions were based on microbiological evidence, with most antibiotics started without culture confirmation.Story continues below this adDr Kamini Walia, Programme Officer (AMR) and Head of the Division of Descriptive Research at ICMR, who was not associated with the present study, says more than half (55 per cent) of antibiotic prescriptions were for prophylaxis rather than treatment, suggesting opportunities to improve surgical prophylaxis, perioperative antibiotic policies and infection prevention practices.She highlights unnecessary duplicate antibiotic coverage, noting that 26.4 per cent of prescriptions included duplicate gram-negative coverage and 8.7 per cent duplicate anaerobic coverage, increasing toxicity, costs and the risk of antimicrobial resistance without improving outcomes.Another concern was the extensive use of injectable antibiotics, with 86.5 per cent administered intravenously, alongside wide variation in prescribing practices across hospitals, where antibiotic use ranged from 37 per cent to 100 per cent.According to Dr Walia, India should particularly focus on reducing unnecessary use of commonly prescribed ‘watch’ antibiotics such as ceftriaxone, cefixime, azithromycin, ciprofloxacin, levofloxacin and piperacillin-tazobactam through better antimicrobial stewardship and awareness. ‘Reserve’ antibiotics, including meropenem, colistin, ceftazidime-avibactam, cefiderocol and aztreonam-avibactam, should be restricted to patients with documented or strongly suspected multidrug-resistant infections.