A wide range of bacterial genera that cause urinary tract infections (UTIs) include: Escherichia, Klebsiella, Proteus, Pseudomonas, Enterococcus, Staphylococcus species, Enterobacter species, and Citrobacter species (Ronald, 2002). The most prevalent uropathogens are GNBs, amongst which E. coli is the most reported cause of UTI and is followed by Proteus spp., Klebsiella spp., and Pseudomonas spp. Whereas, around a quarter of infections are caused by gram-positive bacterium such as Enterococcus spp (Smita et al., 2019). A breakdown of prevalent bacterial genera in different types of urinary tract infections can be found in (Table 2) (Patel et al., 2021; Prabhu et al; Umesha et al., 2018; M et al., 2017; Srivastava et al., 2014).

Reportedly, MDR strains are highly prevalent in India (Mohapatra et al., 2022). Significant resistance to beta-lactam antibiotics, beta-lactamase inhibitor combinations such as piperacillin-tazobactam, third-generation cephalosporins, fluoroquinolones (e.g., ciprofloxacin), and an increasingly concerning rise in resistance to carbapenems which are usually saved for severe infections have been observed in E. coli. While Klebsiella and Proteus species have comparable patterns of resistance demonstrating strong resistance to third-generation cephalosporins, fluoroquinolones, and nitrofurans. High levels of resistance to beta-lactams, cephalosporins, fluoroquinolones, and aminoglycosides are seen in Pseudomonas spp., a challenging pathogen to treat. Beta-lactams, nitrofurans, aminoglycosides, tetracyclines, and some incidences of vancomycin resistance are among the antibiotics against which Enterococcus spp., exhibit alarming patterns of resistance (Smita et al., 2019; Mohapatra et al., 2022).

Airborne pathogens spread quickly, especially in crowded, poorly ventilated situations. Respiratory infections are the most prevalent infectious diseases in the world. From minor ailments like the common cold to potentially fatal ones like pneumonia, they can range in severity. These illnesses fall under the category of upper respiratory tract infections (URTIs), which impact the sinuses, pharynx, larynx, and nose. Airway and lung complications comprise lower respiratory tract infections (LRTIs). It is relatively rare for URTIs to have bacterial origins; instead, viruses, such as rhinoviruses, are usually the source (Jain et al., 2001). Common bacterial respiratory infections include pneumonia, bronchitis, community acquired pneumonia (CAP). Common causal bacterial genera for such diseases include Streptococcus pneumoniae, Staphylococcus spp., Mycoplasma spp., Haemophilus influenzae, Klebsiella pneumoniae, and Pseudomonas spp (Feldman and Shaddock, 2019).

Studies indicate GNB were the most common causes of infections, amongst which Pseudomonas aeruginosa, and Klebsiella pneumoniae were the most isolated organisms (Singh et al., 2020). Additionally, gram - positive bacteria Streptococcus pneumoniae is the leading cause of pneumonia in hospitalized patients (Sangale et al., 2021).

MDR Klebsiella pneumoniae and Pseudomonas aeruginosa strains show very high levels of resistance towards cephalosporins (ceftriaxone), fluoroquinolones (ciprofloxacin), beta lactam/beta lactamase inhibitors (piperacillin -tazobactam) have been reported (Kaleem Ullah et al., 2022; Sharma et al., 2023b). Streptococcus pneumoniae showed high levels of resistance for macrolides (Erythromycin), an increase in resistance for fluoroquinolones (Levofloxacin), and a concerning increase in resistance towards carbapenems (Meropenem) (Kulkarni et al., 2023).

Microorganisms that give rise to SSTIs are generally divided into transitory pollutants and resident skin flora. While resident bacteria on the skin typically coexist harmlessly, they might turn infectious in rare situations such as trauma or immunosuppression. Staphylococcus aureus, Staphylococcus warneri, Streptococcus pyogenes, and Corynebacterium species are typical transitory flora. Additionally, GNB are often implicated, including Proteus species, Escherichia coli, and Pseudomonas aeruginosa (Tognetti et al., 2012).

In India, studies show a predominance of Gram-positive cocci (GPC) in SSTIs in comparison to GNB (Roopashree et al., 2021). Amongst GPCs, S. aureus is the most prevalent, with studies pointing towards an increase in prevalence of Methicillin-resistant S. aureus (MRSA) strains. Many S. aureus isolates showed high levels of resistance towards penicillin and cephalosporin drugs (Roopashree et al., 2021; Shah et al., 2022). MDR P. aeruginosa and E. coli were the most prevalent GNBs, being highly resistant to penicillin and penicillin derivative drugs, cephalosporins, beta lactams/beta-lactamase inhibitors (Deka et al., 2020; Kakhandki et al., 2020; Ramakrishna et al., 2021).

Diarrhoea can be caused by different infectious agents such as bacteria (E. coli, Salmonella, Shigella, Vibrio), viruses (Rotavirus, Adenovirus), and protozoans (Giardia, Cyclospora, Cryptosporidium, Isospora, Microsporidia) (Shrivastava et al., 2017).

Diarrheagenic E. coli (DEC) strains are most prevalent and show resistance towards beta-lactams (Ampicillin), macrolides (Azithromycin), fluoroquinolones (Ofloxacin, Ciprofloxacin), and tetracyclines (Doxycycline) (Biswas et al., 2024). Shigella species were also frequently seen, with S. flexneri being the most prevalent, followed by S. sonnei, S. dysentriae and S. boydii. Shigella spp., showed high resistance towards fluoroquinolones (Ofloxacin, Ciprofloxacin, Nalidixic acid, Norfloxacin), tetracyclines (Tetracycline), sulfonamides (Co-trimoxazole), aminoglycosides (Streptomycin) and a growing resistance towards amphenicols (chloramphenicol) and beta lactams (Ampicillin) (Bose et al., 2024; Jain et al., 2020).

Amongst Salmonella spp., S. typhi, the most common species showed high resistance towards fluoroquinolones (Ciprofloxacin, Nalidixic acid) and increasing resistance towards cephalosporins (Cefixime, Ceftriaxone) (Biswas et al., 2022). Nontyphoidal Salmonella (NTS) also were moderately prevalent, showing MDR patterns encompassing fluoroquinolones (Ciprofloxacin, Levofloxacin), aminoglycosides (Gentamycin), macrolides (Azithromycin), and sulphonamides (Trimethoprim/Sulfamethoxazole) (Mahindroo et al., 2024).

In India, GNBs such as P. aeruginosa, Klebsiella spp., Acinetobacter baumanii, Citrobacter spp., Aeromonas spp., are the most prevalent organisms causing ventilator associated pneumonia (VAP). Among GPC, Staphylococcus aureus is also a significant contributor to VAP cases. Enterococcus spp. showed very high prevalence in catheter-associated urinary tract infections (CAUTI) followed by Klebsiella spp., Citrobacter spp., showing significant prevalence. For catheter-related bloodstream infections (CRBSI), the leading pathogens are P. aeruginosa, Klebsiella spp., Acinetobacter baumanii, Citrobacter spp., and S. aureus (Kumar et al., 2021; Saikeerthana et al., 2021; Dr. Ranjeet et al., 2024). (Table 3) (Crank and O’Driscoll, 2015; Hassoun et al., 2017; Nandhini et al., 2022; Singhal et al., 2022) provides insights of treatment options for hard-to-treat bacterial diseases.

A concerning trend in Indian healthcare is the alarming rate of AMR among hospitalized patients in India. A significant number of bacterial isolates have been classified as MDR, and an even greater proportion are suspected to be extremely-drug resistant (XDR). Particularly, many strains of P. aeruginosa, Acinetobacter baumanii and Klebsiella spp., have shown XDR patterns. Furthermore, many isolates of S. aureus have also been reported as MDR (Vaithiyam et al., 2020). An alarming increase in carbapenem - resistant Enterobacteriaceae (CRE) is reported amongst which Klebsiella spp. is the most reported CRE showing high levels of resistance towards carbapenems (Modi et al., 2021).

Global estimates indicate that only 50% of the global antibiotic consumption is appropriately justified (Iskandar et al., 2020). Dispensing antimicrobial drugs without prescription by pharmacies in the private sector in India within an urban setting was unacceptably high (around 67%) (Shet et al., 2015). Reports indicate that 44% of outpatient antibiotic prescriptions are intended to inappropriately treat acute respiratory conditions (e.g., viral upper respiratory tract infections, bronchitis, asthma, allergies, and influenza) (Laxminarayan and Chaudhury, 2016). In India nearly 60% mortality of children aged 5 to 14 years is due to infectious diseases such as diarrhea, pneumonia, measles, etc (Morris et al., 2011). The rate of infectious disease is also linked with increased sale and consumption of antibiotic in India. The lack of diagnostic facilities, irrational prescription, lack of knowledge, experience about antibiotic use and pharma companies’ incentives are the factors which cause misuse of antibiotics.

A 2018 study found that more than 60% of fixed drug combinations (FDCs) had no regulatory approval (McGettigan et al., 2019). They found many formulations were pharmacologically incompatible, reinforcing the need for better regulation and oversight of the pharmaceutical industry. Schedule H1, an amendment to the Drugs and Cosmetics Rules Act of 1945 that imposed restrictions on OTC dispensing of certain antibiotics (mostly third and fourth-generation cephalosporins, carbapenems, and newer fluoroquinolones) was perceived as a vital policy with ineffective implementation and adherence (Nair et al., 2023). Universal coverage of vaccines is expected to prevent 11.4 million days of antibiotic use per year in children less than 5 years of age. Consequently shows an estimated 47% reduction in antibiotics used to treat these pneumococcal infections (Wu et al., 2021).

Due to healthcare costs, patients avoid diagnostic and purchase antibiotics without a prescription and self-medicate with older prescriptions to have a rapid recovery. These collectively promote the misuse of antibiotics and increase AMR (Jani et al., 2021). In rural areas, many healthcare providers are often inefficient and employ unqualified staff. Thereby, urging the patients to choose private healthcare, which leads to high costs, particularly for the middle-class and low-income earners. To cut this expense, patients turn to self-medication, which results in high consumption of antibiotics. The observation validates the finding of Wu et al (Wu et al., 2021), which highlighted a rise in parents self-medicating their children (below 5 yrs), posing a serious threat to child health. This behavior causes AMR to first-generation and broad-spectrum antibiotics (Gandra et al., 2017).

Antibiotics are extensively used to compensate for poor sanitation, prevent diseases in herds/flocks, treat bacterial infections, and to promote animal growth in the distinct agricultural sectors (Page and Gautier, 2012). The magnitude and contribution of cross-reservoir resistance transmission from animals to humans is difficult to quantify and track mainly because of globalized food trade (Mather et al., 2013). Wastewater is flagged as a significant environmental reservoir of drug-resistant bacteria; horizontal gene transfer of antimicrobial resistance genes (ARGs) results in the dissemination of AMR in microbial communities. India has become the center for MDR and XDR Mycobacterium tuberculosis, which complicates the control of tuberculosis. In addition, the genomic flexibility of many resistant organisms allows them to acquire resistance to reserved antibiotics like carbapenem and colistin (Jani et al., 2021).

People’s health is directly impacted by antibiotic resistance. It impairs our capacity to create a successful treatment strategy to eradicate infectious diseases and lower rates of morbidity and death. Patients who become resistant to many drugs are more likely to experience higher morbidity or even mortality (Cornejo-Juárez et al., 2015). AMR poses a risk to the treatment of pre-operative and post-operative nosocomial infections, making treatments difficult for already debilitated patients. The burden of patient mortality is as high as 13.1% overall in MDR infections, with MDR A. baumanii infections resulting in 2–3 fold higher mortality (29%) (Barrasa-Villar et al., 2017; Massart et al., 2022; Figueiredo Costa, 2008). However, it to be noted that long course colistin treatment over short course for Carbapenem resistant Acinetobacter baumanii proved to be promising and beneficial for critically ill patients and helped in reduction of 30-day mortality rate (aOR = 0.46, 95% CI: 0.26 – 0.83, p = 0.009) amongst the long course colistin group with negligible differences in nephrotoxicity amongst the two groups (aOR 1.28, 95% CI: 0.74 – 2.22, p = 0.368) (Katip et al., 2023).

For hospitalized patients, increased length of ICU stay is higher in patients with HAIs, averaging at 13 days, and is also associated with a higher risk of mortality (Ramsamy et al., 2017). Similarly, for community-acquired infections, MDR infections were associated with inappropriate antibiotic use and were directly related to higher mortality (adjusted odds ratio (aOR), 6.06, 95% CI, 1.2 – 55.7) (Lohiya et al., 2020). Bacteraemia, being a life-threatening condition, often resulting in half of the patients succumbing to illness, requires exhaustive antimicrobial treatment. Due to ever-increasing AMR, antimicrobial therapy is often ineffective resulting in increased patient mortality (Figueiredo Costa, 2008; Ramsamy et al., 2017). Additionally, it makes the treatment plan more difficult for patients with long-term antibiotic-dependent conditions such as tuberculosis, whose prevalence is already rampant in India (Lohiya et al., 2020).

Antimicrobial resistance (AMR) has become a widespread public health concern across India; however, significant differences in resistance patterns and underlying drivers are observed between rural and urban settings. These variations are influenced by multiple socio-economic, environmental, and healthcare-related factors. Urban areas, in particular, are often densely populated and experience higher levels of environmental pollution, conditions that facilitate the rapid transmission of infectious diseases and potentially accelerate the emergence and spread of AMR (Balachandra et al., 2021).

In contrast, rural areas may have comparatively lower access to antibiotics due to limited healthcare infrastructure; however, inappropriate antibiotic use remains a significant concern. Limited awareness regarding proper antibiotic usage, coupled with widespread over-the-counter (OTC) availability, contributes to misuse in rural India (Sharma et al., 2023a). The situation is particularly alarming in states such as Bihar—India’s third most populous state—where scarce healthcare resources and inadequate infrastructure exacerbate the problem. Evidence indicates a substantial rise in antimicrobial resistance to β-lactams, carbapenems, and fluoroquinolones in Bihar. Methicillin-resistant Staphylococcus aureus (MRSA) prevalence is notably high at 65%, significantly exceeding the national average of 47.8% (Modgil et al., 2025). Furthermore, community-level comparative studies between urban and rural settings demonstrate a consistently higher prevalence of resistant pathogens in rural regions, with rural AMR trends surpassing corresponding data reported by ICMR.

It is now evident that MDR infections take a significant toll on patient and hospital finances. Studies pointing towards increased length-of-stay (LOS) and increased patient mortality can be extrapolated to higher expenditures on patient health (Nathwani et al., 2014). AMR increases the cost of healthcare due to additional nursing and medical care needed for the patient (Pulingam et al., 2022). Treatment of drug-resistant pathogens inadvertently promotes further utilization of antimicrobials to curb the infection. This never-ending cycle results in the burden of purchasing costly antibiotics (Dadgostar, 2019). The median total cost of managing resistant infections in India is calculated at US$ 199 in comparison to US$ 109 for susceptible infections, the median cost of hospitalization per day is US$ 65 and US$ 35 for resistant and susceptible infections respectively. This resulted in heavy economic burdens as nearly half of the patients borrowed money for treatment expenses (Kadam et al., 2024).

Outpatient AMR patterns in India provide valuable insights for healthcare professionals worldwide. India’s high antibiotic use and diverse resistance profiles mirror challenges faced by many low- and middle-income countries, offering a model for strengthening global surveillance and stewardship. Data from India support WHO-led initiatives such as GLASS, enhancing evidence-based AMR monitoring and policy development (World Health, 2014; Okeke et al., 2024). The AMR patterns observed in India can help healthcare professionals globally understand prescription trends, antibiotic guideline, and AMSP practice-related resistance mechanisms. Beyond national policy reforms, these insights can inform global antibiotic use strategies and guide the evolution of international frameworks for rational and precision-based antimicrobial therapy.

According to the Global Burden of Disease study, bacterial infections cause around 37 million deaths globally, making AMR among dangerous bacteria a significant health problem (Murray et al., 2022). The 68^th World Health Assembly created and accepted the Global Action Plan on AMR (GAP–AMR) in 2015 after receiving support from several international organizations (World Health, 2024b). The AMR Political Declaration adopted by the 71^st UN General Assembly in 2016 affirmed the GAP-AMR and its five strategic objectives as the blueprint for addressing AMR globally and has informed the development of National Action Plans (NAPs). By the end of 2023, 178 countries had developed NAPs based on this framework with 68% implementing their plans, 25% having costed and budgeted NAPs and with Monitoring & Evaluation frameworks. However, so far only 10% of countries have responded that they have made specific financial provisions for implementing their NAPs which highlights the cross-cutting nature of AMR interventions.) (Gupta and Bhatia, 2023). In India, the 12th (2012-2017) five-year plan included the National Program on AMR Containment, which was started in 2013 and is managed by the National Centre for Disease Control (NCDC). The National Antimicrobial Resistance Surveillance Network (NARS-Net) was gradually extended to all states and Union Territories (UTs). (Figure 3) illustrates priority pathogens monitored under NARS - Net. Because of this effort, by March 2024, the program had 50 medical colleges and labs in 27 states and 6 UTs, guaranteeing geographic representation. After certification, “WHONET” an offline, open-source program for managing microbiological data, is used by the NCDC to evaluate surveillance data from NARS-Net sentinel sites. The 5-year NAP-AMR (2017–2021) was a crucial foundation for states to create action plans to address AMR locally because India’s healthcare system is state-governed (Nair et al., 2021). Similarly, ICMR created an AMR monitoring network (AMRSN) to gather nationally representative data on the trends and patterns of antibiotic resistance in pathogens of public health significance.

Current treatment practices can be boiled down to a “one-size-fits-all” approach (Merker et al., 2020). Conventional antibiotic therapy comprises either a single dose or a combination of two or more antibiotics. Limitations of this approach relate to issues such as misuse, overuse and underuse of antibiotics. These increased risk of adverse effects and toxicities, also reducing the efficacy of antibiotics (Ahmed et al., 2024a; Wawruch et al., 2002).

Precision Medicine helps to make customized and informed medical decisions, tailoring therapies by considering patients’ genetic makeup, immune response, specific infection, and socio-environmental and lifestyle factors. Precision medicine affirms the belief that every patient has different demands rather than a “one-size-fits-all” approach (Naithani et al., 2021). Such informed therapies allow for better treatment outcomes by selecting the most appropriate antibiotics, quick modifications of antibiotic regimens, and allowing for better antimicrobial stewardship. These ultimately prevent the development of AMR (Ahmed et al., 2024a; Watkins, 2022).

AMR is a significant threat to public health, driven by several key issues. These include inappropriate and overuse of antibiotics in humans and agriculture, and poor infection control and management. This is further exacerbated by the inaccessibility of clean drinking water and proper sanitation, increased travel and globalization, and the slow development of novel or improved antimicrobial drugs (Mukherjee, 2024). The management of antimicrobial resistance now requires antimicrobial stewardship, which seeks to maximize antibiotic use through coordinated actions across healthcare settings, especially considering the slow development of new antibiotics (Ha et al., 2019). Studies reveal that integrating antimicrobial stewardship programs (ASPs) with infection prevention and control improves the efficacy of both approaches, as evidenced by notable decreases in infections, including Clostridium difficile infections, brought about by these coordinated initiatives (Knobloch et al., 2021). Moreover, in 2019, ICMR published the second version of its guidelines on using antibiotics in common syndromes, which includes updated information on how to treat skin infections, soft tissues, central nervous system, and bones and joints (Sandeep et al., 2020). So that ASPs are necessary for optimizing antibiotic use, improving patient safety, and lowering AMR (Ponto, 2010).

Antimicrobial stewardship methods can be applied in several ways: