For antibiotics, the right dose is restraint
India’sdependence on antibioticsas a convenient cure-all for routine illnesses has reached an inflection point. A global study published in The Lancet Public Health has highlighted a worrying imbalance in the country’s antibiotic use: An over-reliance on stronger medicines even as safer first-line medicines remain underused. The World Health Organisation classifies antibiotics into three categories — “access” drugs, which are recommended as first-line treatments for common infections; “watch” drugs, which are broader-spectrum medicines that should be reserved for specific situations; and “reserve” drugs, intended as a last line of defence against highly resistant infections. The study estimates India’s optimal antibiotic use at 9.9 to 14.7 defined daily doses per 1,000 people per day. Actual use, however, stands much higher at 18.3 doses, with “watch” antibiotics at 9.3 doses against a recommended 6 doses. “Access” antibiotics, at 4.5 doses, fall well short of what is needed. The preference for “watch” drugs reveals the challenge in how antibiotics are understood, prescribed and consumed. A prescription for a broad-spectrum antibiotic can often feel like reassurance both to a patient seeking quick recovery and to a doctor working in an overstretched healthcare system. But each unnecessary dose narrows the options available for future infections. At the same time, the underuse of “reserve” antibiotics in genuinely resistant cases points to another systemic failure: Ensuring that the right medicine reaches the right patient at the right moment. Fragmented healthcare delivery, poor diagnostic access, and — beyond the clinic — the liberal use of antibiotics in livestock and agriculture, all feed India’s rising burden of antimicrobial resistance, where bacteria become resistant to common drugs and infections become more difficult and expensive to treat. Given the country’s burden of infectious disease, antibiotics will remain indispensable. Addressing the problem must, thus, begin with replacing quick-fix prescriptions with evidence-based care. National Action Plan on Antimicrobial Resistance 2.0 (2025–2029) places antimicrobial stewardship at the heart of the response, seeking to curb inappropriate usage across human healthcare, animal husbandry and agriculture. A stricter and more coordinated compliance mechanism across the pharmaceutical supply chain is essential to curb indiscriminate over-the-counter sales and irrational fixed-dose combinations.
- 1Public health regulation in India operates concurrently between the Union and states, meaning frameworks like the National Action Plan on Antimicrobial Resistance require coordinated implementation across state health departments, drug controllers, and municipal bodies. The Ministry of Health and Family Welfare, along with the Indian Council of Medical Research, leads India's antimicrobial resistance surveillance network. Effective stewardship therefore depends heavily on Centre-state cooperation, a recurring governance challenge within India's federal health architecture.
- 2India's National Action Plan on Antimicrobial Resistance 2.0, covering 2025 to 2029, adopts a One Health approach recognising that resistance spreads across human medicine, veterinary use, and agriculture, an approach the World Health Organisation and the Food and Agriculture Organization have jointly endorsed globally. This matters because India is often cited among countries with the world's highest absolute burden of antimicrobial-resistant infections, given its population size and antibiotic consumption volumes. Coordinated policy across the health, agriculture, and environment ministries is now treated as a national public health priority.
- 3Antibiotic sales in India are regulated under the Drugs and Cosmetics Act, 1940, and its Schedule H1, which mandates that certain antibiotics be sold only against a registered medical practitioner's prescription, with the sale recorded in a separate register. Despite this, over-the-counter sales without prescriptions remain widespread due to weak enforcement by state drug controllers, a gap the editorial implicitly references in calling for stricter, coordinated compliance. The Central Drugs Standard Control Organisation is the apex regulator responsible for approving fixed-dose combinations, several of which have previously been banned by the Union Health Ministry for being irrational or unsafe.
- 4The Lancet Public Health study's figures are precise: India's actual antibiotic use stands at 18.3 defined daily doses per 1,000 people per day, against an optimal range of 9.9 to 14.7, with Watch category drugs used at 9.3 doses against a recommended 6. This gap carries economic weight, since a 2016 UK government-commissioned global review projected that antimicrobial resistance could cause 10 million deaths a year by 2050 if left unaddressed. For India specifically, the underuse of low-cost first-line Access antibiotics, at just 4.5 doses against need, represents both a clinical and an economic inefficiency.