Why Are 90% of India’s Drug-Resistant Infections Going Untreated?

In 2019, India saw an estimated 1.07 million people infected with deadly, drug-resistant bacteria. Fewer than 8 per cent received the treatment they needed. According to a new study published in The Lancet Infectious Diseases, “only 7.8% of infections [in India] were treated appropriately,” leaving almost a million patients without life-saving care.

The bacteria in question are known as carbapenem-resistant Gram-negative (CRGN) organisms. These are not ordinary germs. They resist almost all commonly used antibiotics, including carbapenems, which are often used as a last line of defence. Infections caused by CRGN bacteria can lead to severe illness and death, especially when not treated promptly with specific drugs known as World Health Organization (WHO) Reserve antibiotics.

According to the study, it is the first to quantify the gap between the need for treatment and actual access in low- and middle-income countries (LMICs). India, with its high burden of antimicrobial resistance (AMR), had the largest number of infections among the eight countries studied. The others were Bangladesh, Brazil, Egypt, Kenya, Mexico, Pakistan, and South Africa.

Using data from the Global Burden of Disease study and antibiotic sales figures from IQVIA [a healthcare and clinical research company], the researchers found that India alone had 10,66,316 CRGN infections in 2019. Of these, only 83,468 treatment courses were sold for appropriate antibiotics. This meant that “the treatment gap [in India] was 982,848 cases,” and even this estimate was described as conservative.

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The scale of the problem dwarfs treatment efforts. The most commonly used antibiotics in India were tigecycline and colistin. Yet these drugs were not nearly enough to meet the need. No other WHO Reserve antibiotic was widely used. “India, Brazil, and Mexico each procured at least four different antibiotics, whereas Bangladesh, Kenya, and South Africa procured two or fewer,” the study notes. But despite India’s broader range, the quantity was far too small to make a dent.

Diagnostics, access, and a failing system

Why is this happening in a country with a large pharmaceutical industry and a rapidly expanding health sector?

One major reason is the lack of diagnostic capacity. In India, many hospitals and clinics cannot confirm whether a patient has a CRGN infection. Without a lab test, doctors are forced to treat patients empirically, often with antibiotics that do not work. The study warns that “barriers along the treatment pathway—from initial health facility presentation to laboratory diagnostic testing or antibiotic access—might drive undertreatment of drug-resistant infections.”

Even when tests are available, the correct drugs are not. WHO Reserve antibiotics are expensive, limited in supply, and often missing from hospital formularies. Some are not registered for use in India, or are not stocked due to their high cost. According to the researchers, “there is currently no concerted, comprehensive approach to address this treatment gap”.

The consequences are deadly. CRGN bacteria are responsible for infections like bloodstream infections and pneumonia, which carry high fatality rates. The study calculated that bloodstream infections alone have a 55 per cent case fatality rate, while lower respiratory tract infections have a 39 per cent fatality rate. Using these and other clinical data, the authors determined that the overall case fatality rate for CRGN infections is about 32 per cent.

Based on this, the researchers worked backwards from death estimates to calculate how many infections occurred. Then they compared that number with IQVIA’s 2019 data on antibiotic sales in each country. “The IQVIA database is estimated to capture more than 85% of sales,” the study notes.

In India, the mismatch was stark. While the country accounted for over 80 per cent of all treatment courses sold among the eight nations studied, it still managed to treat only a small share of patients. Bangladesh treated only 1 per cent, Pakistan 3.5 per cent, and Kenya a mere 0.2 per cent. In contrast, Mexico and Egypt treated 14.9 per cent of their estimated cases—still low, but double India’s rate.

This poor treatment coverage, the study argues, worsens the AMR crisis. When patients receive the wrong antibiotic, or no antibiotic at all, the bacteria survive and spread. “Undertreatment or inappropriate treatment of these infections further compound the effects of antibiotic resistance,” the study warns.

AMR crisis worsened post-COVID

The COVID-19 pandemic may have made things worse. The authors note that, while their study is based on 2019 data, “Given the continued rise in CRGN bacterial infections, the effects of the COVID-19 pandemic, and dramatic reductions in global foreign aid, we believe that this gap might have increased.”

The study proposes a bold new approach: to track treatment like HIV is tracked. They suggest a care cascade for AMR, similar to the UNAIDS 95–95–95 model, which measures how many patients are diagnosed, treated, and virally suppressed. In the case of CRGN infections, a care cascade could track how many patients access care, receive a timely diagnosis, get the right drug, and recover.

“Normative agencies, national governments, and implementing partners worldwide” could use such a cascade to improve decision-making and allocate resources better. India, with its existing surveillance systems like the Indian Council of Medical Research’s AMR network, is well positioned to take the lead.

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But first, India needs to address key obstacles. These include “inadequate registration of therapies, high prices, and a scarcity of diagnostics to guide appropriate antibiotic choice.” Tackling these issues will require investment, regulation, and policy reform—not just in Delhi, but in State capitals and district health centres as well.

The problem, the study says, is not one of awareness but of will. Global health bodies have known about AMR for years. What is missing is action. “Despite the large amount of antibiotic sales in south Asia, our study showed appropriate treatment coverage ranging from 1.0% (Bangladesh) to 7.8% (India).”

India’s health system is under strain, but it has strengths to build upon. Its pharmaceutical capacity is unmatched in the region. It already has AMR surveillance sites. With better planning and coordination, the country could close much of the treatment gap. For now, the numbers speak for themselves. More than a million Indians may have suffered CRGN infections in 2019. Most did not get the drugs they needed. The result was likely tens of thousands of avoidable deaths.

AMR is no longer a future threat—it is a present emergency. And unless India acts fast, it will only get worse.