Abstract
Antibacterial resistance (ABR) in India has emerged as a critical public health challenge. Increasing resistance to key antibiotics, including fluoroquinolones and carbapenems, in prevalent pathogens is driven by several factors. This review aims to summarize (1) the mechanisms of action of antibiotics and the emergence of resistance in India, (2) the multifactorial drivers of ABR across human, animal, and environmental sectors, and (3) public health strategic insights based on historical and contemporary literature to provide a roadmap for future interventions. A literature search was conducted using various keywords and databases such as PubMed, Scopus, and Google. Articles published between 1977 and 2025 were retrieved and reviewed. Additional data were integrated from national healthcare strategies and the Indian Priority Pathogens List. Over 200 articles were analyzed to understand the mechanisms of action of antibiotics, the evolution of resistance patterns, the underlying drivers, and the effectiveness of current policies and interventions. The analysis revealed alarmingly high resistance rates, particularly among gram-negative bacteria such as Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii, as well as significant resistance among gram-positive pathogens such as methicillin-resistant Staphylococcus aureus. Key contributing factors include unregulated antibiotic sales, overprescription, inadequate infection control, and misuse in animal husbandry. The findings further underscore the benefits of integrated approaches, such as the One Health framework and targeted stewardship programs, although regulatory heterogeneity and limited surveillance infrastructure remain substantial obstacles. Addressing the ABR crisis in India requires an integrated, multi-pronged strategy. Over the next 5-10 years, India must prioritize developing and expanding robust surveillance systems for the timely detection of resistance trends, scaling up comprehensive antibiotic stewardship programs in clinical and community settings, and committing significant investment to research and development for new antibiotics and diagnostics. Embracing these forward-looking priorities is essential to mitigate ABR and secure sustainable healthcare outcomes.