There is a huge dearth of cleanliness in India – open defecation is rampant, garbage management in most cities is in shambles, toxic hospital and industrial wastes and sewage are allowed to drain into water sources, and food products are laced with chemicals.
The recent episode of a sewage pipeline leak that led to the mixing of contaminated water with drinking water causing multiple deaths and hospitalisations due to diarrhoea and vomiting in Indore, has put back the spotlight on the grave threat of the incessant poisoning of our drinking water resources, its impacts on the health of populations, poor water management in cities and the inability of the system to fix the problem.
While these incidents are reported from all corners of the country from time to time with disastrous outcomes, we still seem to be oblivious to the much more dangerous consequence of this contamination of our water resources and its impact on our long-term health and survival.
For lurking behind the filth are superbugs, or antibiotic-resistant bacteria.
Antibiotics are medicines that kill bacteria and cure infections. They were once called “miracle drugs” because they saved countless lives from diseases that were previously deadly. However, bacteria are living organisms that can adapt to survive. When they change in ways that make antibiotics no longer effective, this is called antibiotic resistance. Some bacteria even resist multiple antibiotics, earning the name superbugs.
Yes. 'Antimicrobial resistance' is a broader term that is used to refer to antibiotic resistance among other kinds of microbes, such as parasites, viruses and fungi.
Antibiotic resistance often develops in environments where bacteria are constantly exposed to antibiotics. Contaminated water is one of the major drivers of antibiotic resistance. Untreated sewage and industrial wastes containing antibiotic compounds are often released into water sources in India. Bacteria living in these polluted waters learn to survive or withstand the impacts of the specific antibiotics dissolved in the waters by:
Producing enzymes that destroy antibiotics
Blocking antibiotics from entering their cells
Changing their internal structures so the drugs no longer work
Bacteria in contaminated water can exchange genetic material, spreading resistance across species. Over time, these resistant bacteria spread and become harder to treat.
Antibiotic resistance can spread through water (rivers, lakes, and oceans can transport resistant bacteria and genes over long distances), soil (antibiotic residues and resistant bacteria can remain in the soil over long periods, entering the food chain and also affecting the microbial communities living in the soil), air (aerosols from manure, wastewater treatment, and other sources can also spread resistant bacteria and genes through the air) and animals (birds, insects, and other wildlife can act as carriers, spreading resistant bacteria across different locations).
When these resistant bacteria, or superbugs, develop resistance to a particular antibiotic used to treat infections like, say, diarrhoea, the antibiotics can become ineffective. This will result in the person continuing to suffer from the condition, which could even become fatal.
And the risk doesn’t stop with one person. Resistant bacteria can spread from host to host, multiplying across communities. What begins as a hidden microbial skirmish in polluted waters can escalate into a public health crisis, where our most trusted medicines no longer work, leading to difficult-to-treat infections, longer hospital stays, higher medical costs, and finally, increased mortality.
Bacteria can become resistant:
Through mutations
Bacteria and other types of microorganisms usually divide and reproduce on a regular basis and are evolving and adapting constantly. Mutations can occur during the replication process, and this can develop the capacity of a microorganism to survive after being exposed to an antibiotic that previously would destroy it. Mutations can happen randomly or due to exposure to harmful chemicals or radiation.
Ineffective antibiotic manufacturing and disposal practices
Pharmaceutical industries in India often release untreated wastes that are loaded with antibiotic residues into the soil and rivers. These contribute to antibiotic resistance. Evidence shows that pharmaceutical waste from plants in China and India is a major contributor to antibiotic resistance.
Antibiotics in wastewater
Untreated wastewater can contain several types of disinfectants and antibiotic residues from pharmaceutical industries, animal farms, manufacturing plants, and hospitals, as well as human waste that can contain antibiotic residues. When bacteria from faecal waste in the untreated wastewater come in contact with these antibiotics, they can develop resistance to the specific antibiotics. These resistant bacteria in the wastewater can mix with soil and food and seep into groundwater and surface water sources.
Agriculture and aquaculture use
Veterinarians often prescribe antibiotics for farm animals. The waste from farm animals often contains antibiotic residues. Most of this manure does not go through proper disposal mechanisms and is left in the environment, where it often makes its way into surface water and groundwater. Fisheries, especially salmon farming, use antibiotics to increase production, and the antibiotics thus get into the food and water, contributing to antibiotic resistance.
Over prescription of antibiotics among patients
Over prescription of unnecessary antibiotics among patients often leads to the development of antibiotic resistance among people, and people harbouring antibiotic-resistant genes can transmit these into the environment through infected food and water and through faecal waste.
Water and food are two important sources of antibiotic-resistant bacteria in India, besides over-prescription and overuse or erratic use of antibiotics in healthcare settings.
Wastewater in India is a mix of domestic sewage, industrial effluents, agricultural products such as fertilisers and pesticides, byproducts of mining and thermal plants, and religious activities. Domestic sewage from wastewater continues to be the top polluter of surface and groundwater resources in India. The estimated urban sewage generation in the country is 72,368 MLD, of which only 20,235 MLD is treated and utilised. The remaining quantity of 52,133 MLD remains untreated.
The untreated sewage and effluents that are released into the water and soil are laden with various disease-producing bacteria that develop antibiotic resistance due to prolonged exposure to antibiotics present in the industrial and hospital effluents.
A recent WHO GLASS 2025 report reveals that antibiotic-resistant bacteria are directly responsible for 1.27 million deaths worldwide. One in three bacterial infections in India are resistant to common antibiotics, especially for E. coli, K. pneumoniae, and S. aureus, necessitating urgent action. A major study in the journal Lancet has highlighted that 83% of patients in India carry "superbugs" (bacteria resistant to most antibiotics). In many cases, common and even last-resort antibiotics are becoming ineffective, leading to higher mortality rates. Another study in Nature Scientific Reports highlights that urban sewage is one of the major sources of antibiotic-resistant bacteria in india.
India ranks 60th among 24 countries in age-standardised mortality rate per 100,000 population associated with resistance to bacteria, parasites, viruses and fungi. Besides, it has the highest resistance rate across multiple pathogens, contributing to a mortality rate of 417 per 100,000 people from infectious diseases and was responsible for 297,000 and 1,042,500 direct and associated deaths, respectively, in 2019.
India is also among the world’s largest producers of antibiotics, accounting for 80% of the global supply, which influences the local use, resistance development, and environmental impacts.
Evidence shows that:
Contaminated water resources harbour antibiotic-resistant bacteria
A large proportion of unused and expired antibiotics are found in urban drains or nullahs along with other household waste in India. A recent study from Roorkee found high levels of antibiotic-resistant bacteria in its gutters.
Another study has found that 80% of the length of India’s rivers falls under the high-to-very-high environmental risk category due to antibiotic pollution, posing a health risk to 315 million people in the country.
Wastewater from farms in Delhi containing antibiotic-laden animal manure and unused antibiotics often finds its way into the Yamuna River system. This contaminated river water is also used for irrigation in the agricultural fields, potentially contaminating the food crops with resistant bacteria or their residues.
Waterborne antibiotic-resistant bacteria (ARB), such as Escherichia coli, Klebsiella species, and Salmonella species, and antimicrobial resistance genes (ARG), such as blaNDM-1, blaOXA-48 and mcr-1, are commonly found in rivers and groundwater receiving untreated sewage in India.
Elevated levels of waterborne resistant bacteria, particularly those resistant to broad-spectrum antibiotics such as cephalosporins, have been found in major Indian rivers, including the Yamuna and Ganga in the north and the Cauvery in the south. In 2013–2014, 40% (169 out of 446) of E. coli isolates from rivers in five Indian states were resistant to extended-spectrum cephalosporins.
Sulfonamide resistance genes were found in both deep groundwater and surface water in Bihar, including the sacred Ganges River, where wastewater from urban drains containing hospital waste and domestic waste was considered the major source of contamination.
Water samples taken from rivers and sewage treatment plants (STPs) from Bihar, Goa, Karnataka, Tamil Nadu, and Telangana found E. coli in the waters that were resistant to antibiotics. Drinking water collected from rivers, kunds, ponds, tube wells, hand pumps, piped supply, and dug wells in Ayodhya-Faizabad, located on the banks of the river Saryu and water sources from east Sikkim showed that bacteria such as E. coli and Klebsiella species were resistant to the latest antibiotics. Analysis of water sources from streams, lakes, tube wells, and community-supplied water in Kashmir also showed that E. coli was resistant to antibiotics.
Tap water, borewell water and water from rivers and lakes, water sources contaminated by sewage treatment plants, and surface water near drug manufacturing units in Hyderabad were found to have antibiotic-resistant bacteria in the waters. Wastewater samples from sewage treatment plants (STPs) in South India showed that hospital wastewater inflow led to increase in drug-resistant bacteria
Animal food too harbours antibiotic-resistant bacteria
Samples from food products such as poultry, fish, eggs, and milk have also been found to harbour antibiotic-resistant bacteria. This is because low doses of antibiotics are routinely used as growth promoters in livestock in India.
Antibiotic-resistant bacteria were found in fresh herbs and vegetables imported from India to Switzerland and raw chicken, meat, egg and unpasteurised milk samples from Hyderabad. Studies from poultry and shrimp farms of Andhra Pradesh, Karnataka, Kerala, and Tamil Nadu; milk samples from livestock in Tamil Nadu; and fish samples from Kerala, Karnataka and West Bengal also found antibiotic-resistant bacteria in the food samples tested.
India has launched the:
Wastewater and waste management programs
These include the Swachh Bharat Abhiyan (SBM), launched in 2014. The Solid Waste Management Rules, 2016, provide a regulatory framework for handling municipal solid waste. Additionally, programmes such as the National River Conservation Plan (NRCP) and the Namami Gange Programme specifically target river pollution through the development of Sewage Treatment Plants (STPs) and sewerage infrastructure. The Atal Mission for Rejuvenation and Urban Transformation (AMRUT) also supports urban wastewater management, while the GOBAR-Dhan Scheme launched in 2018 promotes converting organic waste into useful resources like biogas and organic compost. However, inadequate wastewater treatment and waste disposal still continue to be major challenges in the country.
National Action Plan on AMR (NAP-AMR) within a Global One Health Context:
This has been developed in alignment with the Global Action Plan on AMR (GAP-AMR), and its overarching goals, like “Strengthening Surveillance” and “Optimising Antimicrobial Use”, focus on reducing the overall AMR burden by reducing the release of antibiotics into the environment. Current efforts to develop NAP-AMR-2.0 specifically focus on environmental dimensions of AMR.
National One Health Mission (NOHM)
India launched the National One Health Mission (NOHM) in 2022 to tackle human, animal and environmental health in a holistic way with a focus on the rising antimicrobial resistance (AMR) and other zoonotic diseases (OPSA 2024). NOHM brings together government ministries, academic institutions, NGOs, and industry partners to build an integrated disease control system spanning human, animal, and plant health.
National AMR surveillance network (NARS-Net):
It was established in 2013 under the National Programme on AMR Containment and monitors AMR magnitude and trends through medical college laboratories. However, lack of integrated AMR surveillance data from across health, food safety, livestock, and environmental sectors makes it difficult to allocate responsibility for developing appropriate technical and behavioural interventions across the sectors to control AMR.
State-level action plans with growing water emphasis:
States such as Kerala, Madhya Pradesh, New Delhi, Karnataka, Gujarat, and Telangana have incorporated the One Health approach in their state-specific action plans. Of these, only the action plans for New Delhi and Gujarat have directly integrated water-related aspects into their strategies for AMR spread and control.
New indigenous antibiotics in India:
India has now developed a new indigenous macrolide antibiotic known as Nafithromycin after three decades of research to combat the multidrug-resistant pathogen, a step towards the fight against AMR. However, waterborne AMR still needs to be addressed through research and development.
Regulatory efforts for antimicrobial use:
Schedule H and H1 policies mandate prescription-based sales to optimise antimicrobial use in human health. Schedule H involves the sale of drugs which cannot be sold without the doctor’s prescription. Schedule H1 policy strictly prohibits over-the-counter sale of third- and fourth-generation antibiotics and psychotropic drugs, including anti-TB drugs. These regulations help by indirectly reducing the uncontrolled flow of active compounds into the environment. However, strict enforcement and implementation of these regulations still remain a challenge.
To help prevent resistance and protect yourself and your family:
Do not take antibiotics on your own without a prescription or use older prescriptions: Take care to see that you and your family members take antibiotics only when prescribed by a registered medical practitioner
Learn the right ways to use antibiotics: Antibiotics are not effective against all infections. Make sure you are getting the right antibiotic, at the right dose, for the right amount of time. Never demand antibiotics if a healthcare professional says they are unnecessary.
Never share or use leftover antibiotics: Take antibiotics exactly as prescribed, and do not stop early or share unused prescription medications.
Wash your hands and maintain hygiene: Proper handwashing can help fight germs and prevent illness.
Know the symptoms: Learn how to recognise early symptoms of an infection. Talk with a healthcare professional if you think you have an infection, or if your infection is not getting better or is getting worse.
Ask questions: Talk with a healthcare professional about why antibiotics are being prescribed, possible side effects, and how long you will need to take them.
Prepare food safely: Water and foods such as meat, fruits, and vegetables can be contaminated with bacteria. Boil water and wash, clean, separate and cook food properly before consuming.
Get vaccinated: Get vaccinated to prevent infections.
Take care while travelling abroad: Know what vaccinations are needed, check health alerts, stick to safe food and drinks, and plan in advance in case you do get sick.
Manage pets and livestock responsibly: Do not give antibiotics in animals without veterinary advice, as resistant bacteria can spread between animals and humans
How can healthcare professionals help
Healthcare professionals can take steps to help protect patients from drug-resistant infections:
By prescribing antibiotics only when needed, staying up to date on recommended antibiotic practices and doses and prescribing antibiotics only when needed for the shortest amount of time required.
Educating patients by telling them about the side effects and risks associated with the antibiotics and about antibiotic resistance and the dangers of misuse.
Using proper hand hygiene by washing hands frequently with soap and water and using gloves.
Getting vaccinated, as vaccines can help maintain health by developing resistance and preventing the transfer of pathogens to patients.