Scopingreporton Antimicrobialresistancein India

Scoping Report on Antimicrobial
Resistance in India
November 2017
Suggested citation:
Sumanth Gandra, Jyoti Joshi, Anna Trett, Anjana Sankhil Lamkang, and Ramanan
Laxminarayan. 2017. Scoping Report on Antimicrobial Resistance in India.
Washington, DC: Center for Disease Dynamics, Economics & Policy.
Disclaimer:
Please note that while every effort has been made to ensure the information
provided is accurate, the views and statements expressed in these publications
are those of the authors and do not necessarily reflect those of Research Councils
United Kingdom or Department of Biotechnology.
This work is licensed under a Creative Commons Attribution 4.0 International

License
Foreword
Antimicrobial Resistance (AMR) is
recognised as a complex problem and
addressing it requires countries to make
joint efforts across various disciplines.
Considering the complex nature of the
AMR problem, no individual country
has the capacity to address this major
public health problem independently.
Accordingly, India and the United
Kingdom came together to fight against I sincerely hope that this report
AMR in November 2016 with a new £13 encourages Indian scientists to fill
million UK-India research program to evidence gaps in addressing the AMR
conduct collaborative research across challenge through innovations and new
multiple disciplines to come up with technologies tailored to local needs.
comprehensive and creative solutions to Such innovations require effective
overcome AMR. collaboration among UK and Indian
scientists across several disciplines,
As the first step, the Department for
including medical scientists, natural
Biotechnology (DBT), Government of
scientists, sociologists, engineers and
India, in partnership with Research
economists to name a few.
Councils United Kingdom (RCUK)- the
strategic partnership of the UK’s seven
Research Councils, commissioned
this study to map the AMR research
landscape mapping in India. This
report summarizes the current AMR
situation in India with a focus on
antibacterial resistance and identifies
the current research gaps to determine Prof K VijayRaghavan
future research priorities in India. Secretary, Department of Biotechnology,
This report should be a ready reckoner Ministry of Science and Technology,
to scientists and policy makers for Government of India.
designing interventions to address AMR
problems jointly and unequivocally.
Table of Contents
List of Figures iii
List of Tables v
Acknowledgments vii
Abbreviations ix
Executive Summary 1
Section 1. Background and Purpose 15
Section 2. Methodology 17
Section 3. The Antimicrobial Resistance Situation in India 19
3.1. Antimicrobial Resistance in Humans 19
3.1.1. Healthcare delivery in India 19
3.1.2. Resistance rates in humans by bacterium 20
3.1.3. Carbapenemases 23
3.1.4. Colistin resistance 24
3.1.5. Neonatal infections due to antibiotic-resistant bacteria 24
3.2. Antibiotic Resistance in Food Animals 24
3.2.1. Antibiotic-resistant bacteria in poultry 25
3.2.2. Antibiotic-resistant bacteria in livestock 26
3.2.3. Antibiotic-resistant bacteria in aquaculture 28
3.3. Antibiotic Resistance in the Environment 29
3.3.1. Antibiotic-resistant bacteria and genes in sewage and hospital 29
wastewater
3.3.2. Antibiotic-resistant bacteria and genes in rivers 30
3.3.3. Antibiotic-resistant bacteria and genes in surface water and 31
groundwater
3.4. Factors Driving Antibiotic Resistance in India 33
3.4.1. Antibiotic consumption in humans 33
3.4.1.1. High consumption of broad-spectrum antibiotics 33
3.4.1.2. Increasing faropenem consumption 35
3.4.1.3. Antibiotic fixed-dose combinations 35
3.4.2. Social factors 36
3.4.3. Cultural activities 37
3.4.4. Antibiotic consumption in food animals 37
3.4.5. Pharmaceutical industry pollution 38
3.4.6. Environmental sanitation 43
3.4.7. Infection control practices in healthcare settings 43
3.5. AMR Policy Situation in India 44
3.5.1. AMR-related policies for human health 45
3.5.2. AMR-related policies for animal health 48
3.5.3. AMR policies related to the environment 49
3.5.4. Launch of National Action Plan for Containment of AMR (NAP- 49
AMR) and Delhi Declaration on AMR
i
3.5.5. Effectiveness of the AMR policies 50
Section 4. The Antimicrobial Resistance Research Landscape in India 51
4.1. Overall Summary of Studies 51
4.2. Results by Category of Studies 52
4.2.1. Humans 52
4.2.2. Animals 54
4.2.3. Environment 54
4.2.4. Novel agents 56
4.2.5. Miscellaneous 57
4.2.6. Diagnostics 57
4.2.7. One health 58
4.3. Prominent researchers in AMR field in India 59
4.4. Survey Responses 59
Section 5. Discussion and Recommendations 61
5.1. Humans 61
5.2. Animals 62
5.3. Environment 62
5.4. Other (Novel Agents, Diagnostics, One Health, Miscellaneous) 63
5.5. Limitations of the Current Study 63
5.6. Conclusion 64
References 65
Appendix 71
ii
List of Figures
Figure 3.1: Carbapenem (meropenem/imipenem) resistance among four gram- 21

negative bacteria isolated from blood cultures
Figure 3.2: Mortality associated with dual carbapenem- and colistin-resistant 24
Klebsiella pneumoniae bloodstream infections
Figure 3.3: E. coli resistance to third-generation cephalosporins among sewage 30
treatment plants (STPs) receiving waste from various sources
Figure 3.4: Trends in antibiotic consumption in India, 2000–2015 33
Figure 3.5: Trends in proportion of three antibiotic classes among total antibiotics in 34
India, 2005–2015
Figure 3.6: Number of formulation companies manufacturing various antibiotics for 35
human use
Figure 3.7: Number of formulation companies manufacturing various antibiotics for 38
animal use
Figure 3.8: Leading antibiotic formulation companies and the number of antibiotics 41
they manufacture (excluding antituberculosis agents) for human use in India
Figure 3.9: Leading companies and the number of antibiotics they manufacture for 41
animal use in India
Figure 3.10: Sites of human antibiotic active pharmaceutical ingredient (API) 42
manufacturing companies in India
Figure 3.11: Sites of human and animal antibiotic formulation manufacturing units 43
in India
Figure 3.12: Causes of early onset neonatal sepsis in three NICUs in Delhi 44
Figure 4.1: Number of publications in each of the seven categories of AMR research 51
(N=2,152)
Figure 4.3: Distribution of human studies by three categories of AMR research 52
(N=1,040)
Figure 4.2: Top 10 institutions with AMR publications by category (excluding review 52
publications)
Figure 4.4: Top 10 institutions with publications on AMR in humans by category 53
Figure 4.5: Distribution of AMR research studies in animals (N=70) 54
Figure 4.6: Distribution of AMR research studies on the environment (N=90) 55
Figure 4.7: Antibacterial spectrum of novel agent studies (N=379) 56
Figure 4.8: Areas of current research activities in all three areas (human, animal, 60
environment), based on responses from 50 researchers
iii
iv
List of Tables
Table 3.1: Percentage of resistance to various antibiotics among four gram-negative 20
bacteria isolated from blood cultures
Table 3.2: Percentage of resistance to various antibiotics among Staphylococcus 21
aureus and Enterococcus faecium isolated from blood cultures
Table 3.3: Percentage of resistance to various antibiotics among Salmonella Typhi, 22
Shigella species, and Vibrio cholerae
Table 3.4: Percentage of resistance to various antibiotics among Neisseria 23
gonorrhoeae
Table 3.5: Different types of carbapenemases in Enterobacteriaceae detected in India 23
Table 3.6: Antibiotic resistance in poultry in various studies in India 26
Table 3.7: Antibiotic resistance in livestock in various studies in India 27
Table 3.8: Antibiotic resistance in aquaculture in various studies in India 29
Table 3.9: Antibiotic-resistant bacteria in various rivers in India 31
Table 3.10: Presence of carbapenemases and colistin resistance genes in Indian 31
rivers
Table 3.11: Antibiotic resistance in surface water and groundwater sources in various 32
studies in India
Table 3.12: Pharmaceutical industry effluent standards in India 39
Table 3.13: List of human antibiotic active pharmaceutical ingredient (API) 40
manufacturing companies
Table 3.14: Timeline of AMR policy-related activities in India 45
Table 3.15: Tolerance limits for antibiotics in seafood 48
Table 3.16: Tolerance limits for antibiotics in honey 48
Table 4.1: Top 10 institutions that published AMR-related research in humans in 53
India, 2012–2017
Table 4.2: Institutions that published more than one AMR research study in animals 54
in India, 2012–2017
Table 4.3: Institutes that published more than one AMR research study on the 55
environment in India, 2012–2017
Table 4.4: Institutions that published more than five AMR research studies on novel 56
agents in India, 2012–2017
Table 4.5: Institutions that published more than five studies on miscellaneous 57
aspects of AMR in India, 2012–2017
Table 4.6: Institutions that published AMR research studies on diagnostics in India, 58
2012–2017
Table 4.7: Institutions that published AMR research studies on one health in India, 59
2012–2017
Table 4.8: Prominent researchers in AMR field in humans 59
Table 4.9: Prominent researchers in AMR field in animals, environment, novel 60
agents, miscellaneous, one health and diagnostics
Table A.1: Formulation companies manufacturing antibiotics for human use 71
(excluding antituberculosis agents) in India
Table A.2: Formulation companies manufacturing antibiotics for animal use in India 74
Table A.3: Institutions with at least one publication on AMR in India 75
Table A.4: Institutions with at least one publication on AMR in humans 106
v
Table A.5: Institutions with at least one publication on AMR in animals 120
Table A.6: Institutions with at least one publication on AMR in the environment 122
Table A.7: Institutions with at least one publication on AMR in the novel agents 124
category
Table A.8: Institutions with at least one publication on AMR in the miscellaneous 128
category
vi
ACKNOWLEDGMENTS
Scoping Report on Antimicrobial Resistance in India was prepared for the

Department of Biotechnology (DBT), government of India, and Research Councils
United Kingdom (RCUK) by the Center for Disease Dynamics, Economics & Policy,
India (CDDEP). The head of the project was Dr. Ramanan Laxminarayan, and the
technical lead was Dr. Sumanth Gandra. CDDEP team members who contributed
to this report are Dr. Jyoti Joshi, Ms. Anna Trett, and Dr. Anjana Sankhil
Lamkang. We thank Dr. Anshu Bhardwaj from CSIR–Institute of Microbial
Technology, Chandigarh, for helping us with the survey aspect of the report.
We thank Dr. Shailja Vaidya Gupta and Dr. Sanjay Kalia from the DBT, Ms. Sarah
Lobo and Ms. Naomi Beaumont from the Economic and Social Research Council,
and Dr. Monika Sharma and Ms. Sukanya Kumar-Sinha from RCUK, New Delhi,
for their valuable comments on the draft document.
We thank DBT for organizing our visit to DSM Sinochem Pharmaceuticals active
pharmaceutical ingredient (API) manufacturing facility. We thank DSM Sinochem
Pharmaceuticals India team for giving us insight into the antibiotic manufacturing
and waste management in their API manufacturing facility. We also thank DSM
Sinochem Pharmaceuticals India team for providing us the list of antibiotic API
manufacturers in India.
vii
viii
ABBREVIATIONS
ABR Antibacterial resistance
AMR Antimicrobial resistance
AMRSN Antimicrobial Resistance and Surveillance Research Network
ARGs Antibiotic resistance genes
CIMS Current Index of Medical Specialties
CPCB Central Pollution Control Board
DBT Department of Biotechnology
ESBL Extended-spectrum beta-lactamase
FDCs Fixed-dose combinations
FSSAI Food Safety and Standards Authority of India
GMP Good manufacturing practices
HAIs Healthcare-associated infections
ICMR Indian Council of Medical Research
IPC Infection prevention and control
MDR Multidrug resistant
MRL Maximum residue levels
MRSA Methicillin-resistant S. aureus
NAP National Action Plan
NCDC National Center for Disease Control
NDM New Delhi metallo-beta-lactamase
NICUs Neonatal intensive care units
RCUK Research Councils United Kingdom
STPs Sewage treatment plants
TB Tuberculosis
WHO World Health Organization
ix
x
EXECUTIVE SUMMARY
Antimicrobial resistance (AMR) is a research in India. The aims of the

major public health problem globally. mapping exercise are to understand
While all types of AMR are concerning, the current situation of AMR, with
antibacterial resistance (ABR) is seen particular focus on ABR in India, and
as currently posing the most serious to identify the current research gaps to
health threat. Bacteria are present determine the future research priorities
everywhere, including in every living in India.
being and in the soil, water, and air.
With the interconnected ecosystems METHODOLOGY
(humans, animals, the environment), To understand the AMR situation
the exchange of bacteria is continuous, and research landscape in India, we
and thus the ABR problem is no longer searched the PubMed and Google
limited to medical science alone. It Scholar databases for literature relating
requires effective collaboration among to AMR in India, using the following
several disciplines. search terms: “antimicrobial OR
Considering the complex nature of the antibiotic AND resistance AND India.”
ABR problem, no individual nation The search was limited to the last five
has the capacity to address this major years (July 1, 2012, to June 30, 2017).
public health problem independently. Articles were screened and selected
In response, the United Kingdom and based on their titles and extracted.
India came together to fight against Articles relating to tuberculosis,
AMR in November 2016 with a new £13 malaria, leprosy, nontuberculous
million UK-India research program. mycobacteria, and HIV were excluded.
The goal of this initiative was for the Recently, another study conducted a
UK and India to conduct collaborative tuberculosis research mapping exercise
research across multiple disciplines in India (see Maharana et al. 2014).
to come up with comprehensive and Research publications not associated
creative solutions to overcome AMR. with Indian-based institutions were
As the first step, the Department for also excluded. Each article was assigned
Biotechnology (DBT), government of to one of the following eight categories:
India, in partnership with Research àà Humans: Studies that focused on
Councils United Kingdom (RCUK) humans
decided to undertake mapping of AMR àà Animals: Studies that focused on
Scoping Report on Antimicrobial Resistance in India
2
animals, including agriculture

àà Environment: Studies that focused on the environment
àà Novel agents: Studies that focused on natural or synthetic compounds with
antimicrobial activity
àà Diagnostics: Studies that focused on new diagnostics
àà One health: Studies that focused on a combination of these categories:
humans, animals, or environment
àà Reviews/editorials: Studies that did not include primary research
àà Miscellaneous: Studies that did not fit into any of the above categories
àà If a study would fit into more than one category, it was assigned to only one
main category.
THE ANTIMICROBIAL Escherichia coli, and Klebsiella

RESISTANCE SITUATION pneumoniae, and more than 50% in
Pseudomonas aeruginosa.
IN INDIA
Carbapenem resistance
Antimicrobial Resistance in
Humans The carbapenem class of antibiotics
is one of the last-resort antibiotics to
AMR is a global public health threat,
treat serious bacterial infections in
but nowhere is it as stark as in India.
humans, and resistance to carbapenems
India has some of the highest antibiotic among various gram-negative bacteria
resistance rates among bacteria that was extremely high (Gandra et al.
commonly cause infections in the 2016; ICMR 20151 ). The highest
community and healthcare facilities. carbapenem resistance was observed in
Resistance to the broad-spectrum A. baumannii (67.3%; 70.9%), followed
antibiotics fluoroquinolones and third- by K. pneumoniae (56.6%; 56.6%), P.
generation cephalosporin was more aeruginosa (46.8%; 41.8%) and E. coli
than 70% in Acinetobacter baumannii, (11.5%; 16.2%) (Figure ES-1).
Figure ES-1:
Gandra S et. al 2016 ICMR 2015 Carbapenem (meropenem/

imipenem) resistance
among various bacteria
isolated from blood culture
Source: Gandra et al.
(2016); ICMR (2015).
The ICMR AMR surveillance network includes data from four tertiary care hospitals. This information was
1
obtained from ICMR for the purpose of this report.

3
Colistin resistance conducted in food animals, high levels

of antibiotic-resistant bacteria were
Colistin is considered to be the last- identified.
resort antibiotic in human medicine.
With increasing use of colistin for Antibiotic-resistant bacteria in
treatment of carbapenem-resistant Poultry
gram-negative bacterial infections,
Several studies reported isolation of
colistin resistance among gram-
extended-spectrum beta-lactamase
negative bacteria has emerged in India
(ESBL) producing E. coli strains from
(Kaur et al. 2017; Pragasam et al. 2016;
fecal samples of chickens (Brower et
Manohar et al. 2017). Bloodstream
al. 2017; Kar et al. 2015; Shrivastav
infections due to dual carbapenem-
et al. 2016). Chicken meat samples
and colistin-resistant K. pneumoniae
contaminated with Salmonella species
are associated with 69.3% mortality
resistant to multiple antibiotics have
among Indian patients (Kaur et al.
been reported (Kaushik et al. 2014;
2017) (Figure ES-2). However, known
Naik et al. 2015). New Delhi metallo-
plasmid-mediated colistin resistance
beta-lactamase-1 (NDM-1) producing
genes mcr-1 and mcr-2 were not
bacteria conferring resistance to
detected frequently.
carbapenems and mcr-1/mcr-2
gene producing bacteria conferring
resistance to colistin have not been
reported in chickens so far.
Antibiotic-resistant bacteria in
Figure ES-2: Livestock
Mortality associated NDM-1 (Ghatak et al. 2013) and ESBL-
with dual carbapenem-
and colistin-resistant
producing gram-negative bacteria (Das
Klebsiella pneumoniae et al. 2017) isolated in milk samples
bloodstream infections obtained from cattle with mastitis have
Source: Kaur et al. (2017). been reported. In addition, one study
reported isolation vancomycin-resistant
Staphylococcus aureus (VRSA) strains
in milk samples obtained from cows
with mastitis (Bhattacharyya et al.
Antimicrobial Resistance in 2016). Among pigs, a few studies
Animals reported detection of ESBL-producing
E. coli from fecal samples of healthy
The use of antibiotics in food animals
pigs (Lalzampuia et al. 2013; Samanta
plays a major role in human health,
et al. 2015). So far, mcr-1/mcr-2
as antibiotic-resistant bacteria can
gene-producing bacteria conferring
be transmitted between humans and
resistance to colistin have not been
animals through contact, in food
reported in livestock.
products, and from the environment
(Landers et al. 2012). Although a
limited number of studies were
4
Antibiotic-resistant bacteria in the environment indicate high levels

Aquaculture of antibiotic-resistant bacteria and
antibiotic resistance genes (ARGs) in
In a study involving tilapia fish
various water bodies.
obtained from urban lakes and rivers,
42% of Enterobacteriaceae isolates Antibiotic-resistant bacteria
obtained from the gut of tilapia fish and genes in Sewage and
were ESBL producers (Marathe et al. Hospital wastewater
2016). In another study, Vibrio species
Hospital wastewater has high levels of
associated with food poisoning were
antibiotic resistant organisms. A study
identified among shrimp, shellfish, and
examining wastewater samples from
clams obtained from retail markets in
three different sewage treatment plants
Kerala. These Vibrio species were 100%
(STPs) found that hospital wastewater
resistant to ampicillin but remained
inflow significantly increased the
highly sensitive to chloramphenicol
prevalence of third-generation
(Sudha et al. 2014). NDM-1 and mcr-1/
cephalosporin-resistant E. coli (Akiba et
mcr-2 gene-producing bacteria have
al. 2015) (Figure ES-3).
not been reported in fish samples.
Antibiotic-resistant bacteria
Antibiotic Resistance in the
and genes in Rivers
Environment
Major rivers in India have bacteria
With the interconnectedness
with high levels of resistance to broad-
of ecosystems, the role of the
spectrum antibiotics such as third-
environment, particularly water, in the
generation cephalosporins. In a study
spread of antibiotic-resistant bacteria
involving River Cauvery in Karnataka,
is increasingly gaining attention. A
100% of E. coli isolates were found
limited number of published studies on
Figure ES-3:
E. coli resistance to third-

generation cephalosporins
among sewage treatment
plants (STPs) receiving
waste from various sources
Source: Akiba et al. (2015).
5
to be resistant to third-generation had Enterobacteriaceae and other

cephalosporins (Skariyachan et al. gram-negative bacteria, 100% of them
2015). In a second study, involving were ESBL producers, and more than
River Yamuna, 17.4% (40) of isolates 95% were blaOXA-48 producers.
belonging to different groups of gram-
negative bacteria were found to be FACTORS DRIVING
ESBL producers (Azam et al. 2016). ANTIBIOTIC RESISTANCE
In addition to antibiotic-resistant IN INDIA
bacteria, ARGs that confer resistance to
Antibiotic consumption in
broad-spectrum antibiotics, including
Humans
last-resort agents, were detected in
major rivers of India. These include the In 2014, India was the highest
blaCTX-M gene (Azam et al. 2016; Akiba consumer of antibiotics, followed
et al. 2016; Devarajan et al. 2016), the by China and the United States.
blaNDM-1 gene (Ahammad et al. 2014; However, the per capita consumption of
Devarajan et al. 2016; Marathe et al. antibiotics in India is much lower than
2017), and the mcr-1 gene (Marathe et in several other high-income countries
al. 2017). (Laxminarayan et al. 2016). Some of
the reasons for high resistance rates in
Antibiotic-resistant bacteria
India are discussed in this section.
and genes in Surface water
and Groundwater High consumption of broad-
spectrum antibiotics
Studies have also shown potable water
sources apart from rivers to have Broad-spectrum antibiotics are those
bacteria with high levels of resistance that are effective against a wide range
to broad-spectrum antibiotics. A study of disease-causing bacteria, in contrast
involving water from drinking and to narrow-spectrum antibiotics, which
recreational sources in the Ayodhya- are effective against specific families
Faizabad area showed that 17% of of bacteria. From 2000 to 2015,
E. coli and 13% of Klebsiella species cephalosporin and broad-spectrum
were resistant to third-generation penicillin consumption increased
cephalosporins (Kumar et al. 2013). rapidly, whereas narrow-spectrum
Another study involving natural sources penicillin consumption was low and
of water in East Sikkim throughout decreasing (Figure ES-4).
the year 2011–12 found that 50% of
E. coli and 72% of Klebsiella species The rapid increase of third-generation
were resistant to third-generation cephalosporin consumption could
cephalosporins (Poonia et al. 2014). be attributed to multiple factors,
And a study involving four tap water such as increasing resistance to
samples, one bore-hole water sample, fluoroquinolones among bacteria
and 23 environmental water samples in causing enteric fever and bacterial
the Hyderabad area found that among dysentery, making third-generation
23 environmental water samples, 22
6
Figure ES-4:
Trends in antibiotic
consumption in India,
2000–2015
Source: QuintilesIMS.
cephalosporins empiric treatment third-generation cephalosporin (Figure

choices for these two common ES-5).
infections (Taneja 2007; Mukherjee et
Antibiotic fixed-dose
al. 2013; Gandra et al. 2016). Changing
combinations
prescribing practices by healthcare
providers, with third-generation Antibiotic fixed-dose combinations
cephalsoporins being substituted for (FDCs) are combinations of two or
penicillins in the treatment of upper more active antibiotics in a single-
respiratory tract infections in outpatient dosage form. Antibiotic FDCs should
settings and lower respiratory tract be prescribed when the combination
infections in inpatient settings has a proven advantage over single
(Gandra et al. 2017; Kotwani and compounds administered separately
Holloway 2014; Kotwani et al. 2015). in therapeutic effect, safety, or
Another factor is a lack of widespread compliance (Gautam and Saha 2008).
availability of narrow-spectrum agents However, in India, antibiotic FDCs
such as first-generation penicillins are heavily prescribed even without
(penicillin G, benzathine penicillin) the knowledge of a proven advantage
in contrast to third-generation over single compounds. Injudicious
cephalosporins in the pharmacies use of antibiotic FDCs could lead to
(Kotwani and Holloway 2013). In emergence of bacterial strains resistant
India, only one formulation company to multiple antibiotics. Approximately
is making penicillin G or benzathine 118 antibiotic FDCs are available in India
penicillin, whereas 135 formualtion (Ahmad et al. 2016; Shankar et al. 2016).
companies manufacture cefixime, a
7
Figure ES-5:
Number of formulation
companies manufacturing
various antibiotics for
human use
Source: CIMS INDIA, April–
July 2017 edition.
Social Factors continuing medical education (Kotwani

et al. 2010; Kotwani and Holloway
Several social factors drive 2013).
inappropriate antibiotic use in India.
Among the general public, such factors Cultural Activities
include self-medication, access to
One of the major cultural activities
antibiotics without prescription, use of
associated with potential acquisition
pharmacies and informal healthcare
and spread of antibiotic-resistant
providers as sources of healthcare,
bacteria and ARGs is mass bathing
and lack of knowledge about when
in rivers as part of religious mass
to use antibiotics (Barker et al.
gathering occasions. In one study
2017; Chandy et al. 2013). Among
(Ahammad et al. 2014), blaNDM-1 was
healthcare providers who provide
found to be over 20 times greater in the
care in the private sector, reasons for
Ganges River during pilgrimage season
inappropriate antibiotic prescribing
than at other times of year, indicating
include perceived patient demand,
that pilgrimage areas may act as hot
fear of losing patients if asked for
spots for the broader transmission of
diagnostic investigations, diagnostic
blaNDM-1 and other antibiotic resistance
uncertainty, economic incentives from
genes.
pharmaceutical companies, and lack of
continuing medical education (Chandy Antibiotic consumption in
et al. 2013; GARP India 2011; Kotwani
Animals
and Holloway 2013). Among healthcare
providers in the public sector, reasons It is estimated that India was the fifth-
include a heavy patient load resulting largest consumer of antibiotics in food
in a lack of time to counsel against animals (poultry, pigs, and cattle) in
antibiotics, pressure to use short-dated 2010, and with rising incomes and
medicines including antibiotics, lack changing dietary patterns leading
of diagnostic facilities, and lack of to an increase in the demand for
8
animal protein, especially for poultry, Pharmaceutical companies can

antibiotic use is projected to grow by be broadly classified as active
312%, making India the fourth-largest pharmaceutical ingredient (API)
consumer of antibiotics in food animals manufacturers and formulation
by 2030 (Van Boeckel et al. 2015). Use companies. API manufacturers produce
of antibiotics as growth promoters in antibiotics in bulk that are then sold
food animals and poultry is a common to formulation companies to produce
practice; however, the true extent of finished products like tablets, syrups
this practice is unknown. Antibiotics and vials. Effluents coming from both
such as tetracycline, doxycycline, and types of manufacturing units contain
ciprofloxacin, which are critical to antibiotic residues but significantly
human health, are commonly used higher amount of residues are expected
for growth promotion in poultry in the effluents of API manufacturing
(Brower et al. 2017; CSE 2014). A more units. The existing good manufacturing
concerning issue is the use of colistin practices (GMP) framework is restricted
for growth promotion, prophylaxis, and to drug safety and does not include
therapeutic purposes in poultry (CSE environmental safeguards. Regulation
2014). Studies show the presence of of environmental discharges from the
antimicrobial residues in chicken meat manufacturing units is left to the local
and shrimp samples sold for human governments. In India, the Central
consumption (Sahu and Saxena 2014; Pollution Control Board (CPCB)
Swapna et al. 2012). established effluent standards for
pharmaceutical industry waste, and all
Pharmaceutical industry state pollution control boards follow
pollution the same standards. Unfortunately,
the current standards do not include
The Indian pharmaceutical industry
antibiotic residues, and thus they are
supplies 20% of generic drugs, with
not monitored in the pharmaceutical
an estimated US$15 billion in revenue
industry effluents (CPCB Effluent
in 2014 (Nordea Asset Management
Standards 2013).
2015). With respect to antibiotics, it is
estimated that 80% of the antibiotics In India, there are at least 40 antibiotic
sold by multinational pharmaceutical API manufacturers and at least 250
companies on the global market are antibiotic formulation companies
manufactured in India and China (Sum manufacturing at least one antibiotic for
of Us 2015). However, the effluents human use. The leading manufacturers
from the antibiotic manufacturing of antibiotics for human use in India are
units contain a substantial amount of displayed in Figure ES-6.
antibiotics, leading to contamination of
rivers and lakes in India (Larsson et al. Although published studies on
2007; Lübbert et al. 2017; Gothwal and antibiotic pollution have been
Shashidhar 2017). restricted to the Hyderabad area in
the state of Telangana, the number of
9
39
AHPL
39
Cipla
38
Macleods
Figure ES-6: 31
Hetero HC
25
Leading antibiotic Invision
formulation companies and 25
Zydus
the number of antibiotics 24
Cadila
they manufacture for 24
human use in India United Biotech
23
Source: CIMS INDIA, April– FDC
July 2017 edition. 23
Intra Labs
23
Ranbaxy
pharmaceutical companies involved in of Gujarat, Aurangabad, Mumbai

manufacturing antibiotics suggests the area, and Tarapur in the state of
potential possibility of environmental Maharashtra, Baddi and Paonta Sahib
antibiotic pollution in several other in the state of Himachal Pradesh,
locations in India as well (Figure Derabassi in the state of Punjab
ES-7). Some of the antibiotic API and Hyderabad area in the state of
manufacturer hot spots include, Telangana.
Ankleshwar and Karkhadi in state
Figure ES-7:
Sites of human antibiotic

active pharmaceutical
ingredient (API)
manufacturing companies
in India
Note: Manufacturing unit
locations were identified
by reviewing websites of
individual companies
10
Environmental Sanitation among hospitalized patients globally

(Ramasubramanian et al. 2014). Only
Antibiotic selection pressure is a a few multicenter studies have been
prerequisite for the emergence of conducted assessing infection control
resistance; however, poor sanitation practices in India. One study in the
plays a major role in the spread of state of Gujarat that assessed infection
antibiotic-resistant bacteria and control practices in 20 delivery care
ARGs. More than 50% of the Indian units showed that surgical gloves
population does not have access to were reused in over 70% of facilities,
sanitation facilities for safe disposal of only 15% of the facilities reported
human waste (World Bank 2017). In wiping of surfaces immediately after
addition, a large proportion of sewage is delivery in labor rooms, and one-third
disposed untreated into receiving water of facilities did not have wash basins
bodies, leading to gross contamination with hands-free taps (Mehta et al.
of rivers with antibiotic residues, 2011). These poor infection prevention
antibiotic-resistant organisms, and practices in delivery care units reflect
ARGs (Marathe et al. 2017). the types of organisms seen in early
onset neonatal sepsis cases. In a recent
Infection Control practices
large prospective study involving
in Healthcare settings three NICUs, Acinetobacter species (a
The prevalence of various healthcare- common healthcare-acquired pathogen)
associated infections (HAIs) among was the most common organism
Indian hospitals ranges from 11% to causing early onset neonatal sepsis
83%, in contrast to the World Health (occurring within 72 hours of birth)
Organization (WHO) estimate of (Figure ES-8).
about 7% to 12% of the HAI burden
Figure ES-8:
Causes of early onset

neonatal sepsis in three
NICUs in Delhi
Source: Chaurasia et al. (2016)
Note: CONS = coagulase-
negative Staphylococci
11
AMR Policy situation in nongovernmental initiatives such as the

India Chennai Declaration were published
to create a roadmap to tackle the AMR
In India, the issue of AMR came to problem. Over the last seven years,
the attention of policymakers with several policies were enacted, and in
the 2010 discovery of NDM-1 and April 2017, a comprehensive National
the controversy2 over its name. Action Plan for Containment of AMR
Subsequently, AMR-related policies was launched. The timeline of AMR
were initiated in 2011 by publishing policy–related activities appears in
the National Policy on Containment Table ES-1.
of AMR. In addition, other
Year Activity
2010 Establishment of the National Task Force on AMR Containment
2011 Publication of the Situation Analysis on AMR
2011 Publication of National Policy on AMR Containment
2011 Jaipur Declaration on AMR Containmentontainment
2011 The Food Safety and Standards (Contaminants, Toxins and Residues) Regulations
in seafood
2011 Establishment of the National Programme on AMR Containment under the
Twelfth Five Year Plan (2012–2017)
2012 National Program on Antimicrobial Stewardship, Prevention of Infection and
Control by ICMR
2013 Establishment of a National AMR Surveillance Network by NCDC and ICMR
2014 Inclusion of antibiotics in Schedule H1 category to avoid nonprescription sales of
antibiotics
Table ES-1: 2016 Launch of the Red Line Campaign on Antibiotics to create awareness on rational
use of antibiotics
Timeline of AMR Policy–
Related Activities in India 2016 Publication of National Treatment Guidelines for Antimicrobial Use in Infectious
Diseases by NCDC
2016 National address by prime minister on the issue of antibiotic resistance in his
Man Ki Baat (a radio program hosted by the honorable prime minister of India) in
August
2017 Publication of the National Action Plan for Containment of AMR and Delhi
Declaration
in food animals
2
https://timesofindia.indiatimes.com/india/Lancet-says-sorry-for-Delhi-bug-/articleshow/7261135.
cms?referral=PM
12
THE ANTIMICROBIAL
RESISTANCE RESEARCH
LANDSCAPE IN INDIA
Overall summary of researchers based in Indian institutions
were identified. The breakdown of these
studies
publications into major categories is
A total of 2,152 studies published by shown in Figure ES-9.
Figure ES-9:
Number of publications in
each of the seven categories
of AMR research (N=2,152)
There were approximately 630 of Medical Sciences, New Delhi, with

institutions with at least one 2.5% of the total publications. The top
publication on AMR. Christian Medical 10 institutions that published AMR-
College, Vellore, accounted for 3.1% of related research studies are shown in
the total publications (excluding review Figure ES-10.
studies), followed by All India Institute
Figure ES-10:
Top 10 institutions with

AMR publications by
category (excluding review
publications)
13
RECOMMENDATIONS Humans
FOR FUTURE STUDIES àà Understanding transmission
mechanisms by which antibiotic
This mapping exercise indicates that
resistance spreads in hospitals and
AMR research studies in India were
in the community
of limited scope in all areas, including
àà Developing and studying the
humans, animals, environment,
impact of various antimicrobial
and others. In humans, the majority
stewardship activities and
were retrospective single-center
infection control measures in
surveillance-based studies examining
healthcare facilities with varying
the prevalence of phenotypic resistance
resources and in the community
and molecular characterization of
àà Examining the impact of
resistance for various pathogens.
behavioral interventions on
Animal studies were confined to
antibiotic use in healthcare
examining resistance profiles of
settings and in the community
bacteria isolated from food animals;
àà Developing methods for
studies examining the frequency of
communicating the issue of
antibiotic use and reasons for use
antibiotic resistance to the general
during animal rearing were absent.
public and healthcare workers and
Similarly, environmental studies were
studying their impact on antibiotic
confined to examining resistance
use
profiles of bacteria or antibiotic
àà Focusing on the burden of
resistance genes isolated from various
antibiotic resistance in various
water bodies. Novel agent studies were
groups (neonates, children,
limited to in vitro experiments, and
young adults, the elderly) in the
none of them progressed to clinical
community and in various levels of
evaluation. Studies concentrating
healthcare settings
on comprehensive understanding of
àà Studying supply systems and
molecular mechanisms of emerging
market dynamics of antibiotic
resistance among various pathogens
production to understand the lack
were lacking. A limited number of
of availability of narrow-spectrum
studies focused on new diagnostics
antibiotics or old antibiotics such
and interdisciplinary studies. Studies
as penicillin
categorized as “one health” were
merely surveillance studies looking at Animals
the resistance proportion in various àà Conducting large-scale studies on
bacteria isolated from humans, surveillance of antibiotic resistance
animals, and the environment. Studies in food animals
examining the impact of various àà Conducting large-scale studies on
policies were also lacking. The following antibiotic use for various purposes
research in various categories is (growth promotion, prophylaxis,
urgently needed in India:
14
treatment) among food animals, àà Focusing on waste management to

especially in poultry reduce the contamination of rivers
àà Understanding the social aspects during religious mass gatherings
of antibiotic use in food animals àà Developing novel technologies
and subsequent behavioral to remove antibiotic-resistant
interventions bacteria and ARGs from STPs and
àà Studying variations in antibiotic hospital wastewater
use in different farming practices, àà Examining behavioral aspects
such as industrial and backyard of human waste disposal and its
farming contribution to the problem of
àà Examining alternative practices antibiotic resistance
of food animal rearing and their
Others (novel agents,
economic impacts
àà Focusing on supply systems and
diagnostics, one health,
market dynamics of antibiotic miscellaneous):
production for animal use àà Studying novel diagnostics and
àà Understanding transmission their impact on antibiotic use and
mechanisms by which antibiotic clinical outcomes in humans
resistance spreads from food àà Understanding molecular
animals to humans mechanisms of bacterial resistance
àà Focusing on the one health
Environment
approach to understand the
àà Studying the extent of transmission mechanisms by
environmental antibiotic pollution which antibiotic resistance can
through pharmaceutical industrial spread between different (animal,
waste (wastewater, solid waste and human, environmental) reservoirs
air) in various parts of India àà Studying the relative contribution
àà Developing standards and of different reservoirs to the
detection tools for antibiotic burden of antibiotic resistance.
residues in pharmaceutical
industrial effluents
àà Examining acquisition of
antibiotic-resistant bacteria during
religious mass gatherings in rivers
15
SECTION
BACKGROUND AND
1
PURPOSE
Antimicrobial resistance (AMR) is a and promoting growth and preventing

major public health problem globally. disease in livestock and other food
AMR is the ability of microorganisms animals. However, several bacterial
(bacteria, virus, fungi, parasites) to organisms have become resistant to
overcome the effect of antimicrobials more than one antibiotic, and resistance
(antibiotics, antivirals, antifungal, to last-resort antibiotics is increasing.
antiparasitic agents) and continue Declining antibiotic effectiveness has
to proliferate, whereas antibacterial risen from being a minor problem to
resistance (ABR) refers to the ability a major societal threat, regardless of a
of bacteria to overcome the effect of country’s income or the sophistication
antibiotics and continue to multiply. of its healthcare system.
While all types of AMR are concerning,
Bacteria are present everywhere,
ABR is seen as currently posing the
including in every living being and
most serious health threat. This is
in the soil, water, and air. With the
because routine bacterial infections are
interconnected ecosystems, the
much more common, making antibiotic
exchange of bacteria is continuous,
consumption significantly greater than
and thus the ABR problem is no longer
consumption of other antimicrobial
limited to medical science. It requires
agents, and infections with resistant
effective collaboration among several
bacteria are associated with adverse
disciplines, such as microbiology,
health outcomes.
evolutionary biology, epidemiology,
The discovery of antibiotics in the 1940s ecology, sociology, and engineering.
revolutionized medical care and had an Accordingly, a multidisciplinary
enormous impact on human and animal approach involving medical scientists,
health. The role of antibiotics expanded natural scientists, sociologists, engineers,
from treating serious infections to economists, and communication
preventing infections in surgical specialists is needed to overcome ABR.
patients, protecting cancer patients
16
India is among the countries with the research across multiple disciplines
highest bacterial disease burden in the to come up with comprehensive and
world, and thus the consequences of creative solutions to overcome AMR.
ABR could be devastating. Considering As the first step, the Department for
the complex nature of the ABR Biotechnology (DBT), government of
problem, no individual nation has the India, in partnership with Research
capacity to address this major public Councils UK (RCUK) decided to
health problem independently. In undertake mapping of AMR research in
response, the United Kingdom and India. The aims of the mapping exercise
India came together to fight against are to understand the current situation
AMR, in November 2016, with a new of AMR, with particular focus on ABR
£13million UK-India research program. in India, and to identify the current
The goal of this initiative was for the research gaps to determine the future
UK and India to conduct collaborative research priorities in India.
17
SECTION
METHODOLOGY
2
Considering the complex nature of and read to determine whether they
AMR, the United Kingdom and India should be included. Articles relating
bilateral collaborative initiative is a to tuberculosis, malaria, leprosy,
welcoming move and exemplifies the nontuberculous mycobacteria, and HIV
appropriate strategy to overcome the were excluded. Research publications
threat of AMR. This research mapping not associated with Indian-based
exercise is confined to ABR and does institutions were also excluded.
not include mapping of research for Duplicate articles from both databases
tuberculosis and other non-bacterial were identified and removed.
infections like malaria and HIV. Other
The following information was
studies (e.g., Maharana and Maharana
extracted from articles:
et al. 2014) have recently conducted
research mapping exercises on àà Title
tuberculosis and malaria in India. àà Year of publication
àà Authors’ names
To understand the AMR situation àà First or corresponding author and
and research landscape in India, we his or her institution
searched the PubMed and Google àà State where the institution was
Scholar databases for literature relating located
to AMR in India, using the following
If the first author and corresponding
search terms: “antimicrobial OR
author were affiliated with different
antibiotic AND resistance AND India.”
institution, we considered the
The search was limited to the last five
corresponding author’s institution only.
years (July 1, 2012, to June 30, 2017).
In addition, each article was assigned to
Articles were screened and selected
one of the following eight categories:
based on their titles and extracted.
If articles could not be selected by àà Humans: Studies that focused on
title name, abstracts were read, and if humans
necessary, full articles were obtained àà Animals: Studies that focused on
18
animals, including agriculture aspects, policy, or regulatory

àà Environment: Studies that aspects related to antibiotic use
focused on the environment and resistance
àà Novel agents: Studies that àà Transmission: Studies that
focused on natural or synthetic focused on understanding
compounds with antimicrobial transmission of resistant bacteria
activity in humans
àà Diagnostics: Studies that focused As the above methodology does not
on new diagnostics capture the current ongoing research
àà One health: Studies that activities, we sent a questionnaire to
focused on a combination of these lead researchers in the field of AMR
categories: humans, animals, or identified in through this mapping
the environment exercise, asking about their current
àà Reviews/editorials: Studies that ongoing research activities. All the
did not include primary research information was entered into Microsoft-
àà Miscellaneous: Studies that Excel (2013) and subsequently
did not fit into any of the above imported into STATA v15.0 (StataCorp,
categories College Station, Texas, USA), and
If a study would fit into more than one descriptive analysis was conducted.
category, it was assigned to only one
Although the majority of studies
main category. Human studies were
included in the section on the AMR
subcategorized as follows:
situation in India (section 3) were
àà Surveillance: Studies that from the five-year study period, we
reported prevalence of antibiotic included some important studies
resistance (phenotypic and that are related to AMR but were not
molecular) or antimicrobial use part of the study period and were not
in various settings, including conducted in India. For example, we
hospitals and the community included some new studies that were
àà Clinical: Studies that assessed published before July 1, 2012, or after
clinical outcomes of infections, June 30, 2017, and government reports
risk factors, or effects of new that are not identified in the literature
interventions (such as treatments, search. The AMR research landscape
stewardship, infection control), or section (section 4) and the discussion
case reports related to antibiotic and recommendations section (section
resistance 5) were entirely based on published
àà Social: Studies that involved studies during the five-year study
knowledge, attitude, behavior, period.
practices, ethical issues, economic
19
SECTION
3
THE ANTIMICROBIAL
RESISTANCE SITUATION IN
INDIA
3.1. Antimicrobial al. 2015). There was a steady decrease

Resistance in Humans in the use of public hospitalization
services between 1995 and 2014 in
3.1.1. Healthcare delivery in both urban and rural areas (Patel et
India al. 2015). In India, the total number
of doctors, nurses, and midwives is
Healthcare services in India are
11.9 per 10,000 population, which is
delivered by both public and private
half the World Health Organization
sector (Gupta and Bhatia 2017; Patel
(WHO) benchmark of 25.4 workers
et al. 2015). The public healthcare
per 10 000 population (Rao et al.
system is a three-tier structure, divided
2011). The private health sector ranges
into primary, secondary, and tertiary
from individual private clinics to large
care services. All services at public
tertiary care hospitals. The majority of
facilities, including preventive care,
individuals providing private primary
diagnostic services, and outpatient
care services, particularly in rural areas,
and inpatient hospital care, are
have no formal training (Rao et al. 2011;
delivered free of charge (Gupta and
Das J et al. 2015). The private hospital
Bhatia 2017). Medications that are
sector has expanded rapidly in the last
part of the essential drug list, including
two decades due to India’s economic
antimicrobials, are free, while other
liberalization, growing middle class,
prescription drugs are purchased from
and rise in medical tourism (Gupta and
private pharmacies (Patel et al. 2015).
Bhatia 2017). In 2014, the private sector
Although public healthcare services are
accounted for 70% of outpatient care
available to all citizens, poor quality of
and 60% of inpatient care (Patel et al.
services and severe shortages of staff
2015). Out-of-pocket payments made
and supplies force individuals to seek
at the point of service account for 70%
private care (Rao et al. 2011; Patel et
20
of healthcare expenditures (Patel et al. isolated from bloodstream infections

2015; Das J et al. 2015). There is limited (Table 3.1). Resistance to the broad-
uptake of voluntary private insurance spectrum antibiotics fluoroquinolones
in spite of tax exemptions for insurance and third-generation cephalosporin
premiums (Gupta and Bhatia 2017). was more than 70% in Acinetobacter
However, private insurance covers only baumannii, Escherichia coli, and
hospitalizations and not outpatient Klebsiella pneumoniae, and more than
services. 50% in Pseudomonas aeruginosa.
The proportion of resistance to the
3.1.2. Resistance rates in
carbapenem class of antibiotics,
humans by bacteruim
considered to be one of the last-
India has some of the highest antibiotic resort agents, was very high among
resistance rates among bacteria that these four gram-negative bacteria.
commonly cause infections in the Approximately 70% of A. baumannii,
community and healthcare facilities. 57% of K. pneumoniae, more than 40%
A recent national-scale laboratory- of P. aeruginosa, and more than 10%
based study (Gandra et al. 2016) of E. coli were carbapenem resistant
and data from the newly established (Figure 3.1). Unfortunately, resistance
Indian Council of Medical Research to colistin, which is the last-resort
(ICMR) AMR surveillance network1 antibiotic in human medicine, also
showed high levels of resistance emerged in these four organisms (Table
to first-line and broad-spectrum 3.1).
antibiotics among various bacteria Table 3.1:
Percentage of resistance
to various antibiotics
among four gram-
negative bacteria isolated
from blood cultures
Gram-negative Study Year Ciprofloxacin Ceftriaxone/ Meropenem/ Piperacillin- Colistin

bacteria of data ceftazidime imipenem tazobactam
collection
Gandra 2014 84% 93% 67.3% — 4.1%

Acinetobacter et al. 2016
baumannii ICMR 2015 — 83.1% 70.9% — —
2015
Gandra 2014 85.1% 83.3% 11.5% 37.3% 3.1%
Escherichia et al. 2016
coli ICMR 2015 76.4% 79% 16.2% 34% 0.2%
2015
Klebsiella Gandra 2014 72.9% 79.9% 56.6% 62.7% 3.2%
pneumoniae et al. 2016
ICMR 2015 — 86.9% 56.6% 64.6% 0.5%
2015
Pseudomonas Gandra 2014 55% 67.9% 46.8% 61.8% 0%
aeruginosa et al. 2016
ICMR 2015 54.5% 44.9% 41.8% 26.9% 0.6%
2015
The ICMR AMR surveillance network includes 2015 data from four tertiary care hospitals. This information was
1
obtained from ICMR for the purpose of this report.

21
Gandra S et. al 2016 ICMR 2015
Figure 3.1:
Carbapenem
(meropenem/imipenem)
resistance among four
gram-negative bacteria
isolated from blood
cultures
Source: Gandra et al.
(2016); ICMR (2015).
Among gram-positive bacteria, the Streptococcus pneumoniae, which is a

proportion of methicillin-resistant major cause of pneumonia in children
Staphylococcus aureus (MRSA) was in India, shows a high level of resistance
46.5% in the study by Gandra et al. to first-line antibiotics. A prospective
(2016) and 42.6% in the ICMR AMR multihospital-based study in 11 states
surveillance network. Vancomycin- examining resistance in S. pneumoniae
resistant and linezolid-resistant S. between 2011 and 2015 among children
aureus were also reported (Table 3.2). younger than five years of age showed
For Enterococcus faecium, Gandra 66% resistance to trimethoprim-
et al. (2016) found that ampicillin sulfamethoxazole (TMP-SMX), 37%
resistance was 97.1% and vancomycin to erythromycin, and 8% to penicillin
resistance was 10.5% (Table 3.2). (Manoharan et al. 2017).
Gram-negative Study Year of data Ampicillin Cefoxitin/ Linezolid Vancomycin

bacteria collection oxacillin
Table 3.2:
Percentage of resistance Gandra 2014 — 46.5% 0.6% 1.7%

to various antibiotics Staphylococcus et al. 2016
among Staphylococcus aureus ICMR 2015 — 42.6% 0% 0.2%
aureus and Enterococcus 2015
faecium isolated from Enterococcus Gandra 2014 97.1% — 1.7% 10.5%
blood cultures faecium et al. 2016
22
The percentage of resistance to resistance decreased from 13.1% in

broad-spectrum antibiotics among 2008 to 5.3% in 2014, and TMP-SMX
bacteria causing enteric fever and resistance decreased from 17.1% in
gastrointestinal infections was also 2008 to 4.2% in 2014. Among Shigella
high (Table 3.3). In Salmonella species, resistance to ciprofloxacin and
Typhi, ciprofloxacin resistance was TMP-SMX was 80% and resistance
approximately 30% in the study by to ampicillin was 100% in one study
Gandra et al. (2016) and the ICMR (Bhattacharya et al. 2012) (Table 3.3).
surveillance network. Ceftriaxone- Among Vibrio cholerae, ampicillin
resistant S. Typhi strains were also resistance ranged from 64% to 100%,
reported (Table 3.3). Interestingly, furazolidone resistance was more than
Gandra et al. (2016) found that for S. 75%, and tetracycline resistance ranged Table 3.3:
Typhi, resistance to the older antibiotics from 17% to 75% in two studies (Mandal
ampicillin and TMP-SMX decreased et al. 2012; Raytekar et al. 2014) (Table to various antibiotics
over the seven-year period. Ampicillin 3.3). among Salmonella
Typhi, Shigella species,
and Vibrio cholerae
Bacteria Study Year Ampicillin Ceftriaxone Ciprofloxacin Tetracycline TMP/

of data SMX
collection
Gandra 2014 5.3% 1.7% 29% — 4.2%

Salmonella et al. 2016
Typhi
ICMR 2015 6.3% 0.6% 27.9% — 2.3%
Bhattacharya 2000– 72.7% 0% 0% — 57.6%
Shigella et al. 2012 2002
species Bhattacharya 2006– 100% 12% 82% — 80%
et al. 2012 2009
Mandal 2008– 64.3% 2% 3.2% 16.9% —
Vibrio et al. 2012 20010
cholerae Raytekar 2009– 100% — 79% 75% 100%
et al. 2014 20012
Similarly, a high proportion of Although resistance to ceftriaxone was

antibiotic resistance was also observed not detected, decreased susceptibility
in Neisseria gonorrhoeae, which is a to ceftriaxone was observed, and this
major cause of sexually transmitted percentage increased from 0.8% in
infection (Table 3.4). One study in 2002–2006 to 1.5% in 2007–2012.
the regional reference laboratory
comparing the antibiotic resistance
of N. gonorrhoeae between 2002–
2006 and 2007–2012 showed that
ciprofloxacin resistance increased
from 78% to 89.7% and azithromycin
resistance increased from 0.8% to
1.5% (Bala et al. 2015) (Table 3.4).
23
Table 3.4: Study Years of data Ciprofloxacin Azithromycin Ceftriaxone Tetracycline Tetracycline
collection
Bala 2002–2006 78% 0.8% 0 13.6% —
to various antibiotics et al. 2015
among Neisseria
Bala 2002–2006 78% 0.8% 0 13.6% —
gonorrhoeae
et al. 2015
Finally, multidrug-resistant (MDR) options, and treatment options vary by

and extensively drug-resistant (XDR) individual carbapenemases (Falagas
Mycobacterium tuberculosis cases are et al. 2013). In India, New Delhi
increasingly reported in India. India metallo-beta-lactamase-1 (NDM-1), or
has the highest burden of tuberculosis blaNDM-1, has been the predominant gene
(TB), with an estimated incidence of 2.8 encoding for carabpenem resistance
million cases in 2015, accounting for in Enterobacteriaceae, and blaKPC is
27% of global TB cases (TB India 2017). not frequently detected (Logan and
The incidence of MDR-TB was 4.6%, Weinstein 2017). However, recent
accounting for 27% of global MDR-TB studies indicate increasing occurrence
cases. In a recent review, XDR-TB cases of blaOXA-48 (Table 3.5). In a single center
varied from 0.3% to 60% of MDR-TB study, which examined 115 isolates of
cases in India (Prasad et al. 2017). carbapenem-resistant K. pneumoniae
collected between 2015 and 2016
3.1.3. Carbapenemases
from bloodstream infections, 19% of
The carbapenem class of antibiotics them had blaNDM, 13% had blaOXA-48,
is one of the last-resort antibiotics to and 28% had both blaNDM and blaOXA-48
treat serious gram-negative infections (Veeraraghavan et al. 2017). Another
in humans. Carbapenemases are study that examined 45 carbapenem-
beta-lactamase enzymes produced by resistant E. coli isolates obtained from
bacteria and are capable of neutralizing urinary tract infections showed the
various classes of antibiotics, presence of blaNDM in all isolates, but
including penicillins, cephalosporins, 55% of them also had the blaOXA-48
monobactams, and carbapenems, gene (Khajuria et al. 2014). This
making them ineffective when coexpression of two carbapenemases
administered (Falagas et al. 2013). (blaOXA-48 & blaNDM) is alarming, as it
Infections arising from carbapenemase- poses additional challenges to treating
producing bacteria are difficult to infections caused by these bacteria.
treat, as there are limited therapeutic
Study Organism Specimen % blaNDM % blaOXA-48 % blaOXA-48 &

Table 3.5: blaNDM
Veeraraghavan et al, K. Blood 19% 13% 28%
Different types of 2017 pneumoniae
carbapenemases in Khajuria et al. 2014 E. coli Urine 45% 0 55%
Enterobacteriaceae
detected in India
24
3.1.4. Colistin resistance Figure 3.2:
Colistin is considered to be the last- Mortality associated

resort antibiotic in human medicine. with dual carbapenem-
and colistin-resistant
With increasing use of colistin for
Klebsiella pneumoniae
treatment of carbapenem-resistant bloodstream infections
gram-negative bacterial infections, Source: Kaur et al. (2017).
colistin resistance has emerged in India
(Kaur et al. 2017; Pragasam et al. 2016;
Manohar et al. 2017). In a single center
study, bloodstream infections due to
dual carbapenem- and colistin-resistant
K. pneumoniae were associated
with 69.3% mortality among Indian
patients (Kaur et al. 2017) (Figure
3.2). However, the presence of plasmid found to be the two most frequent
mediated colistin resistance genes mcr- organisms isolated in neonatal sepsis
1 and mcr-2 was not detected frequently cases (Chaurasia et al. 2016). In this
(Pragasam et al. 2016; Manohar et study, 82% of the Acinetobacter species
al. 2017). So far, only one study has and 54% of the Klebsiella species were
reported the presence of the mcr-1 gene MDR, defined as resistant to three or
in E. coli isolated from the urine sample more antibiotic classes. However, the
of a hospitalized patient (Kumar et al. most concerning issue is that 78% of
2016). Acinetobacter species and 35% of the
3.1.5. Neonatal infections due Klebsiella species were carbapenem
to antibiotic-resistant bacteria resistant.
Antibiotic-resistant bacterial infections 3.2. Antibiotic Resistance

are increasingly reported among in Food Animals
neonates. A review of bloodstream
infections among neonates and The use of antibiotics in food animals
children between 2000 and 2015 in plays a major role in human health,
India showed that the most common as antibiotic-resistant bacteria can
pathogens isolated were S. aureus be transmitted between humans and
and Klebsiella species (Dharmapalan animals through contact, in food
et al. 2017). Among the S. aureus products, and from the environment
isolates, 50% were methicillin- (Landers et al. 2012). The same
resistant S. aureus (MRSA), and antibiotics used to treat human
63% of Klebsiella species were third- infections are commonly used in
generation cephalosporin resistant. animals, raising the concern about
In a recent prospective cohort study diminishing the effectiveness of these
conducted between 2011 and 2014 in agents at the expense of human health.
three neonatal intensive care units With a rise in incomes, there has been
(NICUs) in New Delhi, Acinetobacter an increase in the demand for animal-
species and Klebsiella species were derived protein in India. From 2000
25
to 2030, it is expected that poultry broiler chickens indicates increased

consumption will increase by 577% use of antibiotics either for growth
in India (Van Boeckel et al. 2015). promotion or for prophylaxis to prevent
Similarly, India is the largest producer infection during their short lifespan
of milk and second-largest producer of (Sahu and Saxena 2014). Two other
fish, and this production continues to studies (Shrivastav et al. 2016; Kar et
increase (State of Indian Agriculture al. 2015) showed that the proportion
2015–16). This is leading to intensive of ESBL-producing E. coli in poultry
farming with increasing reliance was 33.5% and 9.4%, respectively. Few
on antibiotics in place of improving studies examined for the presence and
hygiene and sanitation. Although antibiotic susceptibility of Salmonella
a limited number of studies were species in chicken meat samples and
conducted in food animals, high levels in samples from healthy chickens and
of antibiotic-resistant bacteria were their environment. In one study, the
identified. prevalence of Salmonella species in
chicken meat samples was 7%, and they
3.2.1. Antibiotic-resistant
were 100% resistant to erythromycin
bacteria in poultry
but 100% sensitive to ciprofloxacin
In a recent study involving 18 poultry (Naik et al. 2015). In a second study,
farms, 1,556 isolates of E. coli obtained the prevalence of Salmonella species in
from cloacal samples of 530 birds were chicken meat samples was 23.7%, and
tested for susceptibility to 11 antibiotics they were 100% resistant to ampicillin,
(Brower et al. 2017). Resistance profiles moderately sensitive to ciprofloxacin,
were significantly different between and highly sensitive to ceftriaxone
broiler and layer farms. Broiler farms (Kaushik et al. 2014). A study by
were 2.2 times more likely to harbor Samanta et al. (2014) found that the
resistant E. coli strains than layer prevalence of Salmonella species in
farms. Increased prevalence of ESBL- healthy chickens and their environment
producing strains was observed in was 6.1%, and they were 100% resistant
broiler farms (87% compared with 42% to ciprofloxacin, gentamicin, and
in layers) (Table 3.6). Broiler chickens tetracycline. In another study, the
are bred for meat; they grow rapidly prevalence of Salmonella species
and live for less than eight weeks was 3.1%, and they were moderately
before they are slaughtered (Sahu and resistant to various antibiotics (Singh et
Saxena 2014). The high resistance in al. 2013) (Table 3.6).
26
Study Year(s) of Specimen Organism Findings

data collection
and state
2014 Cloacal swab samples Not ESBL producing strains (%)

Brower Punjab Broilers (n=270) applicable
et al. 2017 Layers (n=260) Broilers: 87% of cloacal swabs
Layers: 42% of cloacal swabs
2015 Cecal swabs E. coli ESBL producers (%)
Shrivastav
Madhya (n=400)
et al. 2016
Pradesh Broilers: 33.5%
2013–2014 Fecal sample E. coli ESBL producers (%)
Kar
Odisha (n=170)
et al. 2015
Poultry: 9.4%
2013–2014 Chicken meat Salmonella Prevalence of Salmonella: 7%
Chattisgarh samples (n=200) species Resistance %
Naik
(n=14) Ciprofloxacin:0%
et al. 2015
Erythromycin:100%
Oxytetracycline: 42.8%
2010–2013 Chicken meat Salmonella Prevalence of Salmonella: 23.7%
Bihar samples (n=228) species 100% resistance
(n=54) AmpicillinGentamicin
Kaushik
Highly sensitive Ceftriaxone
et al. 2014
Azithromycin
Moderately sensitive Ciprofloxacin
Tetracycline
Year not Cloacal samples, Salmonella Prevalence of Salmonella: 6.1%
mentioned eggs and environment species Resistance %
Samanta West Bengal samples of backyard (n=22) Ciprofloxacin: 100%
et al. 2014 poultry flocks (n=360) Gentamicin: 100%
Tetracycline:100%
Ceftriaxone: 0
Year not Cloacal samples, Salmonella Prevalence of Salmonella- 3.3%
mentioned eggs and environment species Resistance%
Singh Uttar Pradesh samples (n=720) (n=26) Ampicillin: 0%
et al. 2013 Ciprofloxacin: 11.5%
Gentamicin: 7.7%
Tetracycline:23.1%
Table 3.6:
3.2.2. Antibiotic-resistant from buffaloes with mastitis isolated Antibiotic resistance in

bacteria in livestock coagulase negative staphylococci poultry in various studies
(CONS) (n=125), streptococci (n=35), in India
Among livestock, several studies
S. aureus (14), and E. coli (n=21).
focused on the resistance profile of
Oxacillin resistance among CONS,
bacterial pathogens isolated from milk
streptococci, and S. aureus was 5.6%,
obtained from animals with clinical
28.6%, and 21.4%, respectively. With
or subclinical mastitis. Vancomycin-
E. coli, all isolates were resistant to
resistant S. aureus was isolated
ampicillin, whereas resistance to
from milk samples in one study
ceftriaxone and enrofloxacin was 42.1%
(Bhattacharyya et al. 2016) (Table 3.7).
and 47.4%, respectively. One study
In this study, 3.2% of S. aureus isolates
reported isolation of Streptococcus
obtained from cow milk and 2.4% of S.
agalactiae from milk samples of cows
aureus isolates obtained from goat milk
suffering from mastitis and found
were found to be vancomycin resistant.
that 11.1% of S. agalactiae isolates
A Southern Indian study (Preethirani et
were resistant to ampicillin (Jain et al.
al. 2015) that examined milk obtained
2012). In another study, various gram-
27
negative organisms were isolated from samples. The study reported high
milk samples among cattle suffering resistance to ampicillin (100%) and
from mastitis, of which 48% were ESBL moderate resistance to streptomycin
producers (Das et al. 2017). One study (57.89%) and oxytetracycline (47.37%).
reported detection of the blaNDM-1 gene A lower percentage of resistance was
in E. coli isolated from milk samples of observed for TMP-SMX (13.16%) and
cows suffering from mastitis (Ghatak et chloramphenicol (5.26%). Among pigs,
al. 2013) (Table 3.7). two studies reported detection of ESBL-
producing E. coli from fecal samples
A study examined the presence of
of health pigs (Lalzampuia et al. 2013;
bacteria among raw milk samples
Samanta et al. 2015). Interestingly,
obtained from various sources such
the prevalence of ESBL-positive E. coli
as household milk, milk from cattle
was higher from backyard pig farms
farms, and milk vendors (Thaker et
(28%) than from organized farms (8%)
Table 3.7: al. 2012). In this study, E. coli isolates
(Samanta et al. 2015) (Table 3.7)
Antibiotic resistance were found in 38 of the 100 raw milk
in livestock in various
studies in India
Study Livestock Year(s) Specimen source Organism Findings

of data
collection
and state
Cows 2012–2015, Milk samples S. aureus (n=274) Vancomycin resistant
Bhatta-
Goats West Bengal (subclinical and Cow (n=211) S.aureus
charyya
clinical mastitis) Goat (n=63) Cows: 2.4%,
et al. 2016
(354 samples) Goats: 3.2%
Cows 2009–2010, Raw milk S. aureus Antibiotic resistance
Tamil Nadu (clinical/ (n=152) Ampicillin: 3.9%
subclinical Erythromycin:13.8%
Mubarack
bovine mastitis) Gentamicin: 0%
et al. 2012
(250 samples) Penicillin: 41.4%
Streptomycin: 25.7%
Tetracycline:11.8%
Buffaloes Year not Milk samples Coagulase negative Oxacillin resistance %
mentioned, (subclinical and Staphylococci CONS: 5.6%
Karnataka clinical mastitis) (CONS) (n=125) S. aureus: 21.4%
(190 samples) S. aureus (n=14) Streptococcus
Preethirani
Streptococcus s species: 28.6%
et al. 2013
pecies (n=35) E. coli resistance %
E. coli (n=19) Ampicillin:100%
Enrofloxacin: 47.4%
Ceftriaxone: 42.1%
Cows Not Milk samples Streptococcus Resistance %
(89 mentioned (subclinical agalactiae (n=27) Ampicillin: 11.1%
cows) mastitis) TMP-SMX: 11.1%
Jain Enrofloxacin: 7.4%
et al. 2012 Erythromycin: 33.3%
Gentamicin: 3.7%
Streptomycin: 85.1%
Tetracycline: 55.5%
Cattle Year not Milk samples Gram-negative ESBL producers: 48%
mentioned, (subclinical organisms (n=50)
Das West Bengal mastitis) (Escherichia coli,
et al. 2017 Proteus, Pseudomonas,
Klebsiella, and
Enterobacter)
28
Cattle 2012, Milk samples E. coli One isolate

Ghatak West (subclinical and (n=8) harbored
et al. 2013 Bengal clinical mastitis) blaNDM-1
Cattle 2011, Raw milk E. coli Resistance %

Gujarat (100 samples) (n=38) Ampicillin: 100%
individual Amoxy-clav: 42.11%
Thaker household, Chloramphenicol: 5.26%
et al. 2012 cattle farms, Co-trimoxazole: 13.16%
milk collection Streptomycin: 57.89%
centers, Oxytetracycline: 47.5%
and milk vendors
Pigs 2011–2012, Fecal samples E. coli (n=102), ESBL producers

Mizoram (53 samples) Salmonella E. coli: 5.8%
species (n=26) K. pneumoniae: 0%
Lalzampuia Klebsiella Salmonella species: 0%
et al. 2013 pneumoniae
(n=10)
Pigs 2012, Rectal swabs E. coli (organized, ESBL Producers

West (200 samples) n=48, backyard, Organized farms: 8%
Bengal 4 organized n=28) Backyard farms: 28%
farms (n=100)
Samanta
10 backyard
et al. 2015
farms (n=100)
3.2.3. Antibiotic-resistant involving tilapia fish obtained from

bacteria in aquaculture urban lakes and rivers in Karnataka,
42% of Enterobacteriaceae isolates
A limited number of studies examining
obtained from the gut of tilapia fish
resistance in fish and shrimp were
were ESBL producers (Marathe et al.
conducted. A study from Cochin and
2016). In another study, Vibrio species
Mumbai coast (Visnuvinayagam 2014)
associated with food poisoning were
involving 252 S. aureus isolates from
identified among shrimp, shellfish, and
105 fish samples identified only one
clams obtained from retail markets in
MRSA isolate, whereas resistance
Kerala. These Vibrio species were 100%
to tetracycline, TMP-SMX, and
resistant to ampicillin but remained
vancomycin was 3.2%, 4.8%, and 0%,
highly sensitive to chloramphenicol
respectively (Table 3.8). In a study
(Sudha et al. 2014).
29
Study Fishery Year(s) Source Organism Findings

animal of data
collection
and state
Fish Year not Skin and S. aureus Resistance %
(commercial mentioned, muscle tissue (n=252) Oxacillin: 0.4%
Visnuvi-
fishery Kerala, of fish Tetracycline: 3.2%
nayagam
outlets) Maharashtra (105 samples) Co-trimoxazole: 4.8%
et al., 2015
Vancomycin: 0%
Tilapia fish Year not Gut content Entero- ESBL

(lakes and mentioned, of the fish bacteriaceae producers: 42%
Marathe rivers) Maharashtra strains (n=34)
et al. 2016
Shellfish: 2010–2011, Gut of Vibrio species Resistance %

shrimp, Kerala shellfish (n=72) Vibrio species
crabs, clams (110 V. parahem- Ampicillin: 100%
(retail samples) olyticus Ceftazidime: 67%
markets) (n=24) Chloramphenicol: 0%
Sudha Tetracycline: 0%
et al. 2014 V. parahemolyticus
Ampicillin: 100%
Ceftazidime: 96%
Chloramphenicol: 0%
Ciprofloxacin: 0%
Table 3.8:
Antibiotic resistance in
aquaculture in various
3.3. Antibiotic Resistance country (CPCB 2013). Accordingly,
studies in India in the Environment published studies, although limited
in number, indicate high levels of
With the interconnectedness antibiotic-resistant bacteria and
of ecosystems, the role of the antibiotic resistance genes (ARGs) in
environment, particularly water, in various water bodies.
the spread of antibiotic-resistant
bacteria is increasingly gaining 3.3.1. Antibiotic-resistant
attention (Andremont and Walsh 2015). bacteria and genes in sewage
Antibiotic-resistant bacteria along with
and hospital wastewater
antibiotic residues are increasingly Hospital wastewater has high levels
contaminating the environment of antibiotic-resistant organisms. A
through ineffective industrial effluent study examining wastewater samples
and sewage management and in 2013 from three different sewage
subsequently recontaminating humans treatment plants (STPs) in South India
and animals through drinking water showed that hospital wastewater inflow
and food (Andremont and Walsh 2015). significantly increased the prevalence
The national water quality monitoring of third-generation cephalosporin-
results from 1995 to 2011 indicate resistant E. coli (Akiba et al. 2015).
gradual degradation in water quality, In this study, E. coli resistance
with increasing bacterial contamination to cefotaxime (third-generation
in critical water bodies across the cephalosporin) was 25%, 70%, and 95%
30
in STP with an inlet of domestic water, all three sources. Similarly, wastewater
in STP with an inlet of hospital and treatment plants (WWTPs) receiving
domestic waste, and in STP that had wastewater from bulk drug production
an inlet of only hospital wastewater, facilities are observed to have high
respectively (Akiba et al. 2015) (Figure levels of MDR organisms and could
3.3). However, E. coli resistance to act as breeding grounds for transfer of
imipenem was approximately 10% in ARGs (Marathe et al. 2013).
Figure 3.3:
E. coli resistance
to third-generation
cephalosporins among
sewage treatment plants
(STPs) receiving waste
from various sources
Source: Akiba et al. (2015).
3.3.2. Antibiotic-resistant isolates, 17.4% (40) isolates belonging

bacteria and genes in rivers to different groups of gram-negative
bacteria were found to be extended-
Major rivers in India have bacteria
spectrum beta-lactamase (ESBL)
with high levels of resistance to broad-
producers (Azam et al. 2016). Another
spectrum antibiotics such as third-
study involving water samples collected
generation cephalosporins. In a study
from rivers and sewage treatment
involving River Cauvery in Karnataka
plants (STPs) from the five Indian
in 2011–2012, 100% of 283 E. coli
states of Bihar, Goa, Karnataka, Tamil
isolates were found to be resistant
Nadu, and Telangana between 2013 and
to third-generation cephalosporins
2014 showed that 37.9% (169) of 446 E.
(Skariyachan et al. 2015) (Table 3.9).
coli isolates were resistant to extended
In a second study involving River
spectrum cephalosporins (ESC) (Akiba
Yamuna conducted in 2012–2014, out
et al. 2015) (Table 3.9). In addition
of a total of 230 nonduplicate bacterial
31
Table 3.9: River Study Years of Organisms Organism

study
Antibiotic-resistant Skariyachan 2011–2012 E. coli (n=283) Ampicillin: 100%
bacteria in various rivers et al. 2015 Cefotaxime: 100%
Cauvery
in India Ciprofloxacin: 75%
Imipenem: 15%
Azam 2012–2014 Gram-negative Ampicillin: 100%
et al. 2016 bacteria (n=230) Cefotaxime: 75%
Yamuna
Ciprofloxacin: 58%
Imipenem: 8%
Rivers from Akiba 2013–2014 E. coli (n=446) Extended spectrum

5 states et al. 2015 cephalosporins: 37.9%
to resistant organisms, ARGs that 2016; Devarajan et al. 2016), blaNDM-1

confer resistance to broad-spectrum gene (Ahammad et al. 2014; Devarajan
antibiotics including last-resort agents et al. 2016; Marathe et al. 2017), and
were detected in major rivers of India mcr-1 gene (Marathe et al. 2017) (Table
(Table 3.10). These include the blaCTX-M 3.10).
gene (Azam et al. 2016; Akiba et al.
River Study Year(s) of study Antibiotic resistance genes

Table 3.10:
Ahammad 2012 blaNDM-1, blaOXA-48
Presence of Ganga, et al. 2014
carbapenemases and Yamuna
colistin resistance genes
in Indian rivers Devarajan 2012–2013 blaNDM-1
et al. 2016
Cauvery
Marathe Unknown blaNDM-1, blaOXA-48, mcr-1

Mutha et al. 2017
3.3.3. Antibiotic-resistant of E.coli and 13% of Klebsiella species

bacteria and genes in surface were resistant to third-generation
water and groundwater cephalosporins (Kumar et al. 2013)
(Table 3.11). Another study involving
Studies have also shown potable water
water sources from streams, lake, tube
sources apart from rivers to have
wells, and community supply water in
bacteria with high levels of resistance
Kashmir in 2009–2010 showed that 7%
to broad-spectrum antibiotics (Table
of the E. coli were resistant to third-
3.11). A study involving water from
generation cephalosporins (Rather
drinking and recreational sources in
et al. 2013). A third study involving
the Ayodhya-Faizabad area, located on
natural sources of water from East
the bank of the River Saryu, collected
Sikkim in 2011–2012 showed that 50%
from the river, kunds (holy ponds),
of E. coli and 72% of Klebsiella species
ponds, tube well, hand pumps, piped
were resistant to third-generation
supply, and dug wells showed that 17%
cephalosporins (Poonia et al. 2014).
32
Another study involving four tap water in two. One tap water sample had
samples, one bore-hole water sample, Enterobacteriaceae and other gram-
and 23 environmental water samples negative bacteria that produced ESBL
in the Hyderabad area looked for the and carbapenemase (blaOXA-48) genes.
presence of Enterobacteriaceae and All 23 environmental water samples
other gram-negative bacteria (Lübbert had Enterobacteriaceae and other
et al. 2017). The environmental gram-negative bacteria. Alarmingly,
samples were obtained from rivers, 100% of the bacteria isolated from
lakes, groundwater, water sources the 23 environmental samples were
contaminated by sewage treatment ESBL producers, and more than 95%
plants, and surface water in the were carbapenemase producers, with
Table 3.11:
vicinity of bulk drug manufacturing blaOXA-48 being detected in 22 samples
units. Of the four tap water samples, (Table 3.11). Antibiotic resistance
in surface water and
the study did not detect any bacteria groundwater sources in
various studies in India
Place Study Water sources Organisms Resistance (%)

(selected list)
Kumar River, kunds E. coli (n=72) E. coli
et al. 2013 (holy ponds), Klebsiella Cefotaxime: 17%
Ayodhya- ponds, tube well, species (n=30) Norfloxacin: 35%
Faizabad hand pumps, Klebsiella species
piped supply, Cefotaxime: 14%
dug wells
Rather Streams, E. coli (n=60) E. coli
et al. 2013 Dal lake, Salmonella Ciprofloxacin: 0%
tube well species (n=12) Cefotaxime: 7%
Salmonella Gentamicin: 9%
Srinagar
species (n=12) Salmonella species
Nalidix acid: 100%
Ciprofloxacin: 9%
Cefotaxime: 17%
Poonia Streams E. coli (n=122) E. coli
et al. 2014 and springs Klebsiella Ampicillin: 69%
species (n=106) Cefixime: 50%
Sikkim
Gentamicin: 0%
District
Klebsiella species
Cefixime: 41.5%
Gentamicin: 0%
Lübbert Total of 28 samples: Enterobacteriaceae Findings:
et al. 2017 4 tap water samples, Other gram- In 2 (tap water)
1 bore-hole negative bacteria of 28 water samples,
water sample, and Enterobacteriaceae and
23 environmental other gram-negative
water samples in the vic bacteria were not detected
inity of bulk drug 1 of 4 tap water samples
Hyderabad manufacturing contained ESBL and
area units (rivers, lakes, carbapenemase-producing
water sources contaminat bacteriaOf the 23
ed by sewage treatment environmental samples,
plants, surface water) 100% of the isolates were
ESBL positive, and >95%
of the isolates were
carbapenemase producers
33
3.4. Factors Driving illness would result if treatment were

Antibiotic Resistance in delayed. However, unnecessary use of
broad-spectrum antibiotics leads to
India
increased prevalence of MDR bacteria
3.4.1. Antibiotic consumption (Asensio et al. 2011). From 2000
in humans to 2015, cephalosporin and broad-
spectrum penicillin consumption
Based on antibiotic sales data, in 2014,
increased rapidly, whereas narrow-
India was the highest consumer of
spectrum penicillin consumption was
antibiotics, followed by China and the
low and decreasing (Figure 3.4).
United States. However, the per capita
consumption of antibiotics in India is Use of broad-spectrum antibiotics,
much lower than in several other high- particularly third-generation
income countries (Laxminarayan et al. cephalosporins, has increased
2016). Why are resistance rates high in considerably. Between 2000 and 2015,
India? Some possible reasons for the the proportion of third-generation
high ABR rates are discussed in this cephalosporins among the total
section. antibiotics increased significantly,
while penicillin consumption
3.4.1.1. High consumption of
remained constant and the use of
broad-spectrum antibiotics
fluoroquinolones decreased (Figure
Broad-spectrum antibiotics are those 3.5). This increased use of third-
that are effective against a wide range generation cephalosporins is consistent
of disease causing bacteria, in contrast with the high prevalence of third-
to narrow-spectrum antibiotics, which generation cephalosporin-resistant E.
are effective against specific families of coli in India. Use of narrow-spectrum
bacteria. Broad-spectrum antibiotics antibiotics where possible is an
are generally prescribed empirically important strategy of antimicrobial
when there is a wide range of possible stewardship activity in overcoming
illnesses and a potentially serious
Figure 3.4:
Trends in antibiotic
consumption in India,
2000–2015
34
Figure 3.5:
Trends in proportion of
three antibiotic classes
among total antibiotics in
India, 2005–2015
The increasing use of third- inpatient settings (Gandra et al. 2017;

generation cephalosporins could Kotwani and Holloway 2014; Kotwani
be due to multiple factors. First, et al. 2015). The third reason is the
fluoroquinolones have been the lack of widespread availability of
mainstay of treatment for enteric narrow-spectrum agents such as first-
fever and bacterial dysentery, but generation penicillins (penicillin G,
with increasing quinolone resistance, benzathine penicillin) in contrast to
third-generation cephalosporins are third-generation cephalosporins in the
used as empiric treatment choices pharmacies (Kotwani and Holloway
for these two common infections 2013). Accordingly, a review of the
(Taneja 2007; Mukherjee et al. 2013; April–July 2017 edition of the Current
Gandra et al. 2016). The second reason Index of Medical Specialties (CIMS)
is changing prescribing practices INDIA shows that only one formulation
among healthcare providers. Third- company is making penicillin G or
generation cephalosporins are being benzathine penicillin, whereas 135
substituted for penicillins in the companies are manufacturing cefixime
treatment of upper respiratory tract (third-generation cephalosporin)
infections in outpatient settings and (Figure 3.6).
lower respiratory tract infections in
35
Figure 3.6:
companies
manufacturing various
antibiotics for human
use
Source: CIMS INDIA,

April–July 2017 edition.
3.4.1.2. Increasing faropenem situation and selection potential of

consumption faropenem with carbapenems.
With the increasing prevalence of 3.4.1.3. Antibiotic fixed-dose

community-acquired and healthcare- combinations
associated third-generation
Antibiotic fixed-dose combinations
cephalosporin-resistant bacterial
(FDCs) are combinations of two or
infections, penem and carbapenem
more active antibiotics in a single
consumption increased in India
dosage form. Antibiotic FDCs should
(Gandra et al. 2016). However, the
be prescribed when the combination
consumption of faropenem , which
has a proven advantage over single
is an oral penem, a broad-spectrum
compounds administered separately in
antibiotic, increased 150% between
therapeutic effect, safety, or compliance
2010 and 2014. In India, faropenem
(Gautam and Saha 2008). However,
is approved for treatment of a variety
in India, antibiotic FDCs are heavily
of common infections, including
prescribed even without the knowledge
respiratory tract, urinary tract, skin and
of a proven advantage over single
soft tissue, and gynecological infections.
compounds. In 2012, about 15% of total
The sharp increase in use of faropenem
drug sales were attributed to dual anti-
is of concern because of the potential
infectives.2 Lack of diagnostic precision
for cross-resistance to carbapenems. At
due to unavailability of diagnostic
present, susceptibility testing against
laboratory services has led to increased
faropenem is not routinely performed
use of antibiotic FDCs in India
in microbiology laboratories due to
(Gautam and Saha 2008). Injudicious
a lack of guidelines from the Clinical
use of antibiotic FDCs could lead to
& Laboratory Standards Institute
emergence of bacterial strains resistant
(CLSI) or the European Committee on
to multiple antibiotics. Approximately
Antimicrobial Susceptibility Testing
118 antibiotic FDCs are available in
(EUCAST). There is currently a lack of
India (Ahmad et al. 2016; Shankar et
understanding regarding the resistance
al. 2016). These FDCs include dual oral
2
http://www.pa2online.org/abstracts/vol13issue3abst135p.pdf.
36
broad-spectrum antibiotics such as cost to get allopathic services and

third-generation cephalosporins and instead approach informal healthcare
last-resort antibiotics such as linezolid. providers and chemists or pharmacists
The following are some of the common at pharmacy stores. In urban areas,
FDCs available in India: doctor fees and diagnostic investigation
àà azithromycin-cefixime charges may prevent people from
àà cefixime-ofloxacin visiting formal healthcare providers
àà cefixime-levofloxacin (Barker et al. 2017; Chandy et al. 2013).
àà cefixime-linezolid Factors associated with inappropriate
àà azithromycin-levofloxacin antibiotic prescribing among formal
3.4.2. Social factors healthcare providers depend on
whether they provide care in the
Several social factors have been
public or private sector. Among those
associated with inappropriate antibiotic
in the private sector, several factors
use in India among the general public
are associated with inappropriate
and formal healthcare providers.
antibiotic prescribing. First, doctors
Among the general public, such factors
may perceive that they are compelled to
include self-medication, access to
give antibiotics as patients come with
antibiotics without prescription, use of
preconceived ideas and demand quick
pharmacies and informal healthcare
relief (Chandy et al. 2013; GARP India
providers as sources of healthcare,
2011). As patients pay out of pocket
and lack of knowledge about when
for services, doctors may fear that if
to use antibiotics (Barker et al. 2017;
they do not give antibiotics and instead
Shet et al. 2015; Chandy et al. 2013;
request diagnostic investigations, the
GARP India 2011; Sahoo et al. 2014;
patients will never return to them and
Salunkhe et al. 2013). Self-medication
thus they will lose their costumers
is mainly to avoid the financial burden
(Chandy et al. 2013; GARP India 2011;
of expensive allopathic medical visits
Kotwani and Holloway 2013). Second,
and is compounded by the availability
the diagnostic uncertainty due to the
of drugs without a prescription (Barker
inability to perform investigations
et al. 2017; Keche et al. 2012). The
leads physicians to prescribe broad-
major sources of self-medication are
spectrum antibiotics because of the fear
previous doctors’ prescriptions and
of clinical failure (GARP India 2011).
leftover medicines from previous
Third, pharmaceutical companies put
illnesses (Kotwani et al. 2010; Keche
pressure on doctors and pharmacists to
et al. 2012). Self-medication with
prescribe new antibiotics, and in return
antibiotics is a common practice for
they receive incentives (Chandy et al.
infections such as the common cold,
2013; GARP India 2011; Kotwani and
indicating a lack of knowledge of when
Holloway 2013).
to use antibiotics (Nair et al. 2015;
Sahoo et al. 2014; Chandy et al. 2013). Physicians in the public sector have
In rural areas, when there is a lack of to see a huge number of patients in
healthcare services in their village, a limited time period. Thus these
people may want to avoid the travel physicians do not have enough time
37
to counsel patients against the use to be over 20 times greater in the

of antibiotics and instead prescribe river during pilgrimage season than
them (Kotwani et al. 2010; Kotwani at other times of year, indicating that
and Holloway 2013). Second, primary pilgrimage areas may act as hot spots
care facilities and secondary care for the broader transmission of blaNDM-1
hospitals in the public sector do and other ARGs. The study highlights
not have microbiology diagnostic the need for improvement of waste
laboratory services. Patients visiting handling at the time of pilgrimages.
public sector physicians cannot afford
3.4.4. Antibiotic consumption
investigations in private labs, thus
in food animals
compelling physicians to prescribe
antibiotics (Kotwani et al. 2010). Third, Although direct antibiotic sales data
the medicine supply in the public sector in food animals are not available for
could be erratic, with no supply during India, it is estimated that India was the
some months and oversupply during fifth-largest consumer of antibiotics
other months, and could have drugs in food animals (poultry, pigs, and
near their expiration. To dispose of the cattle) in 2010, after China, the United
medicines before they expire, doctors States, Brazil, and Germany, based on
in the public sector may prescribe livestock density (Van Boeckel et al.
antibiotics even though they are not 2015). Changing patterns of affluence
required for the patient (Kotwani et al. and dietary preferences mean that
2010). there is increasing demand for animal
protein, which is driving antibiotic use
Some factors are common to both
in food animals. Accordingly, antibiotic
public and private sector healthcare
consumption in food animal production
providers. One such factor is varying
in India is projected to grow by 312%,
knowledge among healthcare providers
making India the fourth-largest
on the problem of AMR and lack of
consumer of antibiotics in animals in
continuing medical education on this
2030 (Van Boeckel et al. 2015).
problem (Kotwani et al. 2010; Chandy
et al. 2013). Use of antibiotics as growth promoters
in food animals in poultry is a
3.4.3. Cultural activities
common practice; however, the true
One of the major cultural activities extent of this practice is unknown.
associated with potential acquisition Antibiotics such as colistin, tetracycline,
and spread of antibiotic-resistant doxycycline, and ciprofloxacin, which
bacteria or ARGs is mass bathing are critical to human health, are
in rivers as part of religious mass commonly used for growth promotion
gathering occasions. One study in poultry (Brower et al. 2017; CSE
compared the fecal coliform and 2014). A recent study examining
blaNDM-1 abundances in waters and antimicrobial residues in chicken meat
sediments before and during the sold for human consumption found that
pilgrimage season in Upper Ganges of the 70 chicken meat samples tested,
(Ahammad et al. 2014). In this 40% contained antimicrobial residues.
particular study, the blaNDM-1 was found The most common antimicrobials
38
detected were enrofloxacin (20%), to treat serious infections in humans

ciprofloxacin (14.3%), doxycycline (CSE 2014). Because of the emergence
(14.3%), oxytetracycline (11.4%), and of plasmid mediated resistance (mcr-1
chlortetracycline (1.4%) (Sahu and gene) with use of polymyxins in food
Saxena 2014). Similarly, antibiotic animals (Liu et al. 2016) and potential
residues of chloramphenicol, transfer of this gene to humans, there
sulphonamides, and erythromycin were is an urgent need to ban the use of
detected in various shrimp samples antibiotics that are critically important
collected from major shrimp farms of to humans for growth promotion
Andhra Pradesh, Karnataka, Kerala, in food animals. Whereas only one
and Tamil Nadu (Swapna et al. 2012). antibiotic formulation company
manufactures benzathine penicillin
A more concerning issue is the
for human use, at least six companies
use of polymyxins (colistin) for
manufacture benzathine penicillin for
growth promotion, prophylaxis, and
animal use (Figure 3.7).
therapeutic purposes in poultry, as this
class of drugs is the last-resort medicine
Figure 3.7:
companies
manufacturing various
antibiotics for animal use
Source: VETNDEX Issue
VII (2016).
3.4.5. Pharmaceutical pharmaceutical companies on the

industry pollution global market are manufactured in
India and China (Sum of Us 2015).
The Indian pharmaceutical industry
However, the wastewater effluents
supplies 20% of generic drugs, with
from the antibiotic manufacturing
an estimated US$15 billion in revenue
units contain a substantial amount of
in 2014 (Nordea Asset Management
antibiotics, leading to contamination
2015). It is estimated that 80% of
of rivers and lakes (Larsson et al.
the antibiotics sold by multinational
2007; Lübbert et al. 2017; Gothwal
39
and Shashidhar 2017). The existing products. Effluents coming from both
good manufacturing practices (GMP) types of manufacturing units contain
framework (WHO 2016) is restricted antibiotic residues but significantly
to drug safety and does not include higher amount of residues are expected
environmental safeguards. GMP in the effluents of API manufacturing
ensures that products are consistently units. However, the huge number and
produced and controlled according the diversity of the antibiotic product
to quality standards to minimize the range in the formulation companies
risks involved in any pharmaceutical could cause significant environmental
production. GMP covers all aspects of contamination.
production, from the starting materials,
In India, the Central Pollution Control
premises, and equipment to the training
Board (CPCB) established effluent
and personal hygiene of the staff. Many
standards for pharmaceutical industry
countries have formulated their own
waste, and all state pollution control
requirements based on the WHO GMP,
boards use the same standards.
and others have harmonized their
The current standards do not
requirements. However, regulation
include antibiotic residues, and
of environmental discharges from the
thus they are not monitored in the
manufacturing units is left to the local
pharmaceutical industry effluents
governments.
(CPCB Effluent Standards 2013). The
Pharmaceutical companies can current parameters monitored in the
be broadly classified as active pharmaceutical industrial effluents are
pharmaceutical ingredient (API) listed in Table 3.12. However, there
manufacturers and formulation are no consensus guidelines on the
companies. API manufacturers antibiotic residue discharge limits in
produce antibiotics in bulk that are industrial waste even outside India and
then sold to formulation companies to one research group recently proposed
produce finished products like tablets, discharge limits for various antibiotics
syrups and vials. Some companies (Bengtsson-Palme, Larsson 2016).
manufacture both APIs and formulation
Table 3.12: Compulsory parameters Tolerance limits in mg/l except for pH

pH 6.0–8.5
Pharmaceutical industry Oil & grease 10
effluent standards in BOD (3 days 27°C) 100*
India Total suspended solids 100
Bioassay test 90% survival of fish after first
Source: Central Pollution
96 hours in 100% effluent
Control Board Effluent
Standards (2013).
Additional parameters Tolerance limits in mg/l except for pH
Note: BOD = biochemical
oxygen demand; Mercury 0.01
*The BOD limit shall be Arsenic 0.2
Chromium 0.1
30mg/l and 250mg/l,
Lead 0.1
respectively, if treated Cyanide 0.1
effluent is discharged Phenolics 1
directly into a freshwater Sulfides 2
body. Phosphate 5
40
Two studies (Larsson et al. 2007; flows through the city of Hyderabad.
Lübbert et al. 2017), which examined Fluoroquinolone concentrations
the effluents coming from antibiotic higher than 1,000 times the usual
manufacturing units conducted 10 concentrations found in rivers of
years apart (2006 and 2016) in the developed countries were observed
same industrial area near the city in Musi River in 2015 (Gothwal
of Hyderabad, India, have shown and Shashidhar 2017). Although,
excessive amount of antibiotics pharmaceutical industrial wastewater
critical for human health. In 2006, the effluents are apparent source of
concentration of ciprofloxacin in the antibiotic residues, it is important to
effluents was extremely high (31,000 acknowledge the possibility of antibiotic
micrograms/ml), a discharge equivalent environmental contaminants through
to 45 kilograms of ciprofloxacin solid waste and possibly even by air
per day. In 2016, in addition to pollution (Larsson 2014).
ciprofloxacin, several other antibiotics,
There are at least 40 human antibiotic
such as moxifloxacin, levofloxacin,
API manufacturers in India (Table
linezolid, ampicillin, doxycycline, and
3.13). In contrast, there are at least
sulfamethoxazole, were abundant
250 pharmaceutical formulation
in the effluents, indicating the
companies manufacturing at least one
widening of the antibiotic portfolio
antibiotic for human use and at least 94
of these manufacturing units. This
pharmaceutical formulation companies
inappropriate disposal of antibiotics has
manufacturing at least one antibiotic
led to the contamination of the aquatic
environment of Musi River, which
Manufacturer Manufacturer Table 3.13:
Aarti Drugs Ltd* Kopran* List of human antibiotic

Abbott* Lee Pharma Ltd active pharmaceutical
Ajanta Pharma Ltd* Lupin Ltd* ingredient (API)
Alembic Pharmaceuticals* Mankind* manufacturing
Arch Pharmalabs Meck Pharmaceuticals & Chemicals
companies#
Aurobindo Pharma* Mehta Pharmaceutical Ltd.
Calyx Pharma Mylan Labs* Note: # This list includes
Century Pharmaceuticals Limited Nectar Lifesciences Ltd* major antibiotic API
Chromo Labs Neuland Laboratories Limited* manufacturers in India and
Cipla* Orange Pharma Private Limited not a complete list
Covalent Laboratories* Orchid Chem & Pharma* * Both API and formulation
Dalas Biotech Limited Panchsheel Organics*
companies
Dishman Pharmaceuticals Penam Laboratories Ltd
Dr Reddys labs* Pravah Laboratories Pvt Ltd
DSM Sinochem Smruthi Organics Limited
Glenmark Labs* Srini Pharmaceuticals
Granules India* Sun Pharma*
Hetero Labs* Unimark Remedies
Ind-Swift* Vardhman Chemtech Ltd
Indoco* Wockhardt*
Jubilant Pharma* Zydus Cadila*
41
The leading antibiotic formulation and 3.9. Complete list of antibiotic

companies for human and animal use formulation companies in India are
in India are displayed in Figures 3.8 listed in Appendix Tables A.1 and A.2.
Figure 3.8:
Leading antibiotic
formulation companies
and the number
of antibiotics they
manufacture (excluding
antituberculosis agents)
for human use in India
Source: CIMS INDIA,

April–July 2017 edition.
Note: AHPL = Ahaan

Healthcare Private Limited;
Hetero HC = Hetero
Healthcare; FDC = Fairdeal
Corporation Private Limited
Figure 3.9:
Leading companies and

the number of antibiotics
they manufacture for
animal use in India
Source: VETNDEX Issue
VII (2016).
Note: Zydus AHL =
Zydus Animal Health
Limited; HAL = Hindustan
Antibiotics Limited; KAPL
= Karnataka Antibiotics &
Pharmaceuticals Limited.
The list of manufacturers
is not complete, as the
information gathered in
VETNDEX was based on
voluntary response from
the companies to a survey
conducted by the author
of VETNDEX. Not all
companies responded to the
author’s survey.
42
Although published studies on Mumbai area, and Tarapur in the

antibiotic pollution have been state of Maharashtra, Baddi and
restricted to the Hyderabad area in Paonta Sahib in the state of Himachal
the state of Telangana, the number of Pradesh, Derabassi in the state of
pharmaceutical companies involved in Punjab and Hyderabad area in the
manufacturing antibiotics suggests the state of Telangana (Figure 3.10).
potential possibility of environmental Similarly, some of the antibiotic
antibiotic pollution in several other formulation companies’ hot spots
locations in India as well (Figure include Ahmedabad in the state of
3.10 and Figure 3.11). Some of the Gujarat, Aurangabad in the state of
antibiotic API manufacturer hot spots Maharashtra, Bengaluru in the state of
include, Ankleshwar and Karkhadi Karnataka, Hyderabad in the state of
in state of Gujarat, Aurangabad, Telangana, Verna in the state of Goa,
and Sikkim (Figure 3.11).
Figure 3.10:
Sites of human antibiotic

active pharmaceutical
ingredient (API)
manufacturing
companies in India
Note: Manufacturing unit
locations were identified
by reviewing websites of
individual companies.
43
Figure 3.11:
Sites of human and

animal antibiotic
formulation
manufacturing units in
India
Note: Manufacturing
unit locations were
identified by reviewing
websites of individual
companies (manufacturers
of antibiotics for both
human and animal use).
However, it is unknown
whether antibiotics are
manufactured at all these
locations. There are also
several companies for which
manufacturing location
was not mentioned on the
company website.
3.4.6. Environmental for acquisition of ARGs such as ESBLs.

sanitation In one study, the risk of asymptomatic
intestinal colonization with ESBL-
Antibiotic selection pressure is a
producing E. coli among Swiss travelers
prerequisite for the emergence of
visiting India was 87% (Kuenzli et al.
resistance; however, poor sanitation
2014).
plays a major role in the spread of
antibiotic-resistant bacteria and ARGs. 3.4.7. Infection control
According to the World Bank, more practices in healthcare
than 50% of the Indian population settings
does not have access to sanitation
The prevalence of various healthcare-
facilities for safe disposal of human
associated infections (HAIs) among
waste (World Bank 2017). In addition,
Indian hospitals ranges from 11% to
a large proportion of sewage is disposed
83%, in contrast to the WHO estimate
untreated into receiving water bodies,
of about 7% to 12% of the HAI burden
leading to gross contamination
among hospitalized patients globally
of rivers with antibiotic residues,
(Ramasubramanian et al. 2014). Only
antibiotic-resistant organisms, and
a few multicenter studies have been
ARGs (Marathe et al. 2017). As a
conducted assessing infection control
result, recreational travel to India is
practices in India. A study involving
recognized as an important risk factor
eight hospitals, including one nursing
44
home in the city of Mangalore, assessed 3.5. AMR Policy Situation

hand-washing practices of nurses and in India
doctors and found that only 31.8% of
them washed hands after contact with In India, the issue of AMR came
patients (Dileep 2013). A multicenter to the attention of policymakers
study involving a single operation with the 2010 discovery of NDM-
theater in each of six tertiary care 1 and the controversy3 over its
hospitals in Delhi showed a hand name. Subsequently, AMR-related
hygiene compliance of 80.5% (Kumar et policies were initiated in 2011 by
al. 2014). publishing the National Policy on
Containment of AMR. In addition,
Another study in Gujarat that assessed other nongovernmental initiatives
infection control practices in 20 such as the Chennai Declaration were
delivery care units showed that surgical published to create a roadmap to tackle
gloves were reused in over 70% of the AMR problem. Over the last seven
facilities, only 15% of the facilities years, several policies were enacted,
Figure 3.12:
Causes of early onset

neonatal sepsis in three
NICUs in Delhi
Source: Chaurasia et al.

(2016).
Note: CONS = coagulase-
negative Staphylococci
reported wiping of surfaces immediately and in April 2017, a comprehensive

after delivery in labor rooms, and one- National Action Plan for Containment
third of facilities did not have wash of AMR was launched and the Delhi
basins with hands-free taps (Mehta Declaration on AMR was pledged. Table
et al. 2011). These poor infection 3.13 provides a timeline of AMR policy-
prevention practices in delivery care related activities, which are described in
units reflect the types of organisms seen detail below.
in early onset neonatal sepsis cases. In a
3.5.1 AMR-related policies for
recent large prospective study involving
human health
three NICUs, Acinetobacter species (a
common healthcare-acquired pathogen) The Ministry of Health and Family
was the most common organism Welfare (MoHFW) is responsible for
causing early onset neonatal sepsis developing policies related to human
(occurring within 72 hours of birth) health. In 2010, a working group on
(Figure 3.11).
3 https://timesofindia.indiatimes.com/india/Lancet-says-sorry-for-Delhi-bug-/articleshow/7261135.
cms?referral=PM
45
Year Activity
2010 Establishment of the National Task Force on AMR Containment
Table 3.14: 2011 Publication of the Situation Analysis on AMR
2011 Publication of National Policy on AMR Containment
Timeline of AMR policy-
related activities in India 2011 Jaipur Declaration on AMR Containment
2011 The Food Safety and Standards (Contaminants, Toxins and Residues)
Regulations, by FSSAI
2011 Establishment of the National Programme on AMR Containment under the
Twelfth Five Year Plan (2012–2017)
2012 National Program on Antimicrobial Stewardship, Prevention of Infection and
Control (ASPIC) by ICMR
2013 Establishment of a National AMR Surveillance Network by NCDC and ICMR
2014 Inclusion of antibiotics in Schedule H1 category to avoid nonprescription sales of
antibiotics
2016 Launch of the Red Line Campaign on Antibiotics to create awareness regarding
rational usage of antibiotics
2016 Publication of National Treatment Guidelines for Antimicrobial Use in Infectious
Diseases by NCDC
2016 National address by prime minister on the issue of antibiotic resistance in his
Man Ki Baat (a radio program hosted by the honorable prime minister of India) in
August
2017 Publication of the National Action Plan for Containment of AMR and Delhi
Declaration
in food animals
AMR, with the support of the Global challenge of AMR (Ghafur et al. 2013).
Antimicrobial Resistance Partnership It recognized the need that although a
(GARP), was formed to conduct a ban on the sale of antibiotics without
situational analysis for the country and prescriptions would be the ideal step,
suggest the way forward for combating this was not practical to implement, and
the AMR problem (GARP India 2011). instead recommended a step-by-step
Subsequently, the National Policy for regulation, beginning immediately with
Containment of AMR for India was controls on sales of third- and fourth-
published in 2011 (Directorate General generation antibiotics and anti-TB
of Health Services 2011). agents, and then gradually expanding
the list. Additional recommendations
In September 2011, the Health
encompassing accreditation, hospital
Ministers of Member States of the
antibiotic usage policies, veterinary
South-East Asian Region of WHO,
practices, strengthening diagnostic
including India, signed the Jaipur
laboratories, education, training, and
Declaration on containment of
research were made with the aim to
AMR (Jaipur Declaration 2011).
provide “an implementable antibiotic
Subsequently, a joint meeting of
policy” and not “a perfect policy.”
Medical Societies in India was
organized in Chennai in August The National Programme on the
2012, which ended in the Chennai Containment of Antimicrobial
Declaration, drafting a roadmap by Resistance was launched under the
and for stakeholders to tackle the aegis of the National Centre for Disease
46
Control (NCDC) under the 12th Five year program to develop the capacity
Year Plan (2012–2017).4 The objectives of key stakeholders in antibiotic
of this program were to establish AMR stewardship.
surveillance system with 30 network
In 2013, ICMR established a national
laboratories, generating quality data
network on surveillance of AMR
on AMR pathogens of public health
in laboratories based at tertiary
importance; strengthen infection
care academic centers, targeting
control guidelines and practices;
medically important bacterial
promote appropriate use of antibiotics;
pathogens identified by WHO. The
and generate awareness about the use
Antimicrobial Resistance Surveillance
of antibiotics both among healthcare
and Research Network (AMRSN),
providers and in the community.
established by ICMR, started with
The policy focus included situational
six reference labs located in four
analysis regarding the manufacture,
tertiary care medical institutions.
use, and misuse of antimicrobials;
The network is being expanded to
creation of a national surveillance
include 15 more medical colleges and
system; identification of prescription
private hospitals. The AMRSN also
patterns and establishment of a
includes in-depth understanding
monitoring system for the same;
of molecular mechanisms of
enforcement of enhanced regulatory
drug-resistant pathogens and the
provisions with respect to marketing
transmission dynamics to enable
of antimicrobials; development of
better understanding of AMR in the
specific intervention measures such
Indian context and devise suitable
as antibiotic policies for healthcare
interventions. The AMRSN is currently
facilities; and development of
limited to the human health side, but
diagnostic aids related to monitoring
there are plans to broaden its scope to
AMR. Ten network laboratories have
a national scale and to include samples
been identified in the first phase of
from a wider spectrum of sources,
the program, in which four pathogens
including animal, environmental, and
of public health importance are being
food samples, to reflect the principles of
tracked: Klebsiella species, E. coli, S.
a one health based surveillance system.
aureus, and Enterococcus species.
More recently, P. aeruginosa and In March 2014, to prevent sales
Acinetobacter species were also of important antibiotics without
included. prescriptions, the Central Drugs
Standard Control Organization
In 2012, ICMR launched the
(CDSCO) implemented Schedule H1.
Antimicrobial Stewardship, Prevention
The H1 list includes 24 antibiotics,
of Infection and Control (ASPIC)
such as third- and fourth-generation
program through collaboration among
cephalosporins, carbapenems,
the office of the National Chair of
antituberculosis drugs, and newer
Clinical Pharmacology, ICMR, and
fluoroquinolones. Schedule H1 specifies
the Christian Medical College, Vellore
that the drugs on this list must carry
(Chandy et al. 2014). A national
a prominent Rx symbol in red and a
workshop was hosted as a part of a one-
http://dghs.gov.in/WriteReadData/userfiles/file/National_Programme_on_Containment_of_Anti_Microbial_
4
Resistance.pdf.
47
printed warning inside a box with red prime minister, Shri Narendra Modi,
borders. Moreover, drugs included in recently reaffirmed the joint Indo-
Schedule H1 may be sold only with a US commitment to the Global Health
prescription from a registered medical Security Agenda (GHSA) and the timely
practitioner, and the pharmacist must implementation of its objectives. The
maintain a separate register with the prime minister noted India’s role on
patient’s name, contact details of the the Steering Group of GHSA and its
prescribing doctor, and the name and leadership in AMR arena. He also
dispensed quantity of the drug. The addressed the nation on the issue
register has to be retained for at least of antibiotic resistance in his radio
three years and is subject to audit by the program Mann ki Baat in August
government. 2016, calling on everyone to practice
responsible use of antibiotics. Both
In November 2014, the WHO Regional
ICMR and NCDC released guidelines
Committee meeting advocated with
on infection control for healthcare
member states for acceleration of
facilities, noting the need to establish
national efforts to build capacities to
functional hospital infection control
implement the Jaipur Declaration on
committees (HICCs) to provide
AMR and the South-East Asia Regional
leadership to the infection prevention
Strategy on AMR.
and control (IPC) programs at the
In February 2016, the government institutional level and to integrate
of India conducted a three-day these within the institutional setups.
international conference on AMR Establishing IPC focal experts at the
during which the Red Line Campaign policymaking levels and linking IPC
on Antibiotics was launched to create programs to AMR and nosocomial
awareness regarding rational usage of infection surveillance were identified
antibiotics among the general public. It as key policy integrations to drive more
emphasized the following issues: successful IPC programs in India.
àà Raising awareness about how In March 2017, the National Health

to identify a drug that should be Policy 2017 (MoHFW 2017) highlighted
dispensed only with a prescription the problem of AMR and called for
from a licensed doctor rapid standardization of guidelines
àà Limiting the practice of self- regarding antibiotic use, limiting
medication the use of antibiotics as over-the-
àà Making the public aware of the counter medications, banning or
potential harms that may result restricting the use of antibiotics as
from the misuse of antibiotics growth promoters in livestock, and
During the same month, NCDC practicing pharmacovigilance, including
published the National Treatment prescription audits inclusive of
Guidelines for Antimicrobial Use in antibiotic usage in the hospital and the
Infectious Diseases, which served community.
as a reference guide for hospitals
In April 2017, the National Action
and healthcare providers in the
Plan for Containment of AMR was
country (NCDC 2016). The Indian
48
released and Delhi Declaration on àà chloroform, chloropromazine,

AMR was pledged. In August 2017, colchicine, dapsone, dimetridazole,
a review meeting was held to discuss metronidazole
the next steps, including indicators for àà ronidazole, ipronidazole
implementation of the National Action àà other nitromidazoles, clenbuterol,
Plan. diethylstibestrol
àà sulfanoamide drugs (except
3.5.2 AMR-related policies for
approved sulfadimethoxine,
animal health
sulfabromomethazine, and
The Food Safety and Standards sulfaethoxypyridazine)
Authority of India (FSSAI) set àà fluoroquinolones, glycopeptides
standards for antibiotics in fisheries àà In addition to prohibition of the
in 2011 (FSSAI 2011) and for honey in above antibiotics, tolerance limits
2014 (FSSAI 2014). Use of the following were set for certain antibiotics in
antibiotics is prohibited in any unit seafoods (Table 3.14).
processing seafoods including shrimp, In 2014, FSSAI set tolerance limits for
prawns, or any other variety of fish and following antibiotics in honey (FSSAI In
fishery products (FSSAI 2011): February 2016, FSSAI held a workshop
àà all nitrofurantoins, including on Fixation of Maximum Residue Levels
furaltadone, furazolidone, (MRLs) for Pesticides, Veterinary Drugs
furylfuramide, nifuratel, and Antibiotics in Foods Prepared from
nifuroxime, nifurprazine, Animals, Poultry, Fish and Processed
nitrofurnatoin, nitrofurazone, Foods (FSSAI 2016). Following are
chloramphenicol, neomycin, some of the key recommendations that
nalidixic acid emerged from the workshop:
àà sulfamethoxazole, Aristolochia àà Antibiotics used in human
species and preparations thereof population are best avoided for use
Name of antibiotic Tolerance limit in mg/kg (ppm) Table 3.15:

Tetracycline 0.1
Tolerance limits for
Oxytetracycline 0.1
Trimethoprim 0.05 antibiotics in seafood
Oxolinic acid 0.3
Name of antibiotic Tolerance limit (mcg/kg) Table 3.16:

Chloramphenicol 0.3
Tolerance limits for
Nitrofurans and its metabolites 0.5
Sulphonamides and its metabolites 5.0 antibiotics in honey
Streptomycin 5.0
Tetracycline 5.0
Oxytetracycline 5.0
Chlortetracycline 5.0
Ampicillin 5.0
Enrofloxacin 5.0
Ciprofloxacin 5.0
Erythromycin 5.0
Tylosin 5.0
5.0
49
in food-producing animals. universal sanitation coverage, could

àà There is a need to have approved play a vital role in containment of AMR.
label claims for pesticides, The goals of the Swacch Bharat Abhiyan
antimicrobials, and veterinary are to promote cleanliness and hygiene,
drugs, to be duly authorized by a eliminate open defecation, and improve
competent regulatory authority. waste management.
àà For processed foods from
3.5.4. Launch of National
agricultural commodities, there is
Action Plan for Containment
a need for fixation of MRLs.
of AMR (NAP-AMR) and Delhi
àà National Good Aquaculture
Declaration on AMR
Practices should be developed
to limit the usage of antibiotics The National Action Plan for
and pesticides during farming Containment of AMR (NAP-AMR) was
operations. released in April 2017.5 On the same
àà Because there are data gaps day, an interministerial group pledged
regarding residues of veterinary to adapt a holistic and collaborative
drugs in foods originating from approach for the containment of AMR,
meat, milk, and fish, and data are which resulted in the Delhi Declaration
available only in scattered form on AMR.6 The NCDC is the focal point
from various research institutes, for implementation and coordination
laboratories, individuals, and of the NAP-AMR program. The NAP-
industries, FSSAI may initiate AMR assigned coordinated tasks to
a coordinated Network Project multiple government agencies involving
to develop a central repository health, education, the environment,
database. and livestock to change prescription
àà With the help of the Drug practices and consumer behavior
Controller General of India and to scale up infection control and
(DCGI), manufacturers of antimicrobial surveillance.
veterinary drugs must submit the
required data with the approved The strategic objectives of India’s
method (guidelines need to be NAP-AMR are aligned with the
developed) to FSSAI for fixation of WHO’s Global Action Plan on AMR
MRLs in edible animal products. (GAP-AMR). In addition, India has a
sixth priority, which is dealing with
Accordingly, in June 2017, FSSAI India’s leadership on AMR, including
published the MRLs for antibiotics in international, national, and subnational
various food animals (FSSAI 2017). collaborations on AMR. Six strategic
3.5.3. AMR policies related to priorities have been identified under
the environment the NAP-AMR:
àà Improve awareness and
Policies specifically aimed at AMR
understanding of AMR through
aspects of the environment have not
effective communication,
been formulated. However, the Swacch
education, and training.
Bharat Abhiyan (Clean India Program),
àà Strengthen knowledge and
launched in October 2014 to achieve
5
http://ncdc.gov.in/writereaddata/mainlinkFile/File645.pdf
6
http://ncdc.gov.in/writereaddata/mainlinkFile/File670.pdf
50
evidence through surveillance efforts to contain AMR and

by strengthening laboratories national collaborations to facilitate
in human, animal, food, and collaborations among vertical
environmental sectors, as well as disease control programs.
ensuring surveillance of AMR in Within each strategic priority and
these sectors. focus area, strategic interventions,
àà Reduce the incidence of infection key activities, and outputs have been
through effective IPC to reduce defined with tentative responsibility
the burden of infection, in animal and timelines: short-term (within
health and food to reduce the 1 year), medium (between 1 and 3
spread of AMR and antimicrobials years), and long-term (between 3 and
through animals and food, and 5 years). A stakeholder consultation
in community and environment to operationalize the NAP-AMR was
to reduce the spread of AMR and conducted to develop indicators for
antimicrobials in the environment. implementation of the NAP-AMR in
àà Optimize the use of antimicrobial August 2017.
agents in human health, animals,
and food by strengthening 3.5.5. Effectiveness of the AMR
regulations, ensuring access and policies
surveillance of antimicrobial
Although several policies and
use, and providing antimicrobial
programs have been developed, the
stewardship in healthcare as well
effectiveness of these initiatives on
as animal health and agriculture.
AMR containment or antimicrobial
àà Promote investments for
consumption is unknown and was not
AMR activities, research, and
systematically examined. In addition,
innovations through new
the extent of enforcement of the
medicines and diagnostics,
enacted policies is also unknown. For
innovations to develop alternative
example, antibiotics that were part of
approaches to manage infectious
Schedule H1 are still available without
diseases, and sustainable financing
prescription (Satyanarayana et al.
to ensure adequate resources for
2016). Similarly, the impact of the
containment of AMR.
Red Line Campaign on Antibiotics on
àà Strengthen India’s leadership
antibiotic awareness in general public is
on AMR through international
unknown.
collaborations to ensure India’s
contributions toward global
51
SECTION
4
THE ANTIMICROBIAL
RESISTANCE RESEARCH
LANDSCAPE IN INDIA
4.1. Overall Summary of

Studies
A total of 2,152 studies published by
researchers based in Indian institutions
were identified and extracted into our àà Reviews or editorial articles: 287
database. The breakdown of these (13.3%)
publications into major categories was àà Miscellaneous: 254 (11.8%)
as follows (Figure 4.1): àà Environment: 90 (4.2%)
àà Humans: 1,040 (48.3%) àà Animals: 70 (3.3%)
àà Novel agents: 379 (17.6%) àà Diagnostics: 19 (0.9%)
Figure 4.1:
Number of publications
in each of the seven
categories of AMR
research (N=2,152)
52
There were approximately 630 àà Vellore Institute of Technology

institutions with at least one publication (VIT), Vellore, Tamil Nadu
on AMR. Christian Medical College, A complete list of institutions that
Vellore, accounted for 3.1% of the total published at least one study related to
publications (excluding review studies), AMR appears in Appendix Table A.3
followed by All India Institute of
Medical Sciences, New Delhi, with 2.5% 4.2. Results by Category of
of the total publications. Following are Studies
the top 10 institutes that published
AMR-related research studies (Figure 4.2.1. Humans
4.2): Overall 1040 studies were conducted on
àà Christian Medical College, Vellore, AMR in humans. Of these, 83% (864)
Tamil Nadu were on surveillance, 12.8% (132) were
àà All India Institute of Medical clinical, and 4.2% (44) concerned the
Sciences (AIIMS), New Delhi, social aspect of AMR in humans (Figure
Delhi 4.3). Transmission-based studies were
àà Manipal University, Mangalore, absent.
Karnataka Figure 4.3:
àà Aligarh Muslim University,
Distribution of human
Aligarh, Uttar Pradesh studies by three
àà Banaras Hindu University, categories of AMR
Varanasi, Uttar Pradesh research (N=1,040)
àà Panjab University, Chandigarh

àà National Institute of Cholera
and Enteric Diseases (NICED),
Kolkata, West Bengal
àà Post Graduate Institute of
Medical Education and Research
(PGIMER), Chandigarh
àà Assam University, Silchar, Assam
Figure 4.2:

AMR publications by
category (excluding
review publications)
53
There were approximately 380 4.1. A complete list of institutions that

institutions with at least one published at least one study related to
publication on AMR. The top 10 AMR in humans appears in Appendix
institutions that published AMR-related Table A.4.
research in humans are listed in Table
Institution State Total

publications
Christian Tamil Nadu 46
Medical College
All India Institute Delhi 40
of Medical Sciences
Manipal University Karnataka 29
Table 4.1:
National Institute of West Bengal 22
Top 10 institutions that Cholera and Enteric Diseases
published AMR-related Post Graduate Institute of Chandigarh 21
research in humans in Medical Education & Research
India, 2012–2017
Jawaharlal Institute of Postgraduate Puducherry 21
Medical Education & Research
Banaras Hindu University Uttar Pradesh 21
Government Medical College Chandigarh 18
Vardhman Mahavir Medical Delhi 17

College–Safdarjung Hospital
Assam University Assam 16
Figure 4.4:

publications on AMR in
humans by category
54
4.2.2. Animals
Overall, 70 studies were conducted on

AMR in animals, of which 30% (21)
were in livestock, 24.3% (17) were
in poultry, 15.7% (11) were in fish,
and 30% (21) were classified as other
Figure 4.5:
(Figure 4.5).
Distribution of AMR
The institutions that conducted AMR research studies in
animals (N=70)
research in animals and published
more than one study are listed in Table
4.2. A complete list of institutions that
published at least one study related to
AMR in animals appears in Appendix
Table A.5. were conducted on river water, 11%
(10) concerned freshwater, and
4.2.3. Environment
13% (12) concerned sewage , 10%
A total of 90 studies were (9) concerned hospital effluent, 7%
environmental, of which 22% (20) (6) concerned industry effluent and
Institutions State Total

publications
Anand Agricultural University Gujarat 4
ICAR Research Complex for NEH Region Meghalaya 4
West Bengal University of Animal and Fishery Sciences West Bengal 4
Cochin University of Science and Technology Kerala 3 Table 4.2:
Institutions that
ICAR–National Research on Pig Assam 3
published more than
one AMR research study
Central Institute of Fisheries Technology Kerala Kerala 2 in animals in India,
2012–2017
Chhattisgarh Kamdhenu Vishwavidyalaya Chattisgarh 2
College of Veterinary Science Assam 2
Dr. G. R. Damodaran College of Science Tamil Nadu 2
ICAR–Indian Veterinary Research Institute Uttar Pradesh 2
Indian Veterinary Research Institute, Uttar Pradesh 2

Uttar Pradesh
Indian Veterinary Research Institute, West Bengal 2
West Bengal
Karnataka Veterinary Animal and Karnataka 2
Fisheries Sciences University
Sher-e-Kashmir University Jammu & 2
Kashmir
55
Figure 4.6:
Distribution of AMR 37% (34) constituted others (Figure

research studies on the
4.6). The institutions that conducted
environment (N=90)
AMR research on the environment
and published more than one study
are listed in Table 4.3. A complete
list of institutions that published at
least one study related to AMR in the
environment appears in Appendix
Table A.6.
Institutions State Total

publications
Indian Institute of Technology Delhi Delhi 6
Aligarh Muslim University Uttar Pradesh 4
Cochin University of Science and Technology Kerala 4
RD Gardi Medical College Madhya Pradesh 4

Table 4.3:
Institutes that published Bharathidasan University Tamil Nadu 3

more than one AMR
research study on the Anand Agricultural University Gujarat 2
environment in India,
2012–2017 Annamalai University Tamil Nadu 2
CSIR–Indian Institute of Toxicology Research Uttar Pradesh 2
Dayananda Sagar Institutions Karnataka 2
Integral University Uttar Pradesh 2
Jamia Millia Islamia Delhi 2
National Centre for Cell Science Maharashtra 2
National Institute of Science Education Odisha 2
Sher-e-Kashmir University Jammu & Kashmir 2
University of Delhi Delhi 2
Veer Narmad South Gujarat University Gujarat 2

56
4.2.4. Novel agents 2(0.5%) identified compounds active

against MDR gram-positive bacteria
Overall, 379 studies focused on and 20 (5%) identified compounds
identifying new compounds with active against non-bacterial pathogens
antimicrobial activity. Among these, (Figure 4.7).
145 (38%) identified compounds active
against gram-negative bacteria, 114 The institutions that conducted AMR
(30%) identified compounds active research on novel agents and published
against both gram-negative and gram- more than five studies are listed in
positive bacteria, 91(24%) identified Table 4.4. A complete list of institutions
compounds active against gram-positive that published at least one study related
bacteria, 7(2%) identified compounds to AMR in novel agents appears in
against MDR gram-negative bacteria, Appendix Table A.7.
Figure 4.7:
Antibacterial spectrum
of novel agent studies
(N=379)
Institute State Total

publications Table 4.4:
Jawaharlal Nehru Centre for Advanced Scientific Research Karnataka 18
Institutions that
published more than five
Alagappa University Tamil Nadu 14
AMR research studies
on novel agents in India,
Panjab University Chandigarh 13 2012–2017
Indian Institute of Technology Kharagpur West Bengal 10
Institute of Nuclear Medicine and Allied Sciences Delhi 8
IMS & Sum Hospital Odisha 7
Jadavpur University West Bengal 7
Vellore Institute of Technology University Tamil Nadu 7

57
Anna University Tamil Nadu 5
CSIR–Central Institute of Medicinal and Aromatic Plants Uttar Pradesh 5
Jaypee Institute of Information Technology, UP Himachal Pradesh 5

Sher-e-Kashmir University Jammu & 2
Kashmir
4.2.5. Miscellaneous
institutions that conducted research
Overall, 254 studies were published that on miscellaneous aspects of AMR and
fell into the miscellaneous category. The published five or more studies are
studies focused on several aspects, such listed in Table 4.5. A complete list of
as molecular biology, biofilm formation, institutions that published at least one
genetics, immunology, biochemistry, study related to miscellaneous aspects
and mathematical modeling. The of AMR appears in Appendix Table A.8.
Institution State Total

publications
Vellore Institute of Technology University Tamil Nadu 15
Table 4.5:
Institutions that CSIR–Institute of Microbial Technology Chandigarh 11

published more than five
studies on miscellaneous Panjab University Chandigarh 11
aspects of AMR in India,
2012–2017 Banaras Hindu University Uttar Pradesh 7
Jaypee Institute of Information Technology Himachal Pradesh 7
Indian Institute of Technology Bombay Maharashtra 6
National Dairy Research Institute Haryana 5
4.2.6. Diagnostics
novel diagnostics to identify resistance
Overall, 19 studies were published mechanism in bacteria. The institutions
in the category of diagnostics. The that published studies on diagnostics
majority of the studies were focused on are listed in Table 4.6.
58
Institute State Total publications
Amity University Uttar Pradesh 1
Animal and Fisheries Sciences University Karnataka 1

Table 4.6:
Dr. M.G.R. Educational and Research Institute Tamil Nadu 1 Institutions that
published AMR research
Government Medical College Hospital Chandigarh Chandigarh 1 studies on diagnostics in
India, 2012–2017
Indian Institute of Technology Delhi Delhi 1
KEM Hospital Maharashtra 1
National Institute of Cholera and Enteric Diseases West Bengal 1
Nizam Institute of Medical Sciences Telangana 1
P.D. Hinduja Hospital & Medical Research Centre Maharashtra 1
Sant Gadge Baba Amravati University Maharashtra 1
SRM University Tamil Nadu 1
Subharti Medical College Uttar Pradesh 1
Swami Vivekanand Subharti University Uttar Pradesh 1
Tamil Nadu Veterinary and Tamil Nadu 1

Animal Sciences University
Tata Medical Center West Bengal 1
4.2.7. One health resistance profile isolated from

humans and/or animals and/or the
Overall, 11 studies were published in environment. The institutions that
the one health category. The majority published studies in the one health
of the studies focused on the bacterial category are listed in Table 4.7.
59
Institution State Total publications

Table 4.7:
Institutions that
published AMR research ICAR–Indian Veterinary Research Institute Uttar Pradesh 1
studies on one health in
India, 2012–2017 Indian Veterinary Research Institute, Uttar Pradesh Uttar Pradesh 2

Lovely Professional University Punjab 1
National Salmonella Centre Uttar Pradesh 1
North-Eastern Hill University Meghalaya 1
University of Pune Maharashtra 1
West Bengal University of Animal West Bengal 1

and Fishery Sciences
4.3. Prominent researchers in AMR field in India

Researcher Institution AMR related Major area of work
Table 4.8: Publications
(2012-2017)
Prominent researchers
in AMR field in humans Dr. Balaji Veeraraghavan CMC, Vellore 37 Medical microbiology,
studying phenotypic
Note: AIIMS- All India Dr. Amitabha Assam University, 20
and molecular
Institute of Medical Bhattacharjee Silchar 16
mechanisms of
Sciences; BHU- Banaras Dr. Deep Jyotipaul
resistance, HAIs
Hindu University; CMC- Dr. Arti Kapil AIIMS, Delhi 17
Christian Medical College;
Dr. Jagdish Chander GMC, 16
GMC- Government Medical Chandigarh
college; HAIs- Healthcare
Dr. Ramamurthy NICED, Kolkata 13 Epidemiology, phenotypic
Associated Infections;
Thandavarayan (now in THSTI, and molecular mechanisms
JIPMER- Jawaharlal Faridabad) of resistance among
Institute of Postgraduate dysentery causing bacteria
Medical Education &
Dr. Belgode N Harish JIPMER, 11 Medical microbiology,
Research; NICED- National Dr. Subhash C Parija Puducherry 10 examining phenotypic
Institute of Cholera and and molecular mechanisms
Dr. Shampa Anupurba BHU, Varanasi 10
Enteric Diseases; PGIMER- of resistance, HAIs
Dr. Tuhina Banerjee 10
Post Graduate Institute
of Medical Education & Dr. Neelam Taneja PGIMER, 9
Dr. Vikas Gautam Chandigarh 8
Research
4.4 Survey Responses (19%). Considering humans, animals,

and the environment, they indicated
The questionnaire asking for current the following areas of current research
research activities was sent to 264 activity (Figure 4.8):
individuals, of whom 50 responded
60
Researcher Institution AMR related Major area of work

Table 4.9:
Publications
(2012-2017)
Prominent researchers
Dr. Samiran Indian Veterinary 8 Studying phenotypic in AMR field in animals,
Bandyopadhyay Research Institute, 3 and molecular environment, novel
Dr. Sandeep Ghatak Kolkata mechanisms agents, miscellaneous,
of resistance in
one health and
livestock and poultry
Dr. Indranil Samanta West Bengal University 8 diagnostics
Dr. Achintya Mahanti of Animal and Fishery 5 Note: CSIR-IMTECH-
Dr. Siddhartha N Joardar Sciences, Kolkata 4
Council of Scientific &
Dr. Ashok J Tamhankar RD Gardi Medical 9 EOne-health research, Industrial Research
Dr. Vishal Diwan College, 7 social aspects of
Dr. Ashish Pathak Ujjain 7 antibiotic use, Institute of Microbial
AMR spread with
Technology; JNCASR-
human activities
Jawaharlal Nehru Centre
Dr. Yogesh S Shouche National Centre 7 Pharmaceutical for Advanced Scientific
for Cell Science, industry effluents and
Research; VIT- Vellore
Pune impact on AMR
Institute of Technology
Dr. Atul Mittal Indian Institute of 3 Environmental AMR
Dr. Ziaddin S Ahammad Technology, Delhi 2 aspects and AMR
spread with
human activities
Dr. Asad U Khan Aligarh Muslim 13 Understanding
Dr. Mohammad A Ansari University, 6 molecular
Aligarh mechanisms of
resistance,
development
of novel agents,
diagnostics
Dr. Jayanta Haldar JNCASR 18 Novel agents research
Dr. Chandradhish Ghosh Bengaluru 10
Dr. S. Karutha Pandian Alagappa University 11
Dr. Sudha Ramaiah VIT, Vellore 9 Molecular biology,
biofilm formation,
Dr. Kusum Harjai Panjab University, 8
genetics, immunology,
Chandigarh
biochemistry
Dr. Govindan Rajamohan CSIR-IMTECH, 6 aspects of AMR
Dr. Vijaya B Srinivasan Chandigarh 6
Dr. Jayashree Ramana Jaypee Institute of 6

Information
Technology, Noida
àà 23% on surveillance/epidemiology Figure 4.8:

àà 21% on drug discovery
Areas of current research
àà 19% on diagnostics activities in all three
àà 14% clinical areas (human, animal,
àà 5% on policy environment), based
on responses from 50
àà 5% on sanitation researchers
àà 4% on social aspects
àà 9% on other areas
61
SECTION
5
DISCUSSION AND
RECOMMENDATIONS
5.1. Humans The studies categorized as social were

mainly focused on understanding
The majority of the human studies the knowledge, attitudes, practices,
were surveillance-based, examining and ethical issues involving antibiotic
the prevalence of phenotypic resistance use in the general public and among
and molecular characterization of healthcare providers, chemists, and
resistance for various pathogens. The healthcare trainees. There were
majority of these surveillance studies no studies focusing on the impact
were retrospective single-center studies of behavioral or policy change on
and focused on infected patients. antibiotic use in the community.
There were very few multicenter large
prospective cohort-based or population- Recommendations for future research
based epidemiological studies. The in humans include the following:
majority of the clinical studies were àà Understanding transmission
single center studies focusing on clinical mechanisms by which antibiotic
outcomes and risk factors associated resistance spreads in hospitals and
with antibiotic-resistant infections and in the community
case reports of emerging antibiotic- àà Developing and studying the
resistant infections. A limited number impact of various antimicrobial
of studies examined the impact of stewardship activities and
infection prevention measures or infection control measures in
antimicrobial stewardship activities, healthcare facilities with varying
but none of them were multicenter resources and in the community
studies. There were no studies focusing àà Examining the impact of
on transmission dynamics of bacteria behavioral interventions on
either in hospitals or in the community. antibiotic use in healthcare
62
settings and in the community of antibiotic use in food animals

àà Developing methods for and subsequent behavioral
communicating the issue of interventions
antibiotic resistance to the general àà Studying variations in antibiotic
public and healthcare workers and use in different farming practices,
studying their impact on antibiotic such as industrial and backyard
use farming
àà Focusing on the burden of àà Examining alternative practices
antibiotic resistance in various of food animal rearing and their
groups (neonates, children, economic impacts
young adults, the elderly) in the àà Focusing on supply systems and
community and in various levels of market dynamics of antibiotic
healthcare settings production for animal use
àà Studying supply systems and àà Understanding transmission
market dynamics of antibiotic mechanisms by which antibiotic
production to understand the lack resistance spreads from food
of availability of narrow-spectrum animals to humans
antibiotics or old antibiotics such
5.3. Environment
as penicillin
The majority of studies examined the
5.2. Animals
prevalence of phenotypic resistance
The majority of animal studies of various bacteria, the presence of
examined the resistance profiles ARGs, or the presence of antimicrobial
of bacteria isolated from livestock, residues in various environmental
poultry, and aquaculture; however, the sources such as rivers, recreational
frequency of antibiotic use and reasons water, sewage treatment plants,
for use during animal rearing are poorly hospital effluents, and industrial
represented in the published literature. effluents. Studies examining antibiotic
There were no qualitative studies on pollution from pharmaceutical industry
farmers’ knowledge, attitudes, and effluents were confined to Hyderabad
practices regarding antibiotic use in city; however, several hot spots of
food animals. potential antibiotic pollution have
been identified (Figure 3.10 and Figure
Recommendations for future research
3.11). A limited number of studies
in animals include the following:
examined the impact of religious mass
àà Conducting large-scale studies on gathering occasions on contamination
surveillance of antibiotic resistance of rivers with antibiotic-resistant
in food animals bacteria and ARGs and the impact of
àà Conducting large-scale studies on new technologies in STPs in removing
antibiotic use for various purposes antibiotic-resistant bacteria and ARGs.
(growth promotion, prophylaxis,
treatment) among food animals, Recommendations for future research
especially in poultry on the environment include the
àà Understanding the social aspects following:
63
àà Studying the extent of antibiotic resistance. However, studies

environmental antibiotic pollution concentrating on comprehensive
through pharmaceutical industrial understanding of molecular
waste (wastewater, solid waste and mechanisms of emerging resistance
air) in various parts of India among various pathogens were lacking.
àà Developing standards and A limited number of studies focused
detection tools for antibiotic on diagnostics and one health. Studies
residues in pharmaceutical categorized as one health were merely
industrial effluents surveillance studies looking at the
àà Examining acquisition of percentages of resistance in various
antibiotic-resistant bacteria during bacteria isolated from humans, animals,
religious mass gatherings in rivers and the environment.
àà Focusing on waste management to
Recommendations for future research
reduce the contamination of rivers
in these other areas include the
during religious mass gatherings
following:
àà Developing novel technologies
to remove antibiotic-resistant àà Studying novel diagnostics and
bacteria and ARGs from STPs and their impact on antibiotic use and
hospital wastewater clinical outcomes in humans
àà Examining behavioral aspects àà Understanding molecular
of human waste disposal and its mechanisms of bacterial resistance
contribution to the problem of àà Focusing on the one health
antibiotic resistance approach to understand the
transmission mechanisms by
5.4. Other (Novel Agents,
which antibiotic resistance can
Diagnostics, One Health, spread between different (animal,
Miscellaneous) human, environmental) reservoirs
The majority of studies categorized as àà Studying the relative contribution
novel agents focused on compounds of different reservoirs to antibiotic
with antimicrobial activity, resistance
characterization of antimicrobial 5.5. Limitations of the
properties of natural or synthetic Current Study
compounds, and development of
nanoparticle-based antimicrobial There are some limitations to our
agents. Although several compounds scoping exercise. First, we focused on
have been shown to have antimicrobial published literature that was indexed
activity, these were limited to in in PubMed and Google Scholar, which
vitro experiments, and none of them limited our ability to capture research
progressed to clinical evaluation. In projects that were not indexed, that
the miscellaneous category, studies were completed but have not been
focused on several aspects such as published, or that are currently
molecular biology, biofilm formation, ongoing. Although we attempted
genetics, immunology, biochemistry, to assess current research activities
and mathematical modeling concerning through a survey, the response rate
64
was poor, at only 19%. However, we a particular focus on ABR research

observed an increased concentration in India. This report identifies the
of research in diagnostics in the survey future AMR research priorities to be
results. Second, there is a possibility considered in India for various funding
that we might have missed a few studies agencies, including DBT and RCUK.
in our literature search.
5.6. Conclusion
The mapping exercise determined
the AMR research landscape, with
65
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71
APPENDIX
Table A.1:
Formulation companies manufacturing antibiotics for human use (excluding antituberculosis agents) in India
Manufacturer Number of Manufacturer Number of Manufacturer Number of

antibiotics antibiotics antibiotics
manufactured manufactured manufactured
Aarpik 3 Arlak Biotech 15 Daksh 4
Abbott 4 Assure Aplomb 9 Dallas 1
ABS 3 Asterik 3 Divine Savior 4
Accilex 3 Astra Zeneca 2 DML 2
Acinom HC 9 Astrica 10 Docventures 3
Acinta 4 Auris 1 Dr. Alson Labs 6
Active HC 12 Ausler Snovy 2 Dr. Reddy's 11
Aden Healthcare 8 Azine 5 Drukst Biotech 9
Adley 7 Baroda 1 DWD 6
Aglowmed 3 Baxter 4 Dycine 3
AHPL 39 Bayer 2 East West 3
Akesiss 7 Bestochem 10 Eclipser 1
Alb David 1 Beulah 9 Elder 1
Alde Medi 1 Bharat Serum 1 Elkos 7
Alembic 3 Biochem 5 Elmex 1
Alkem 20 Biocon 14 Eltis 6

Allenge 2 Biomax 7 Emcure 1
Almed 1 Biomiicron 2 Emenox 7
Alna Bio 4 Blubell 5 Encore 2
Ambit 4 Blue Cross 19 Epitome 8
Ancalima 6 Bristol Myers 2 Exeltis 2
Andic 8 Brostin 2 FDC 23
Ankare 5 Cadila 24 Fenestra 1
Anvik Biotech 6 Cipla 39 Finecure 16
Apex 2 Citadel 1 Fitwel 6
Aprique 5 Cross Berry 3 Floreat Medica 4
Aqualife 1 Cubit 4 Forgo Pharma 4
Arist 1 Curex 1 Franco Indian 1
Aristo 1 D.S. Labs 3 Fulford 3
Source: : Current Index of Medical Specialties (CIMS) INDIA, April–July 2017 edition.
72

Future 7 Jenburkt 3 Micro Gratia 2
Galpha 11 Jpee 3 Micro Labs 3
Gen-Biotech 4 Juggat 2 Micro Nova 3
Genesis 2 KAPL 7 Minova 6
Genesis Ram 4 Kepler 3 MNW 6
Gentech HC 4 Konverge 1 Molekule 10
Gladcare 9 Koye 1 MSD 2
Glenmark (Maj) 21 Kusum HC 3 Nanocea Biotec 7
Group 3 Laksun 5 NeeSee 1
GSK 15 Leben Labs 16 Neiss 11
Gujarat Terce 8 Levitas 2 NGS 1
Health Biomed 5 Lexus 5 Nidus 5
Healthkind 8 Lifecare 2 Novagen 2
Helplab 6 Lifestyle 1 Novalab 5
Hetero HC 31 Lincoln 5 Novartis Sandoz 11
Hiral 3 Little Greave 2 Octane 1
HLL Lifecare 2 Lividus 4 Orchid 6
ICARUS 4 Lupin 20 Organic labs 5
Ikon 20 Maan Pharma 5 Orion 9
Indchemie 5 Macleods 38 Pax Healthcare 7
Indus Drugs 2 Madhav Biotech 8 Pfizer 4
Inga 2 Malody 12 Pharmed 2
Intas 3 Maneesh H.care 4 Pharmtech HC 4
Intra Life 9 Mankind 8 Plus India 8
Intra Labs 23 Marc Lab 5 Pranshu 14
Invida 1 Marquess 3 Prime Meditek 6
Invision 25 MDC 2 Procure 2
IPCA 12 Medihealth 4 Progressive 4
Iscon 7 Medopharm 3 Psycorem 6
ISIS 1 Medtronix 2 Q Check 2
Jainik 2 Merck 5 Quality 4
Jaiwik 4 Micro B & B 5 Radicura 13
Jb chemicals 3 Micro Eros 3 Ranbaxy 23
73
Manufacturer Number of antibiotics Manufacturer Number of antibiotics

manufactured manufactured
Rass HC 14 Vensat 11
Regardia 1 Vinca 1
Reliance 2 Wallace 2
Rhine Biogenics 1 Wezen 5
Rishab 7 Win medicare 5
Rowan 1 Winsome 4
Rowez 2 Wintech 2
Saffron 3 Wockhardt Orion 8
Sanat 1 Wonder HC 8
Sanify (7 Bio) 5 World wide 2
Sanofi Aventis 17 Wyeth 12
Santiago 2 Zanetus 1
Sarian 5 Zee Lab 12
Schon (Reco) 4 Zenacts 5
Serum Institute 1 Zenon 9
Shinto Biotech 7 Zodak 13
Signova 13 Zota 11
Soigner 9 Zubin 13
Solitaire Radix 11 Zubit 10
Solvay 1 Zuventus 15
SRK 5 Zydus 25
Stadmed 2
Svizera 6
Systemic 1
Tablets 2
Talent 4
Themis MedC 4
Theo Pharma 2
TNT 2
Treatwell 1
Tulip 6
Unilex 6
United Biotech 24
United Lifecare 1
USV 1
74
Table A.2:
Formulation companies manufacturing antibiotics for animal use in India

AHP 1 IBC-Bayer 1 Stallen 5
Alembic 17 ICI/BE 1 Stancare 2
Alved 8 IDPL 1 Sterling lab 14
Ar-Ex 1 Indian Imlogics 7 Themis 4
Aristo 5 Intas 13 Theodor 2
Astra-IDL 1 Intervet 3 Torrent 6
AVR 2 IPCL 1 Trichem 3
BE 2 Jeps 7 TTK 7
Biochem 3 KAPL 13 Unichem 4
Boehringer Mannheim 1 Lyka 16 Universal Medikit 5
Brihans 8 Marc 5 USV 5
Brilliant 6 Max 1 Varsha labs 4
Burrough's-Wellcome 1 Megacare 1 Venky's 6
Cadila HC 4 Micro 7 Vesper 1
Cadila pharma 7 Micro Labs 1 Vetcare 6
Carevet 7 Morvel 9 Vetindia 12

Cattle remedies 7 Neon Labs 1 Vetnex 15
Century 6 Neospark 18 Vetsfarma 13
Chemeck 1 Novartis 7 Virbac 5
Cipla 2 Osco 4 VIRBEC 2
Core 2 Parke-Davis 1 Wallace 1
Cyanamid 1 Pfizer 8 Wockhardt 13
Dabur 4 Piramal 1 Wyeth lederle 1
Denis 5 Piya 2 Zeita 1
Dey's 1 Pranav 4 Zydus AHL 18
Divine lab 3 Prima Vetcare 6 Venky's 6
DOSCH 8 Rajan 5 Vesper 1
Eli Lily 1 Redeem 3
Fulford 1 Rexcel 3
G-Loucatos 4 Saideep 1
GSK Pharma 1 Salus 3
HAL 13 Sam Browns 1

1 Smith-Kline- 3
Hoechst Marion Roussel
Beecham
IBC 15 Sarabhai 4
Source: :VETNDEX Issue VII (2016).

Table A.3:
Institutions with at least one publication on AMR in India
Institution State Animals Diagnostics Environment Humans Miscellaneous Novel agents One health Total
A.J. Institute of Medical Karnataka 0 0 0 1 0 0 0 1
Sciences and
A.V. Medical College Puducherry 0 0 0 1 0 0 0 1
AECS Maaruti College of Karnataka 0 0 0 1 0 0 0 1
Dental Sciences
AFMC Maharashtra 0 0 0 7 0 0 0 7
AIIMS Chattisgarh Chattisgarh 0 0 0 1 0 0 0 1
AIIMS Delhi Delhi 0 0 0 40 4 1 0 45
AIIMS Karnataka Karnataka 0 0 0 2 0 0 0 2
AIIMS Odisha Odisha 0 0 0 3 0 0 0 3
Acharya & B.M Reddy College Karnataka 0 0 0 1 0 0 0 1
of Pharmacy
Adichunchanagiri Karnataka 0 0 0 0 0 3 0 3
Biotechnology and Cancer
Agartala Government Medical Tripura 0 0 0 1 0 0 0 1
College
Agharkar Research Institute Maharashtra 0 0 0 1 0 0 0 1
Alagappa University Tamil Nadu 0 0 1 4 3 14 0 22
Aligarh Muslim University Uttar 0 2 4 14 5 12 0 37
Pradesh
Amity University Uttar 0 1 0 1 0 2 0 4
Pradesh
Amrita Institute of Medical Kerala 0 0 0 6 0 0 0 6
Sciences
Amrita Vishwa Vidyapeetham Kerala 0 0 0 0 1 0 0 1
University
Anand Agricultural University Gujarat 4 0 3 0 2 0 0 8
Anand Diagnostics Laboratory Karnataka 0 0 0 1 0 0 0 1
Animal Sciences University Punjab 0 0 0 0 1 0 0 1
75
Animal and Fisheries Sciences Karnataka 0 1 0 1 0 0 0 2

University
Anna University Tamil Nadu 0 1 1 0 0 5 0 7 76
Annamalai University Tamil Nadu 0 0 2 3 0 0 0 5
Apollo Cancer Institute Tamil Nadu 0 0 0 1 0 0 0 1
Apollo Hospitals Maharashtra 0 0 0 9 0 0 0 9
Apollo Institute of Medical Telangana 0 0 0 3 1 0 0 4
Sciences
Aravind Eye Care Tamil Nadu 0 0 0 1 0 0 0 1
Coimbatore
Aravind Eye Care Madurai Tamil Nadu 0 0 0 2 1 0 0 3
Aravind Eye Hospital and Tamil Nadu 0 0 0 2 0 0 0 2
Postgraduate Institute
Army College of Dental Telangana 0 0 0 1 0 0 0 1
Sciences
Army Hospital (R&R) Delhi 0 0 0 1 0 0 0 1
Artemis Health Institute Haryana 0 0 0 2 0 0 0 2
Arts, Commerce and Science Maharashtra 0 0 0 0 0 1 0 1
College
Ashok Laboratory Clinical West Bengal 0 0 0 1 0 0 0 1
Testing Centre
Ashok and Rita Patel Gujarat 1 0 0 0 0 0 0 1
Institute of Integrated Study
Asian Institute of Public Odisha 0 0 0 1 0 0 0 1
Health
Assam Medical College Assam 0 0 0 2 0 0 0 2

Assam University Assam 0 0 1 16 5 2 0 24
Aurigene Discovery Karnataka 0 0 0 0 0 1 0 1
Technologies Ltd
Azeezia Medical College Kerala 0 0 0 2 0 0 0 2
B.J. Medical College Gujarat 0 0 0 2 0 0 0 2
B.J. Wadia Hospital for Maharashtra 0 0 0 1 0 0 0 1
Childrens
B.J.B. Autonomous College Odisha 0 0 0 1 0 1 0 2
B.Y.L. Nair Charitable Maharashtra 0 0 0 1 0 0 0 1
Hospital
BIS Group of Institutions Punjab 0 0 1 0 0 0 0 1
BLDEU's Shri B M Patil Karnataka 0 0 0 2 0 0 0 2
Medical College
BLK Superspeciality Delhi 0 0 0 2 0 0 0 2
Hospital
BPS GMC (Women) Haryana 0 0 0 1 0 0 0 1
Baba Farid University of Punjab 0 0 0 0 0 1 0 1
Health Sciences
Baba Saheb Ambedkar Delhi 0 0 0 1 0 0 0 1
Hospital
Banaras Hindu University Uttar 0 0 1 21 7 4 1 34
Pradesh
Bangalore Baptist Hospital Karnataka 0 0 0 1 0 0 0 1
Bangalore Medical College Karnataka 0 0 0 1 0 0 0 1
BarodaMedical College Gujarat 0 0 0 0 0 1 0 1
Base Hospital Delhi 0 0 0 1 0 0 0 1
Belagavi Institute of Medical Delhi 0 0 0 1 0 0 0 1
Sciences
Belgaum Institute of Medical Karnataka 0 0 0 1 0 0 0 1
Sciences
Berhampur University Odisha 0 0 0 3 0 0 0 3
Bhabha Atomic Research Maharashtra 0 0 0 0 2 1 0 3
Centre
Bharat Institute of Telangana 0 0 0 1 0 0 0 1
Technology
Bharath University Tamil Nadu 0 0 0 1 0 0 0 1
Bharathi College of Karnataka 0 0 0 1 0 0 0 1
Pharmacy
Bharathiar University Tamil Nadu 0 0 0 3 0 2 0 5
Bharathidasan University Tamil Nadu 1 0 3 0 2 1 0 7
Bharati Vidyapeeth Deemed Maharashtra 0 0 0 2 0 0 0 2
University
Biju Patnaik University of Odisha 0 0 1 0 0 0 0 1
Technology
Birla Institute of Technology Jharkhand 0 0 0 0 1 1 0 2

& Science
77
Birla Institute of Technology Telangana 0 0 0 1 1 1 0 3

& Science
Birla Institute of Technology Goa 0 0 0 0 0 1 0 1 78
and Science
Bombay College of Pharmacy Maharashtra 0 0 0 0 0 2 0 2
Bose Institute West Bengal 0 0 0 0 2 2 0 4
Browns College of Pharmacy Telangana 0 0 0 1 0 0 0 1
Burdwan Medical College West Bengal 0 0 0 2 0 0 0 2
Burdwan University West Bengal 0 0 0 0 1 0 0 1
Byramjee Jeejeebhoy Maharashtra 0 0 0 2 0 0 0 2
Government Medical C
C.B.S.H., G. B. Pant Uttarakhand 0 0 0 0 0 1 0 1
University of Agric
CHILDS Trust Medical Tamil Nadu 0 0 0 1 0 0 0 1
Research Foundation
CSIR - National Maharashtra 0 0 0 0 1 1 0 2
Environmental Engineerin
CSIR Institute of Genomics Delhi 0 0 0 0 2 2 0 2
and Integrated Biology
CSIR-CSMCRI Gujarat 1 0 0 0 0 0 0 1
CSIR-Central Drug Research Uttar 0 0 0 0 1 1 0 2
Institute Pradesh
CSIR-Central Food Karnataka 1 0 1 0 4 1 0 7
Technological Research
CSIR-Central Institute of Uttar 0 0 0 0 0 5 0 5
Medicinal and Aromatic Pradesh

Plants
CSIR-Indian Institute of Telangana 0 0 0 0 1 0 0 1
Chemical Technology
CSIR-Indian Institute of Jammu and 0 0 0 0 2 4 0 6
Integrative Medicine Kashmir
CSIR-Indian Institute of Uttar 0 0 2 0 0 0 0 2
Toxicology Research Pradesh
CSIR-Institute of Microbial Chandigarh 0 0 0 3 11 4 0 18
Technology
CSIR-National Botanical Uttar 0 0 0 0 0 1 0 1
Research Institu Pradesh
CSIR-National Chemical Maharashtra 0 0 0 0 0 1 0 1
Laboratory
CSIR-National Maharashtra 0 0 0 0 0 1 0 1
Environmental Engineering
CSIR-National Institute of West Bengal 0 0 1 0 0 0 0 1
Oceanography
CU Shah Medical College Gujarat 0 0 0 1 0 0 0 1
Calcutta School of Tropical West Bengal 0 0 0 4 0 2 0 6
Medicine
Cancer Institute Tamil Nadu 0 0 0 1 0 0 0 1
Center for Disease Delhi 1 0 0 5 0 0 0 6
Dynamics, Economics &
Policy
Center for Science and Delhi 1 0 0 0 0 0 0 1
Environment
Central Agricultural Mizoram 1 0 0 2 0 0 0 3
University
Central Avian Research Uttar 1 0 0 0 0 0 0 1
Institute Pradesh
Central Institute of Fisheries Maharashtra 0 0 0 0 1 0 0 1
Education
Central Institute of Fisheries Kerala 2 0 0 0 0 0 0 2
Technolog
Central Institute of Fisheries Maharashtra 1 0 0 0 0 0 0 1
Technolog
Central Institute of Odisha 0 0 0 0 0 1 0 1
Freshwater Aquacul
Central Institute of Uttar 0 0 0 0 0 3 0 3
Medicinal and Aroma Pradesh
Central Leather Research Tamil Nadu 0 0 1 0 0 1 0 2
Institute
Central Leprosy-Teaching Tamil Nadu 0 0 0 1 0 0 0 1
and Research Ins
Central Marine Fisheries Kerala 0 0 1 0 0 0 0 1
Research Instit
Central Research Institute Himachal 0 0 0 4 0 0 0 4
Pradesh
79
Central Tuber Crops Kerala 0 0 0 0 0 2 0 2

Research Institute
Central University of Rajasthan 0 0 0 1 1 2 0 4 80
Rajastan Ajmer
Centre for Cellular and Telangana 0 0 0 0 1 0 0 1
Molecular Biology
Centre for DNA Telangana 0 0 0 0 2 0 0 2
Fingerprinting and Diagno
Centre for Materials for Maharashtra 0 0 0 0 1 0 0 1
Electronics Tec
Centre of Advanced Study Uttar 1 0 0 0 0 0 0 1
Pradesh
Chacha Nehru Bal Delhi 0 0 0 2 0 0 0 2
Chikitsalaya
Chaudhary Charan Singh Gujarat 1 0 0 0 0 0 0 1
(C.C.S.) Universi
Chettinad Hospital and Tamil Nadu 0 0 0 3 1 0 0 4
Research Institut
Chhatrapati Shahuji Maharaj Uttar 0 0 0 1 0 0 0 1
Medical Univ Pradesh
Chhattisgarh Dental College Chattisgarh 0 0 0 0 0 1 0 1
and Research
Chhattisgarh Kamdhenu Chattisgarh 2 0 0 0 0 0 1 3
Vishwavidyalaya
Chirayu Medical College and Madhya 0 0 0 1 0 0 0 1
Hospital Pradesh
Choithram Hospital & Madhya 0 0 0 1 0 0 0 1

Research Centre Pradesh
Christ College Gujarat 0 0 0 0 1 0 0 1
Christian Dental College Punjab 0 0 0 1 0 0 0 1
Christian Medical College, Punjab 0 0 0 4 0 0 0 4
Punjab
Christian Medical College, Tamil Nadu 0 0 0 46 4 3 0 53
Tamil Nadu
Civil Hospital Rajasthan 0 0 0 1 0 0 0 1
Cochin University of Science Kerala 3 0 4 0 1 1 0 9
and Technol
College of Pharmacy, Tamil Nadu 0 0 0 1 0 0 0 1
SRIPMS
College of Veterinary Science Assam 2 0 0 0 0 0 0 2
College of Veterinary and Uttar 1 0 1 0 0 0 0 2
Animal Husband Pradesh
College of Veterinary and Kerala 1 0 0 0 0 0 0 1
Animal Science
College of Veterinary and Uttarakhand 1 0 0 0 0 0 0 1
Animal Science
Command Hospital Maharashtra 0 0 0 3 0 0 0 3
Coorg Institute of Dental Karnataka 0 0 0 0 0 1 0 1
Sciences
Council of Scientific and Kerala 0 0 0 0 0 1 0 1
Industrial Res
DHAFMS Delhi 0 0 0 1 0 0 0 1
DUVASU, Mathura Uttar 0 0 0 1 0 0 0 1
Pradesh
Damodaran College of Tamil Nadu 0 0 0 1 0 0 0 1
Science
Dayanand Medical College Punjab 0 0 0 1 0 0 0 1
and Hospital
Dayananda Sagar Karnataka 0 0 2 0 1 2 0 5
Institutions
Deccan College of Medical Telangana 0 0 0 1 0 0 0 1
Sciences
Deemed University Tamil Tamil Nadu 0 0 0 0 1 0 0 1
Nadu
Deemed University Uttar Uttar 0 0 0 0 1 0 0 1
Pradesh Pradesh
Defence Institute of Delhi 0 0 0 0 0 1 0 1
Physiology and Alli
Defence Research & Madhya 0 0 0 3 0 0 0 3
81
Development Establish Pradesh

Delhi State Cancer Institute Delhi 0 0 0 6 0 0 0 6
Department of Science & Gujarat 0 0 0 0 1 0 0 1 82
Technology
Department of Veterinary Uttar 1 0 0 0 0 0 0 1
Microbiology an Pradesh
Department of Veterinary Uttar 0 0 1 0 0 0 0 1
Pharmacology an Pradesh
Dhanalakshmi Srinivasan Tamil Nadu 0 0 0 1 0 0 0 1
Medical College
Dibrugarh University Assam 0 0 0 0 0 1 0 1
Division of Avian Genetics West Bengal 0 0 0 0 1 0 0 1
and Breeding
Doctors Diagnostic Centre Tamil Nadu 0 0 0 0 0 1 0 1
Dr MGR Educational and Tamil Nadu 0 1 0 1 0 0 0 2
Research Institut
Dr Shankarrao Chavan Maharashtra 0 0 0 1 0 0 0 1
Government Medical
Dr. B C Roy Post Graduate West Bengal 0 0 0 1 0 0 0 1
Institute of B
Dr. B.R Ambedkar Medical Karnataka 0 0 0 2 0 0 0 2
College
Dr. B.R. Ambedkar Uttar 0 0 0 0 0 1 0 1
University Pradesh
Dr. Baba Saheb Ambedkar Delhi 0 0 0 1 1 0 0 2
Hospital
Dr. D.Y Patil Medical College Maharashtra 0 0 0 2 0 0 0 2
Dr. G. R. Damodaran College Tamil Nadu 2 0 0 0 0 0 0 2
of Science
Dr. H.S. Gour Central Madhya 0 0 0 0 0 2 0 2
University Pradesh
Dr. Harvansh Singh Judge Chandigarh 0 0 0 1 0 0 0 1
Institute of De
Dr. N.G.P Arts and Science Tamil Nadu 0 0 0 1 0 0 0 1
College
Dr. Pinnamaneni Siddhartha Andhra 0 0 0 1 0 0 0 1
Institute of Pradesh
Dr. RPGMC Himachal 0 0 0 1 0 0 0 1
Pradesh
Dr. Ram Manohar Lohia Uttar 0 0 1 0 0 0 0 1
Avadh University Pradesh
Dr. Somervell Memorial CSI Kerala 0 0 0 2 0 0 0 2
Medical Colle
Dr. V. P. Medical College, Maharashtra 0 0 0 1 0 0 0 1
Hospital & Research Centre
Dr. Yewale's Multispeciality Maharashtra 0 0 0 1 0 0 0 1
Hospital for Children
ESI-PGIMSR, ESIC Medical West Bengal 0 0 0 1 0 0 0 1
College and ESI
ESIC MC & PGIMSR Karnataka 0 0 0 2 0 0 0 2
ESIC Medical College and West Bengal 0 0 0 1 0 0 0 1
ESIC Hospital
East-West College of Science Karnataka 0 0 0 0 0 1 0 1
Eminent Biosciences Madhya 0 0 0 0 1 0 0 1
Pradesh
Entomology Research Tamil Nadu 0 0 0 0 0 1 0 1
Institute
Eras Lucknow Medical Uttar 0 0 0 2 0 0 0 2
College and Hospital Pradesh
Father Muller Medical Karnataka 0 0 0 3 0 0 0 3
College
Fernandez Hospital Telangana 0 0 0 1 0 0 0 1
Fortis Escorts Hospital Rajasthan 0 0 0 5 0 0 0 5
G. B. Pant Institute of Delhi 0 0 0 4 0 0 0 4
Postgraduate Medical
Education
83
GADVASU Punjab 1 0 0 1 0 0 0 2
GHR Micro Diagnostics Telangana 0 0 0 1 0 0 0 1
GITAM University Andhra 0 0 0 0 2 1 0 3 84
Pradesh
GMERS Medical College Gujarat 0 0 0 1 0 0 0 1
GSK Pharmaceuticals Ltd Karnataka 0 0 0 1 0 0 0 1
GSL Medical College & Andhra 0 0 0 1 0 0 0 1
General Hospital Pradesh
Gandhi Medical College and Telangana 0 0 0 2 0 0 0 2
Hospital
Gangagen Biotechnologies Karnataka 0 0 0 0 1 2 0 3
Pvt. Ltd
Gangasaras Diagnostic and Tamil Nadu 0 0 0 1 0 0 0 1
Research Centre
Garhwal University Uttarakhand 0 0 0 0 0 1 0 1
Gauhati Medical College Assam 0 0 0 2 0 0 0 2
Gauhati University Assam 0 0 0 6 1 0 0 7
Glenmark Pharmaceuticals Maharashtra 0 0 0 1 0 0 0 1
Ltd
Goa Dental College and Goa 0 0 0 1 0 0 0 1
Hospital
Goa University Goa 0 0 0 0 1 0 0 1
Gold Field Institute of Haryana 0 0 0 1 0 0 0 1
Medical Sciences
Golden Jubilee Biotech Park Tamil Nadu 0 0 0 1 0 0 0 1
for Women
Government Degree College Jammu and 0 0 0 1 0 0 0 1
Baramulla Kashmir
Government Dental College Karnataka 0 0 0 1 0 0 0 1
and Research Institute
Government Medical College Gujarat 0 0 0 7 0 0 0 7
Gujarat
Government Medical College Uttarakhand 0 0 0 1 0 0 0 1
Haldwani
Government Medical College Chandigarh 0 1 0 18 0 0 0 19
Hospital
Government Medical College Tamil Nadu 0 0 0 1 0 0 0 1
Hospital Tami
Government Medical College Jammu and 0 0 0 2 0 0 0 2
Jammu and Kashmir Kashmir
Government Medical College Kerala 0 0 0 4 0 0 0 4
Kerala
Government Medical College Punjab 0 0 0 2 0 0 0 2
Punjab
Government Medical College Uttarakhand 0 0 0 4 0 0 0 4
Uttarakhand
Government Medical Maharashtra 0 0 0 1 0 0 0 1
College, Latur
Government Medical Maharashtra 0 0 0 1 0 0 0 1
College, Nagpur
Government Postgraduate Uttarakhand 0 0 0 1 0 0 0 1
College
Government Cancer Hospital Maharashtra 0 0 0 1 0 0 0 1
Govt. Kilpauk Medical Tamil Nadu 0 0 0 2 0 0 0 2
College
Grant Government Medical Maharashtra 0 0 0 1 0 0 0 1
College
Grant Medical College Maharashtra 0 0 0 0 1 0 0 1
Greater Kailash Hospital Madhya 0 0 0 1 0 0 0 1
Pradesh
Gujarat University Gujarat 0 0 0 0 0 1 0 1
Gulbarga University Karnataka 0 0 0 2 2 1 0 5
Guru Angad Dev Veterinary Delhi 1 0 0 0 0 0 0 1
and Animal Sciences
Guru Gobind Singh Delhi 0 0 0 0 0 1 0 1
Indraprastha University
Guru Gobind Singh Medical Punjab 0 0 0 1 0 0 0 1
College and Hospital
Guru Jambheshwer Haryana 0 0 0 0 0 3 0 3
85
University of Science &

Technology
Guru Nanak Dev University Punjab 0 0 0 0 0 2 0 2 86
Gurukul Kangri University Uttarakhand 0 0 0 0 0 1 0 1
Haldia Institute of West Bengal 0 0 0 0 0 2 0 2
Technology
Hamdard University Delhi 0 0 0 0 0 1 0 1
Herbicure Healthcare Bio- Not 0 0 0 0 0 1 0 1
Herbal Foundation Applicable
Himachal Pradesh Himachal 0 0 0 1 0 0 0 1
University Pradesh
Himalayan Institute of Uttarakhand 0 0 0 4 0 0 0 4
Medical Sciences
Hindu Rao Hospital Delhi 0 0 0 1 0 0 0 1
Holy Cross College Tamil Nadu 0 0 0 0 1 0 0 1
Holy Spirit Hospital Maharashtra 0 0 0 1 0 0 0 1
ICAR Research Complex for Meghalaya 4 0 0 0 1 0 0 5
NEH Region
ICAR-Indian Veterinary Uttar 2 0 0 0 0 0 1 3
Research Institut Pradesh
ICARE Eye Hospital and Uttar 0 0 0 1 0 0 0 1
Postgraduate Institute Pradesh
IFTM University Uttar 0 0 0 0 0 1 0 1
Pradesh
IIT Delhi Delhi 0 1 6 0 0 0 0 7
IIT Guwahati Assam 0 0 1 0 1 4 0 6

IIT Hyderabad Telangana 0 0 0 0 1 1 0 2
IIT Kanpur Uttar 0 0 0 0 2 0 0 2
Pradesh
IIT Kharagpur West Bengal 0 0 0 1 6 10 0 17
IIT Madras Tamil Nadu 0 0 0 1 0 0 0 1
IIT Roorkee Uttarakhand 0 0 0 0 3 4 0 7
IMS & Sum Hospital Medical Odisha 0 0 0 7 0 7 0 14
College, S 'O
IPGME&R and SSKM West Bengal 0 0 0 3 0 1 0 4
Hospital
IPGMER & SSKM Hospital West Bengal 0 0 0 1 0 0 0 1
IT University Tamil Nadu 0 0 0 0 1 0 0 1
ITS Dental College Uttar 0 0 0 1 0 0 0 1
Pradesh
Dr G R Damodaran College Tamil Nadu 0 0 0 0 1 0 0 1
of Science
M M College of Pharmacy Haryana 0 0 0 0 0 1 0 1
Indian Academy Degree Karnataka 0 0 0 1 0 0 0 1
College
Indian Agricultural Research Delhi 0 0 0 0 0 1 0 1
Institute
Indian Association for the West Bengal 0 0 0 0 0 1 0 1
Cultivation of Science
Indian Council of Assam 4 0 0 0 0 0 0 4
Agricultural Research
Indian Council of Medical Delhi 0 0 1 2 1 0 0 4
Research
Indian Council of Medical Andaman 0 0 0 7 1 0 0 8
Research & Nicobar
Islands
Indian Council of Medical Assam 0 0 0 1 0 0 0 1
Research
Indian Council of Medical Karnataka 0 0 0 5 0 1 0 6
Research,
Indian Council of Medical Odisha 0 0 0 2 0 0 0 2
Research,
Indian Institute of Advanced Gujarat 0 0 0 4 1 0 0 5
Research
Indian Institute of Chemical Telangana 0 0 0 0 0 1 0 1
Technology
Indian Institute of Science Karnataka 0 0 0 0 4 1 0 5
Indian Institute of Science Madhya 0 0 0 0 2 0 0 2
Education and Research Pradesh
Indian Institute of Science Maharashtra 0 0 0 0 1 1 0 2
Education and Research
87
Indian Institute of Maharashtra 0 0 0 0 6 1 0 7

Technology Bombay
Indian Institute of West Bengal 0 0 1 0 0 0 0 1 88
Technology Kharagpur
Indian Network Multicenter 0 0 0 1 0 0 0 1
for Surveillance of
Antimicrobial Resistance
Indian Veterinary Research Arunachal 1 0 0 0 0 0 0 1
Institute Pradesh
Indian Veterinary Research Uttar 2 0 0 0 0 1 2 5
Institute Pradesh
Indian Veterinary Research West Bengal 2 0 0 0 0 1 0 3
Institute
Indian Institute of Soil Madhya 0 0 0 0 1 0 0 1
Science Pradesh
Indira Gandhi Government Maharashtra 0 0 0 2 0 0 0 2
Medical College
Indira Gandhi Krishi Chattisgarh 0 0 0 0 1 0 0 1
Vishwavidyalaya
Indira Gandhi Medical Himachal 0 0 0 5 0 0 0 5
College Pradesh
Indira Gandhi Medical Puducherry 0 0 0 1 0 0 0 1
College & Research
Institute for Research in Tamil Nadu 0 0 0 1 0 0 0 1
Vision and Ophtholomology
Institute of Advanced Study Assam 0 0 0 0 0 1 0 1
in Science and Technology

Institute of Bioresources and Manipur 0 0 0 0 0 1 0 1
Sustainable Development
Institute of Chemical Maharashtra 0 0 1 0 0 0 0 1
Technology
Institute of Child Health West Bengal 0 0 0 1 0 0 0 1
Institute of Life Sciences Odisha 0 0 0 2 2 0 0 4
Institute of Liver & Biliary Delhi 0 0 0 1 0 0 0 1
Sciences
Institute of Minerals and Odisha 0 0 1 0 0 0 0 1
Materials Technology
Institute of Nuclear Medicine Delhi 0 0 0 1 1 8 0 10
and Allied Sciences
Integral University Uttar 0 0 2 3 2 3 0 10
Pradesh
International Centre for West Bengal 0 0 1 0 0 0 0 1
Ecological Engineering
International Crops Telangana 0 0 0 0 1 0 0 1
Research Institute for Semi-
Arid Tropics
J N Medical College Uttar 0 0 0 3 0 1 0 4
Pradesh
JIPMER Puducherry 0 0 0 21 1 0 0 22
JJM Medical College Karnataka 0 0 0 4 0 0 0 4
JSS Dental College and Karnataka 0 0 0 0 1 0 0 1
Hospital
JSS University Karnataka 0 0 0 0 0 2 0 2
Jadavpur University West Bengal 0 0 1 0 0 7 0 8
Jain Irrigation Systems Ltd Maharashtra 0 0 0 1 0 0 0 1
Jain University Karnataka 0 0 1 3 0 1 0 5
Jamal Mohamed College Tamil Nadu 0 0 1 0 0 0 0 1
Jamia Hamdard Delhi 0 0 0 1 0 0 0 1
Jamia Millia Islamia Delhi 0 0 2 0 0 2 0 4
Janakpuri Super Speciality Delhi 0 0 0 1 0 0 0 1
Hospital
Jawaharlal Nehru Centre for Karnataka 0 0 0 0 1 18 0 19
Advanced Sciences
Jawaharlal Nehru Institute Telangana 1 0 0 0 0 0 0 1
of Advanced Sciences
Jawaharlal Nehru Delhi 0 0 1 2 1 3 0 7
University, Delhi
Jawaharlal Nehru Karnataka 0 0 0 2 0 0 0 2
University, Maharashtra
89
Jawaharlal Nehru Uttar 0 0 1 2 0 3 0 6

University, Uttar Pradesh Pradesh
Jaypee Institute of Himachal 0 0 1 0 7 5 0 13 90
Information Technology Pradesh
Jaypee Institute of Uttar 0 0 0 0 2 0 0 2
Information Technology Pradesh
Jhalawar Medical College Rajasthan 0 0 0 2 0 0 0 2
Joseph Eye Hospital Tamil Nadu 0 0 0 1 0 0 0 1
Jubilant Chemsys Ltd Uttar 0 0 0 0 1 0 0 1
Pradesh
K.S.R. College of Arts and Tamil Nadu 0 0 0 1 0 1 0 2
Science
KEM Hospital Maharashtra 0 1 0 0 0 0 0 1
KG Medical University Uttar 0 0 0 1 0 0 0 1
Pradesh
KIIT University Odisha 0 0 0 0 1 3 0 4
KLE University Karnataka 0 0 0 0 0 1 0 1
KLE VK Institute of Dental Karnataka 0 0 0 0 0 2 0 2
Sciences
KLE's JN Medical College, Karnataka 0 0 0 1 0 0 0 1
Belgaum
KVG Dental College and Karnataka 0 0 0 1 0 0 0 1
Hospital
Kakatiya Government Telangana 0 0 0 0 0 1 0 1
Degree & P.G College
Kalinga Institute of Medical Odisha 0 0 0 2 0 0 0 2

Sciences
Kamalnayan Bajaj Research Tamil Nadu 0 0 0 1 0 0 0 1
Centre, Vision
Kannur Dental College Kerala 0 0 0 1 0 0 0 1
Karnatak University Karnataka 0 0 0 0 0 1 0 1
Karnataka Institute of Karnataka 0 0 0 1 0 0 0 1
Medical Sciences
Karnataka Veterinary Karnataka 2 0 0 0 0 0 1 3
Animal and Fisherie
Karpagam Faculty of Medical Tamil Nadu 0 0 0 2 0 0 0 2
Sciences and
Karunya University Tamil Nadu 0 0 0 1 0 0 0 1
Kashibai Navale Medical Maharashtra 0 0 0 1 0 0 0 1
College
Kasturba Medical College Karnataka 0 0 0 5 0 0 0 5
Katihar Medical College Bihar 0 0 0 1 0 0 0 1
Kempegowda Institute of Karnataka 0 0 0 3 0 0 0 3
Medical Sciences
Kerala Institute of Medical Kerala 0 0 0 1 0 0 0 1
Sciences
Kerala Veterinary and Kerala 0 0 0 0 1 0 0 1
Animal Sciences University
Khadir Mohideen College Tamil Nadu 0 0 0 1 0 0 0 1
Khaja Banda Nawaz institute Karnataka 0 0 0 1 0 0 0 1
of Medical Sciences
Kidwai Memorial Institute of Karnataka 0 0 0 1 0 0 0 1
Oncology,
King George Medical Uttar 0 0 0 3 0 0 0 3
University Pradesh
King Saud University Tamil Nadu 0 0 1 0 0 0 0 1
Kokilaben Dhirubhai Maharashtra 0 0 0 2 0 0 0 2
Ambani Hospital and
Konaseema Institute of Andhra 0 0 0 1 0 0 0 1
Medical Science & Pradesh
Kovai Medical Center and Tamil Nadu 0 0 0 1 0 1 0 2
Hospital
Krishna Institute of Medical Maharashtra 0 0 0 1 0 0 0 1
Sciences
Kurukshetra University Gujarat 1 0 0 0 0 0 0 1
L & T Microbiology Research Tamil Nadu 0 0 0 1 0 0 0 1
Centre
91
L. V. Prasad Eye Institute AP Andhra 0 0 0 5 0 0 0 5

Pradesh
L. V. Prasad Eye Institute Odisha 0 0 0 5 0 0 0 5 92
Odisha
L. V. Prasad Eye Institute Telangana 0 0 0 5 0 0 0 5
Telangana
L.T.M. Medical College Maharashtra 0 0 0 4 0 0 0 4
LBS College of Pharmacy Rajasthan 0 0 0 0 0 1 0 1
LN Medical College & RC Madhya 0 0 0 2 0 0 0 2
Pradesh
Lady Doak College Tamil Nadu 0 0 0 0 1 0 0 1
Lady Hardinge Medical Delhi 0 0 0 2 0 0 0 2
College
Lohia Hospital Delhi 0 0 0 1 0 0 0 1
Lovely Professional Punjab 0 0 1 2 1 1 1 6
University
Loyola College Tamil Nadu 0 0 0 0 0 1 0 1
(Autonomous)
M. D. University Haryana 0 0 0 0 0 1 0 1
M.M. Institute of Medical Haryana 0 0 0 1 0 0 0 1
Sciences and R
MES Medical College Kerala 0 0 0 4 0 0 0 4
MES Ponnani College Kerala 0 0 0 0 1 0 0 1
MGM Eye Institute Chattisgarh 0 0 0 1 0 0 0 1
MGM Medical College and Maharashtra 0 0 0 2 0 0 0 2
Hospital
MIMER Medical College Maharashtra 0 0 0 1 0 0 0 1
MS Ramaiah Medical College Karnataka 0 0 0 2 0 0 0 2
Madha Medical College Tamil Nadu 0 0 0 1 0 0 0 1
Madhav Institute of Madhya 0 0 1 0 1 1 0 3
Technology and Sciences Pradesh
Madras Medical College Tamil Nadu 0 0 0 1 0 0 0 1
Madras Medical Mission Tamil Nadu 0 0 0 1 0 0 0 1
Madurai Kamaraj University Tamil Nadu 0 0 0 2 3 2 0 7
Maharajah’s Institute of Andhra 0 0 0 1 0 0 0 1
Medical Sciences Pradesh
Maharashtra Institute of Maharashtra 0 0 0 1 0 0 0 1
Medical Education
Maharishi Markandeshwar Haryana 0 0 0 1 0 0 0 1
College of Dental Sciences &
Research
Maharshi Dayanand Haryana 0 0 0 0 1 1 0 2
University
Mahatma Gandhi Institute of Gujarat 0 0 0 1 0 0 0 1
Medical Sciences
Mahatma Gandhi Institute of Maharashtra 0 0 0 2 0 0 0 2
Medical Sciences
Mahatma Gandhi Medical Rajasthan 0 0 0 2 0 1 0 3
College
Mahatma Gandhi Medical Puducherry 0 0 0 11 0 1 0 12
College and Research Center
Mahatma Gandhi University Kerala 0 0 0 2 0 2 0 4
Majeedia Hospital Delhi 0 0 0 1 0 0 0 1
Malabar Medical College and Kerala 0 0 0 1 0 0 0 1
Research Centre
Malankara Catholic College Tamil Nadu 0 0 0 0 0 1 0 1
Malda Medical College and West Bengal 0 0 0 1 0 0 0 1
Hospital
Manipal College of Karnataka 0 0 0 0 1 0 0 1
Pharmaceutical Sciencec
Manipal University Karnataka 0 0 6 29 1 2 0 38
Manonmaniam Sundaranar Tamil Nadu 0 0 0 0 0 2 0 2
University
Maulana Azad Medical Delhi 0 0 0 13 0 0 0 13
College
Maulana Azad Medical Uttar 0 0 0 1 0 0 0 1
College Uttar Pradesh Pradesh
Max Super Speciality Delhi 0 0 0 3 0 0 0 3
Hospital
Mayo Institute of Medical Uttar 0 0 0 3 0 0 0 3
Sciences Pradesh
93
Medanta Hospital Haryana 0 0 0 4 0 0 0 4

Medical College Gujarat 0 0 0 1 0 1 0 2
Medical Sciences and Uttarakhand 0 0 0 1 0 0 0 1 94
Research Institute
Medicinal Chemistry Uttar 0 0 0 0 0 1 0 1
Department Pradesh
Meenakshi Ammal Dental Tamil Nadu 0 0 0 1 1 0 0 2
College
Meerut College Gujarat Gujarat 0 0 0 1 0 0 0 1
Meerut College Uttar Uttar 0 0 0 1 0 0 0 1
Pradesh Pradesh
Metropolis Healthcare Ltd Maharashtra 0 0 0 1 0 0 0 1
Military Hospital Meerut Uttar 0 0 0 3 0 0 0 3
Pradesh
Mizoram University Mizoram 0 0 1 0 0 0 0 1
Modern College of Arts Maharashtra 0 0 0 0 0 1 0 1
Modern Dental College and Madhya 0 0 0 2 0 0 0 2
Montessori Mahila Kalasala Andhra 0 0 0 1 0 0 0 1
Pradesh
Motilal Nehru Medical Uttar 0 0 0 3 1 0 0 4
College Pradesh
Motilal Nehru National Uttar 0 0 0 0 2 1 0 3
Institute of Tech Pradesh
Muljibhai Patel Urological Gujarat 0 0 0 1 0 0 0 1
Hospital
Multicenter study Multicenter 0 0 0 1 0 0 0 1
Murshidabad Medical West Bengal 0 0 0 1 0 0 0 1
College
Muzaffarnagar Medical Uttar 0 0 0 1 0 0 0 1
College and Hospital Pradesh
NDMC & Hindu Rao Hospital Delhi 0 0 0 1 0 0 0 1
NGO Gamana Telangana 0 0 1 0 0 0 0 1
NHL Municipal Medical Gujarat 0 0 0 1 0 0 0 1
College
NIIT University Rajasthan 0 0 0 3 0 0 0 3
NIMS Medical College & Rajasthan 0 0 0 4 0 0 0 4
Hospital
NMIMS university Maharashtra 0 0 0 0 0 1 0 1
NRI college of pharmacy Andhra 0 0 0 0 0 1 0 1
Pradesh
NRS Medical College West Bengal 0 0 0 1 0 0 0 1
Nagpur University Maharashtra 0 0 0 1 0 0 0 1
Nagpur Veterinary College Maharashtra 1 0 0 0 0 0 0 1
Nanaji Deshmukh Veterinary Madhya 1 0 0 0 0 0 0 1
Science University Pradesh
Nandha College of Pharmacy Tamil Nadu 0 0 0 0 0 1 0 1
and Research
National AIDS Research Maharashtra 0 0 0 2 0 0 0 2
Institute
National Bureau of Fish Uttar 1 0 0 0 1 0 0 2
Genetic Resource Pradesh
National Centre for Cell Maharashtra 1 0 2 1 1 1 1 7
Science
National Centre Telangana 0 0 0 0 0 1 0 1
for Compositional
Characterisation of
Materials
National Centre for Haryana 0 0 0 0 1 0 0 1
Veterinary Type Cultures
National Chemical Maharashtra 0 0 0 0 0 3 0 3
Laboratory
National Dairy Research Haryana 0 1 0 0 5 2 0 8
Institute
National Environmental Telangana 0 0 0 0 1 0 0 1
Engineering Research
National Institute for Kerala 0 0 0 1 0 1 0 2
Interdisciplinary
National Institute for Maharashtra 0 0 0 0 0 1 0 1
Research in Reproductive
Health
National Institute of Cholera West Bengal 0 1 1 22 1 2 0 27
and Enteric Diseases
95
National Institute of Tamil Nadu 0 0 0 1 0 0 0 1

Epidemiology (ICMR)
National Institute of Maharashtra 0 0 0 0 1 0 0 1 96
Immunohaemotology
National Institute of Mental Karnataka 0 0 0 1 0 0 0 1
Health & Neurosciences
National Institute of Ocean Andaman 0 0 0 1 0 0 0 1
Technology & Nicobar
Islands
National Institute of Assam 0 0 0 1 0 0 0 1
Pharmaceutical Education
National Institute of Punjab 0 0 0 1 0 1 0 2
Pharmaceutical Education
National Institute of Plant Delhi 0 0 0 0 1 0 0 1
Genome Research
National Institute of Science Odisha 0 0 2 2 0 2 0 6
Education
National Institute of Gujarat 0 0 0 0 0 1 0 1
Technology Gujarat
National Institute of Karnataka 0 0 0 0 1 0 0 1
Technology
National Institute of Odisha 0 0 0 0 1 1 0 2
Technology
National Institute of Unani Karnataka 0 0 0 0 0 1 0 1
Medicine
National JALMA Institute for Uttar 0 0 0 1 0 0 0 1
Leprosy Pradesh
National Research Centre Arunachal 1 0 0 0 0 0 0 1
on Yak Pradesh
National Salmonella Centre Uttar 0 0 0 0 0 0 1 1
(Vet) Pradesh
Natubhai V. Patel College of Gujarat 0 0 0 0 0 1 0 1
Pure and Applied Sciences
Navodaya Medical College Karnataka 0 0 0 2 0 0 0 2
Netaji Subhas Institute of Delhi 0 0 0 0 2 0 0 2
Technology
Nilratan Sircar Medical West Bengal 0 0 0 1 0 0 0 1
College & Hospital
Nirma University Gujarat 0 0 0 0 0 1 0 1
Nitte University Karnataka 0 0 0 2 0 0 0 2
Nizam Institute of Medical Telangana 0 1 0 1 0 0 0 2
Sciences
North Eastern Indira Gandhi Meghalaya 0 0 0 3 0 0 0 3
Regional Institute
North Maharashtra Maharashtra 0 0 0 1 1 1 0 3
University
North Orissa University Odisha 0 0 0 0 0 4 0 4
North-Eastern Hill Meghalaya 0 0 0 0 1 0 1 2
University
Orchid Chemicals and Tamil Nadu 0 0 0 1 0 0 0 1
Pharmaceuticals Ltd
P. M. N. M. Dental College Karnataka 0 0 0 0 1 0 0 1
and Hospital
P.D. Hinduja Hospital & Maharashtra 0 1 0 4 0 0 0 5
Medical Research
P.D.U. Govt. Medical College Gujarat 0 0 0 1 0 0 0 1
PDM College of Pharmacy Haryana 0 0 0 0 0 1 0 1
PGIMER Chandigarh 0 0 1 21 3 0 0 25
PGIMSR Karnataka 0 0 0 1 0 0 0 1
PRIST University Tamil Nadu 0 0 0 0 0 1 0 1
PSG College of Arts and Tamil Nadu 0 0 0 0 1 0 0 1
Science
PSG Institute of Medical Tamil Nadu 0 0 0 2 0 0 0 2
Sciences & Research
Pachaiyappa's College Tamil Nadu 0 0 0 1 0 0 0 1
Padmashree Institute of Karnataka 0 0 0 0 0 1 0 1
Management and Sciences
Pandit Bhagwat Dayal Delhi 0 0 0 0 1 0 0 1
Sharma Post Graduation
Panineeya Dental College Telangana 0 0 0 1 0 0 0 1
Panjab University Chandigarh 0 0 0 6 11 13 0 30
Patel College of Paramedical Gujarat 0 0 0 1 0 0 0 1
97
Science and
Patna Womens College Bihar 1 0 0 0 0 0 0 1
Periyar Maniammai Tamil Nadu 0 0 0 0 0 1 0 1 98
University
Periyar University Tamil Nadu 0 0 1 1 0 0 0 2
Piramal Enterprises Ltd Maharashtra 0 0 0 0 1 1 0 2
Pondicherry Institute of Puducherry 0 0 0 3 0 0 0 3
Medical Science
Pondicherry University Puducherry 0 0 0 3 1 2 0 6
Post Graduate Institute of Rajasthan 1 0 0 0 0 0 0 1
Veterinary Education
Pramukh Swami Medical Gujarat 0 0 0 2 0 0 0 2
College and Hospit
Pramukh Swami Science and Gujarat 0 0 1 0 0 0 0 1
H. D. Patel Arts College
Prathima Institute of Telangana 0 0 0 1 1 0 0 2
Medical Sciences
Presidency College Tamil Nadu 0 0 0 1 0 0 0 1
Presidency University West Bengal 0 0 0 1 1 0 0 2
Priti Medical Research and Uttar 0 0 0 1 0 0 0 1
Charitable Trust Pradesh
Pt. B D Sharma PGIMS Haryana 0 0 0 6 0 0 0 6
Public Health Foundation of Delhi 0 0 0 1 0 0 0 1
India
Pune University Maharashtra 0 0 1 0 0 1 0 2
Pushpagiri Institute of Kerala 0 0 0 2 0 0 0 2

Medical Sciences
Quaid-e-Millath Government Tamil Nadu 0 0 0 1 0 0 0 1
Arts College
R. G. Kar Medical College West Bengal 0 0 0 4 0 0 0 4
RD Gardi Medical College Madhya 0 0 4 14 0 0 1 19
Pradesh
RIMS Karnataka 0 0 0 2 0 0 0 2
RML Hospital Delhi 0 0 0 4 0 0 0 4
RTM Nagpur University Maharashtra 0 0 0 2 0 0 0 2
RVS College of Arts and Tamil Nadu 1 0 0 0 0 0 0 1
Science
Raghavendra Institute of Andhra 0 0 0 2 0 0 0 2
Pharmaceutical Pradesh
Rainbow Childrens Hospital Telangana 0 0 0 2 0 0 0 2
Rajah muthiah medical Tamil Nadu 0 0 0 1 0 0 0 1
college and hospital
Rajasthan University of Rajasthan 1 0 0 0 0 0 0 1
Veterinary and Animal
Sciences
Rajendra Memorial Bihar 0 0 0 0 1 0 0 1
Research Institute of
Medical Sciences
Rajiv Gandhi Centre for Kerala 0 0 0 1 0 0 0 1
Biotechnology
Rajiv Gandhi Institute of Telangana 0 0 0 1 0 0 0 1
Medical Sciences
Rajiv Gandhi Cancer Delhi 0 0 0 1 0 0 0 1
Institute and Rese
Rama Medical College Uttar 0 0 0 4 0 0 0 4
Pradesh
Ramananda College West Bengal 0 0 0 0 1 0 0 1
Ranbaxy Research Haryana 0 0 0 0 0 3 0 3
Laboratories
Rohilkhand Medical College Uttar 0 0 0 1 0 0 0 1
Pradesh
Ruhs College of Medical Rajasthan 0 0 0 1 0 0 0 1
Sciences
Rungta College of science Chattisgarh 0 0 0 1 0 0 0 1
and Technology
Rural Development Trust Andhra 0 0 0 3 0 0 0 3
Hospital Pradesh
S L Raheja Hospital Maharashtra 0 0 0 0 0 1 0 1
S. N. M. C. Bagalkot Karnataka 0 0 0 1 0 0 0 1
S. S. Institute of Medical Karnataka 0 0 0 1 0 1 0 2
99
Sciences & Re
S.C.B Medical College Odisha 0 0 0 1 0 0 0 1
SASTRA University Tamil Nadu 0 0 0 0 3 3 0 6 100
SDM College of Medical Karnataka 0 0 0 1 0 0 0 1
Sciences and Hospital
SGB Amravati University Maharashtra 0 0 0 0 0 3 0 3
SGT University Haryana 0 0 0 0 0 1 0 1
SHIATS Uttar 0 0 0 0 1 2 0 3
Pradesh
SRL Ltd, S. V. Road Maharashtra 0 0 0 1 0 0 0 1
SRM University Tamil Nadu 0 1 0 0 0 1 0 2
SRNMN College of Applied Karnataka 0 0 0 0 0 1 0 1
Sciences
SSN College of Engineering Tamil Nadu 0 0 0 0 0 1 0 1
SVMCH &RC Puducherry 0 0 0 2 0 0 0 2
SVS Medical College Telangana 0 0 0 1 0 0 0 1
Saifee Hospital Maharashtra 0 0 0 1 0 0 0 1
Sanjay Gandhi Post Graduate Uttar 0 0 0 8 0 2 0 10
Institute of Medical Sciences Pradesh
Sant Gadge Baba Amravati Maharashtra 0 1 0 0 0 1 0 2
University
Santosh University Uttar 0 0 0 1 0 0 0 1
Pradesh
Sapthagiri Institute of Karnataka 0 0 0 1 0 0 0 1
Medical Science
Saurashtra University Gujarat 0 0 0 0 1 0 0 1

Saveetha Medical College & Tamil Nadu 0 0 0 1 0 0 0 1
Hospital
Savitribai Phule Pune Maharashtra 0 0 0 0 0 1 0 1
University
Sawai Man Singh Medical Rajasthan 0 0 0 3 1 0 0 4
College
School of Biosciences and Tamil Nadu 0 0 0 1 0 0 0 1
Technology
School of Tropical Medicine West Bengal 0 0 0 4 0 0 0 4
Seth GS Medical College & Maharashtra 0 0 0 4 0 0 0 4
KEM Hospital
Sher-e-Kashmir University Jammu and 2 0 2 2 0 0 0 6
Kashmir
Sher-i-Kashmir Institute of Jammu and 0 0 0 4 0 0 0 4
Medical Scie Kashmir
Sheth M.N.Science College Gujarat 0 0 0 0 0 1 0 1
Shivaji University Maharashtra 0 0 0 1 0 0 0 1
Shoolini University Himachal 0 0 0 1 0 0 0 1
Pradesh
Shri B. M. Patil Medical Karnataka 0 0 0 1 0 0 0 1
College
Shri Ram Murti Smarak Uttar 0 0 0 1 0 0 0 1
Institute of Medical Sciences Pradesh
Shri Shivaji Science College Maharashtra 0 0 0 1 0 0 0 1
Department
Shri Vasantrao Naik Maharashtra 0 0 0 1 0 0 0 1
Government Medical College
Siksha 'O' Anusandhan Odisha 0 0 0 1 0 1 0 2
University
Sindhu Mahavidyalaya Maharashtra 0 0 0 1 0 0 0 1
Center for Biotechnology
Sir Ganga Ram Hospital Delhi 0 0 0 6 0 0 0 6
Smt Kashibai Navale Medical Maharashtra 0 0 0 3 0 0 0 3
Sourashtra College Maharashtra 0 0 0 1 0 0 0 1
Sree Chitra Tirunal Institute Kerala 0 0 0 1 0 0 0 1
for Medical Sciences and
Technology
Sree Vidhyanikethan College Andhra 0 0 0 0 0 1 0 1
of Pharmacy Pradesh
Sri Aurobindo Institute of Madhya 0 0 0 6 0 0 0 6
Medical Sciences Pradesh
Sri Devaraj Urs Medical Karnataka 0 0 0 2 0 0 0 2
College
101
Sri Guru Ram Das Institute Punjab 0 0 0 3 0 0 0 3

of Medical Sciences
Sri Krishnadevaraya Andhra 0 0 0 0 0 1 0 1
University Pradesh
102
Sri Narayani Hospital and Tamil Nadu 0 0 0 1 0 0 0 1

Research Center
Sri Ramachandra Medical Tamil Nadu 0 0 1 12 0 4 0 17
College and Research Centre
Sri Sathya Sai Institute of Andhra 0 0 0 0 1 0 0 1
Higher Learning center Pradesh
Sri Siddhartha Medical Karnataka 0 0 0 4 0 0 0 4
College
Sri Venkateswara Institute Andhra 0 0 0 5 0 0 0 5
of Medical Sciences Pradesh
Srimad Andavan Arts and Tamil Nadu 0 0 0 1 0 0 0 1
Science College
Sriram Chandra Bhanj Odisha 0 0 0 1 0 0 0 1
Medical College
St John's Medical College Karnataka 0 0 1 6 0 0 0 7
and Hospital
St. Gregorios Dental College Kerala 0 0 0 0 0 1 0 1
St. Xavier's College Goa Goa 0 0 0 0 0 1 0 1
St. Xavier's College Tamil Tamil Nadu 0 0 0 0 0 1 0 1
Nadu
Subbaiah Institute of Karnataka 0 0 0 1 0 0 0 1
Medical Sciences and

Research Center
Subharti Medical College Uttar 0 1 0 2 0 0 0 3
Pradesh
Swami Ramanand Teerth Maharashtra 0 0 0 0 1 0 0 1
Marathwada University
Swami Vivekanand Subharti Uttar 0 1 0 0 0 0 0 1
University Pradesh
TATA Main Hospital Jharkhand 0 0 0 2 0 0 0 2
Tamil Nadu Veterinary and Tamil Nadu 0 1 0 0 0 0 0 1
Animal Sciences
Tata Consultancy Services Maharashtra 0 0 0 1 0 0 0 1
Ltd.
Tata Institute of Karnataka 0 0 0 0 2 0 0 2
Fundamental Research
Tata Medical Center Maharashtra 0 1 0 5 0 0 0 6
Tata Memorial Hospital Maharashtra 0 0 0 4 0 0 0 4
Teerthanker Mahaveer Uttar 0 0 0 1 0 0 0 1
Medical College Pradesh
Tejasvini Hospital and SSIOT Karnataka 0 0 0 1 0 0 0 1
Tezpur University Assam 0 0 0 0 1 1 0 2
Thapar University Punjab 0 0 0 0 0 1 0 1
The Maharaja Sayajirao Gujarat 0 0 0 0 1 0 0 1
University of Baroda
The Tamil Nadu Dr MGR Tamil Nadu 0 0 0 1 0 0 0 1
Medical University
The West Bengal University West Bengal 0 0 0 1 0 0 0 1
of Health Sciences
Thiagarajar College Tamil Nadu 0 0 0 0 0 1 0 1
Tripura University Tripura 0 0 0 0 1 2 0 3
UNESCO MIRCEN for Karnataka 1 0 0 0 0 0 0 1
Marine Biotechnology
University College of Medical Delhi 0 0 0 6 0 0 0 6
Sciences
University of Allahabad Uttar 0 0 0 0 1 0 0 1
Pradesh
University of Calcutta West Bengal 0 0 0 0 2 4 0 6
University of Delhi Delhi 0 0 2 1 7 4 0 14
University of Hyderabad Telangana 1 0 0 3 2 1 0 7
University of Kalyani West Bengal 0 0 0 0 0 3 0 3
University of Lucknow Uttar 0 0 0 0 0 1 0 1
Pradesh
University of Madras Tamil Nadu 0 0 0 12 3 2 0 17
University of Mysore Karnataka 0 0 0 3 2 3 0 8
103
University of North Bengal West Bengal 1 0 1 0 0 0 0 2

University of Pune Maharashtra 0 0 0 1 0 3 1 5
Unknown Madhya 0 0 0 6 1 3 0 10
Pradesh
104
VHNSN College Tamil Nadu 0 0 0 0 0 1 0 1

VIT University Tamil Nadu 0 0 0 1 15 7 0 23
Vallabhbhai Patel Chest Delhi 0 0 1 12 0 0 0 13
Institute
Vananchal Dental College Jharkhand 0 0 0 1 0 0 0 1
and Hospital
Vardhman Mahavir Medical Delhi 0 0 0 17 0 0 0 17
College & Safdarjung
Hospital
Veer Bahadur Singh Uttar 0 0 1 0 0 0 0 1
Purvanchal University Pradesh
Veer Chandra Singh Uttarakhand 0 0 0 4 0 0 0 4
Garhwali Government Inst.
Of Medical Sciences
Veer Narmad South Gujarat Gujarat 0 0 2 0 0 0 0 2
University
Veer Surendra Sai University Odisha 0 0 0 0 1 0 0 1
of Technology
Velammal Medical College Tamil Nadu 0 0 0 0 1 0 0 1
Hospital
Vels University Tamil Nadu 0 0 0 1 0 0 0 1
Venus Medicine Research Himachal 0 0 0 3 0 0 0 3

Centre Pradesh
Venus Remedies Haryana 0 0 0 0 0 1 0 1
Veterinary College and Tamil Nadu 1 0 0 0 0 0 0 1
Research Institut
Vidyasagar University West Bengal 0 0 0 4 2 4 0 10
Vijaya Institute of Andhra 0 0 0 0 0 1 0 1
Pharmaceutical Sciences Pradesh
Vinayaka Missions Tamil Nadu 0 0 1 0 0 0 0 1
University
Vision Research Foundation Tamil Nadu 0 0 0 2 0 0 0 2
Visva-Bharati University West Bengal 0 0 0 0 0 1 0 1
Visvesvaraya Technological Karnataka 0 0 0 0 1 1 0 2
University
Vivekananda College Tamil Nadu 0 0 0 0 0 1 0 1
Vyas Dental College and Rajasthan 0 0 0 1 0 0 0 1
Hospital
Vydehi Institute of Medical Karnataka 0 0 0 2 0 0 0 2
Sciences
West Bengal University of West Bengal 4 0 0 0 0 0 1 5
Animal and Fishery Sciences
World Health Organization Delhi 0 0 0 1 0 0 0 1
Yashoda Hospital Telangana 0 0 0 1 0 0 0 1
Yashvantrao Chavan Maharashtra 0 0 0 0 0 1 0 1
Institute of Science
Yenepoya Medical College Karnataka 0 0 0 2 0 0 0 2
Yenepoya University Karnataka 0 0 0 0 2 1 0 3
105
106
Table A.4:
Institutions with at least one publication on AMR in humans
Institution State Clinical Surveillance Social Total

A.J. Institute of Medical Karnataka 1 0 0 1
Sciences and
A.V. Medical College Puducherry 0 1 0 1
AECS Maaruti College of Karnataka 0 0 1 1
Dental Sciences
AFMC Maharashtra 0 7 0 7
AIIMS Chattisgarh Chattisgarh 0 1 0 1
AIIMS Delhi Delhi 7 33 0 40
AIIMS Karnataka Karnataka 0 2 0 2
AIIMS Odisha Odisha 0 3 0 3
Acharya & B.M Reddy Karnataka 0 1 0 1
College of Pharmacy
Agartala Government Tripura 0 1 0 1
Medical College
Agharkar Research Maharashtra 0 1 0 1
Institute
Alagappa University Tamil Nadu 0 4 0 4
Aligarh Muslim Uttar Pradesh 4 10 0 14
University
Amity University Uttar Pradesh 0 1 0 1
Amrita Institute of Kerala 1 5 0 6
Medical Sciences
Anand Diagnostics Karnataka 0 1 0 1
Laboratory
Animal and Fisheries Karnataka 0 1 0 1
Sciences University
Annamalai University Tamil Nadu 0 1 2 3
Apollo Cancer Institute Tamil Nadu 0 1 0 1
Apollo Hospitals Maharashtra 8 8 0 9
Apollo Institute of Telangana 1 2 0 3
Medical Sciences and
Aravind Eye Care Tamil Nadu 0 1 0 1
Coimbatore
Aravind Eye Care Tamil Nadu 0 2 0 2
Madurai
Aravind Eye Hospital Tamil Nadu 0 2 0 2
and Postgraduate In
Army College of Dental Telangana 0 1 0 1
Sciences
Army Hospital (R&R) Delhi 0 1 0 1
Artemis Health Institute Haryana 1 1 0 2
Ashok Laboratory West Bengal 0 1 0 1
Clinical Testing Centre
Asian Institute of Public Odisha 0 1 0 1
Health
Assam Medical College Assam 0 2 0 2
Assam University Assam 0 16 0 16
Azeezia Medical College Kerala 1 1 0 2
107

B.J. Medical College Gujarat 0 1 1 2
B.J. Wadia Hospital for Maharashtra 0 1 0 1
Childrens
B.J.B. Autonomous Odisha 0 1 0 1
College
B.Y.L. Nair Charitable Maharashtra 0 1 0 1
Hospital
BLDEU's Shri B M Patil Karnataka 0 2 0 2
Medical College
BLK Superspeciality Delhi 1 1 0 2
Hospital
BPS GMC (Women) Haryana 0 1 0 1
Baba Saheb Ambedkar Delhi 0 1 0 1
Hospital
Banaras Hindu Uttar Pradesh 3 18 0 21
University
Bangalore Baptist Karnataka 0 1 0 1
Hospital
Bangalore Medical Karnataka 0 1 0 1
College
Base Hospital Delhi 0 1 0 1
Belagavi Institute of Delhi 0 1 0 1
Medical Sciences
Belgaum Institute of Karnataka 0 1 0 1
Medical Sciences
Berhampur University Odisha 0 3 0 3
Bharat Institute of Telangana 0 0 1 1
Technology
Bharath University Tamil Nadu 0 1 0 1
Bharathi College of Karnataka 0 0 1 1
Pharmacy
Bharathiar University Tamil Nadu 0 3 0 3
Bharati Vidyapeeth Maharashtra 0 1 1 2
Deemed University
Birla Institute of Telangana 0 1 0 1
Technology & Science
Browns College of Telangana 0 1 0 1
Pharmacy
Burdwan Medical West Bengal 0 2 0 2
College
Byramjee Jeejeebhoy Maharashtra 0 2 0 2
Government Medical
College
CHILDS Trust Medical Tamil Nadu 0 1 0 1
Research Foundation
CSIR-Institute of Chandigarh 0 3 0 3
Microbial Technology
CU Shah Medical College Gujarat 0 1 0 1
Calcutta School of West Bengal 0 4 0 4
Tropical Medicine
Cancer Institute Tamil Nadu 0 1 0 1
108

Center for Disease Delhi 0 4 1 5
Dynamics, Economics &
Policy
Central Agricultural Mizoram 0 2 0 2
University
Central Leprosy- Tamil Nadu 0 1 0 1
Teaching and Research
Central Research Himachal 0 4 0 4
Institute Pradesh
Central University of Rajasthan 1 0 0 1
Rajastan Ajmer
Chacha Nehru Bal Delhi 0 2 0 2
Chikitsalaya
Chettinad Hospital and Tamil Nadu 0 3 0 3
Research Institute
Chhatrapati Shahuji Uttar Pradesh 0 1 0 1
Maharaj Medical Univ
Chirayu Medical College Madhya Pradesh 0 1 0 1
and Hospital
Choithram Hospital & Madhya Pradesh 0 1 0 1
Research Centre
Christian Dental College Punjab 1 0 0 1
Christian Medical Punjab 0 4 0 4
College, Punjab
Christian Medical Tamil Nadu 14 28 4 46
College, Tamil Nadu
Civil Hospital Rajasthan 1 0 0 1
College of Pharmacy, Tamil Nadu 1 0 0 1
SRIPMS
Command Hospital Maharashtra 0 3 0 3
DHAFMS Delhi 0 1 0 1
DUVASU, Mathura Uttar Pradesh 0 1 0 1
Damodaran College of Tamil Nadu 0 1 0 1
Science
Dayanand Medical Punjab 0 1 0 1
Deccan College of Telangana 0 1 0 1
Medical Sciences
Defence Research Madhya Pradesh 0 3 0 3
& Development
Establishment
Delhi State Cancer Delhi 0 6 0 6
Institute
Dhanalakshmi Tamil Nadu 0 1 0 1
Srinivasan Medical
College
Dr MGR Educational and Tamil Nadu 0 1 0 1
Research Institute
Dr Shankarrao Chavan Maharashtra 0 0 1 1
Government Medical
College
109

Dr. B C Roy Post West Bengal 0 1 0 1
Graduate Institute
Dr. B.R Ambedkar Karnataka 0 2 0 2
Medical College
Dr. Baba Saheb Delhi 0 1 0 1
Ambedkar Hospital
Dr. D.Y Patil Medical Maharashtra 0 2 0 2
College
Dr. Harvansh Singh Chandigarh 0 1 0 1
Judge Institute of Dental
Sciences
Dr. N.G.P Arts and Tamil Nadu 0 1 0 1
Science College
Dr. Pinnamaneni Andhra Pradesh 0 1 0 1
Siddhartha Institute of
Medical Sciences
Dr. RPGMC Himachal 0 1 0 1
Pradesh
Dr. Somervell Memorial Kerala 0 1 1 2
CSI Medical College
Dr. V. P. Medical College, Maharashtra 0 1 0 1
Hospital & RC
Dr. Yewale's Maharashtra 0 0 1 1
Multispeciality Hospital
for Children
ESI-PGIMSR, ESIC West Bengal 0 1 0 1
Medical College and ESI
ESIC MC & PGIMSR Karnataka 0 2 0 2
ESIC Medical College West Bengal 0 1 0 1
and ESIC Hospital
Era’s Lucknow Medical Uttar Pradesh 0 2 0 2
Father Muller Medical Karnataka 0 3 0 3
College
Fernandez Hospital Telangana 1 0 0 1
Fortis Escorts Hospital Rajasthan 1 4 0 5
G. B. Pant Institute of Delhi 2 2 0 4
Postgraduate Medicine
GADVASU Punjab 0 1 0 1
GHR Micro Diagnostics Telangana 0 1 0 1
GMERS Medical College Gujarat 0 1 0 1
GSK Pharmaceuticals Karnataka 0 1 0 1
Ltd
GSL Medical College & Andhra Pradesh 0 1 0 1
General Hospital
Gandhi Medical College Telangana 0 1 1 2
and Hospital
Gangasaras Diagnostic Tamil Nadu 0 1 0 1
and Research Centre
Gauhati Medical College Assam 1 1 0 2
110

Gauhati University Assam 1 5 0 6
Glenmark Maharashtra 0 1 0 1
Pharmaceuticals Ltd
Goa Dental College and Goa 1 0 0 1
Hospital
Gold Field Institute of Haryana 0 1 0 1
Medical Sciences
Golden Jubilee Biotech Tamil Nadu 0 1 0 1
Park for Women
Government Degree Jammu and 0 1 0 1
College Baramulla Kashmir
Government Dental Karnataka 1 0 0 1
College and Research
Institute
Government Medical Gujarat 1 6 0 7
College Gujarat
Government Medical Uttarakhand 0 1 0 1
College Haldwani
Government Medical Chandigarh 4 14 0 18
College Hospital Chan
Government Medical Tamil Nadu 0 1 0 1
College Hospital
Government Medical Jammu and 0 2 0 2
College Kashmir
Government Medical Kerala 3 1 0 4
College Kerala
Government Medical Punjab 0 2 0 2
College Punjab
Government Medical Uttarakhand 0 4 0 4
College Uttarakhand
Government Medical Maharashtra 0 1 0 1
College, Latur
Government Medical Maharashtra 0 1 0 1
College, Nagpur
Government Uttarakhand 1 0 0 1
Postgraduate College
Government Cancer Maharashtra 0 1 0 1
Hospital
Govt. Kilpauk Medical Tamil Nadu 0 2 0 2
College
Grant Government Maharashtra 0 1 0 1
Medical College
Greater Kailash Hospital Madhya Pradesh 0 1 0 1
Gulbarga University Karnataka 0 2 0 2
Guru Gobind Singh Punjab 0 1 0 1
Medical College
Himachal Pradesh Himachal 0 1 0 1
University Pradesh
Himalayan Institute of Uttarakhand 1 3 0 4
Medical Sciences
Hindu Rao Hospital Delhi 0 1 0 1
111

Holy Spirit Hospital Maharashtra 0 1 0 1
ICARE Eye Hospital and Uttar Pradesh 1 0 0 1
Postgraduate Inst.
IIT Kharagpur West Bengal 0 1 0 1
IIT Madras Tamil Nadu 0 1 0 1
IMS & Sum Hospital Odisha 0 7 0 7
Medical College, S 'O
IPGME&R and SSKM West Bengal 0 3 0 3
Hospital
IPGMER & SSKM West Bengal 1 0 0 1
Hospital
ITS Dental College Uttar Pradesh 1 0 0 1
Indian Academy Degree Karnataka 0 1 0 1
College
Indian Council of Delhi 0 2 0 2
Medical Research
Indian Council of Andaman & 0 7 0 7
Medical Research Nicobar Islands
Indian Council of Assam 0 1 0 1
Medical Research
Indian Council of Karnataka 0 5 0 5
Medical Research
Indian Council of Odisha 0 2 0 2
Medical Research
Indian Institute of Gujarat 0 4 0 4
Advanced Research
Indian Network for Multicenter 0 1 0 1
Surveillance of AMR
Indira Gandhi Maharashtra 0 2 0 2
Government Medical
College
Indira Gandhi Medical Himachal 2 3 0 5
College Pradesh
Indira Gandhi Medical Puducherry 0 1 0 1
College & Research
Institute for Research Tamil Nadu 0 1 0 1
in Vision and
Ophtholmology
Institute of Child Health West Bengal 0 1 0 1
Institute of Life Sciences Odisha 0 2 0 2
Institute of Liver & Delhi 1 0 0 1
Biliary Sciences
Institute of Nuclear Delhi 0 1 0 1
Medicine and Allied
Sciences
Integral University Uttar Pradesh 0 3 0 3
J N Medical College Uttar Pradesh 0 3 0 3
JIPMER Puducherry 2 18 1 21
JJM Medical College Karnataka 1 3 0 4
Jain Irrigation Systems Maharashtra 0 1 0 1
Ltd
112

Jain University Karnataka 0 3 0 3
Jamia Hamdard Delhi 0 1 0 1
Janakpuri Super Delhi 0 1 0 1
Speciality Hospital
Jawaharlal Nehru Delhi 0 2 0 2
University, Delhi
Jawaharlal Nehru Karnataka 0 2 0 2
University, Maharashtra
Jawaharlal Nehru Uttar Pradesh 0 2 0 2
University
Jhalawar Medical Rajasthan 0 2 0 2
College
Joseph Eye Hospital Tamil Nadu 0 1 0 1
K.S.R. College of Arts Tamil Nadu 0 1 0 1
and Science
KG Medical University Uttar Pradesh 0 1 0 1
KLE's JN Medical Karnataka 0 1 0 1
College, Belgaum
KVG Dental College and Karnataka 1 0 0 1
Hospital
Kalinga Institute of Odisha 0 2 0 2
Medical Sciences
Kamalnayan Bajaj Tamil Nadu 0 1 0 1
Research Centre, Vision
Kannur Dental College Kerala 0 0 1 1
Karnataka Institute of Karnataka 0 1 0 1
Medical Sciences
Karpagam Faculty of Tamil Nadu 1 1 0 2
Medical Sciences
Karunya University Tamil Nadu 0 1 0 1
Kashibai Navale Medical Maharashtra 0 1 0 1
College
Kasturba Medical Karnataka 1 4 0 5
College
Katihar Medical College Bihar 0 1 0 1
Kempegowda Institute of Karnataka 0 3 0 3
Medical Sciences
Kerala Institute of Kerala 1 0 0 1
Medical Sciences
Khadir Mohideen Tamil Nadu 0 1 0 1
College
Khaja Banda Nawaz Karnataka 0 1 0 1
institute of Medical
Sciences
Kidwai Memorial Karnataka 0 1 0 1
Institute of Oncology,
King George Medical Uttar Pradesh 0 3 0 3
University
Kokilaben Dhirubhai Maharashtra 0 2 0 2
Ambani Hospital
113

Konaseema Institute of Andhra Pradesh 0 1 0 1
Medical Science
Kovai Medical Center Tamil Nadu 0 1 0 1
and Hospital
Krishna Institute of Maharashtra 0 1 0 1
Medical Sciences
L & T Microbiology Tamil Nadu 0 1 0 1
Research Centre
L. V. Prasad Eye Andhra Pradesh 1 4 0 5
Institute AP
L. V. Prasad Eye Odisha 3 2 0 5
Institute Odisha
L. V. Prasad Eye Telangana 0 5 0 5
Institute Telangana
L.T.M. Medical College Maharashtra 1 3 0 4
LN Medical College & RC Madhya Pradesh 1 1 0 2
Lady Hardinge Medical Delhi 1 1 0 2
College
Lohia Hospital Delhi 0 1 0 1
Lovely Professional Punjab 0 2 0 2
University
M.M. Institute of Haryana 0 1 0 1
Medical Sciences and R
MES Medical College Kerala 1 2 1 4
MGM Eye Institute Chattisgarh 1 0 0 1
MGM Medical College Maharashtra 0 1 1 2
and Hospital
MIMER Medical College Maharashtra 0 1 0 1
MS Ramaiah Medical Karnataka 0 2 0 2
College
Madha Medical College Tamil Nadu 0 1 0 1
Madras Medical College Tamil Nadu 1 0 0 1
Madras Medical Mission Tamil Nadu 0 1 0 1
Madurai Kamaraj Tamil Nadu 0 2 0 2
University
Maharajah’s Institute of Andhra Pradesh 0 1 0 1
Medical Sciences
Maharashtra Institute of Maharashtra 0 1 0 1
Medical Education
Maharishi Haryana 0 1 0 1
Markandeshwar College
of Denta
Mahatma Gandhi Gujarat 0 1 0 1
Institute of Medical
Sciences
Mahatma Gandhi Maharashtra 0 2 0 2
Sciences
Mahatma Gandhi Rajasthan 0 1 1 2
Medical College
114

Mahatma Gandhi Puducherry 8 8 1 11
Medical College and
Research Center
Mahatma Gandhi Kerala 0 2 0 2
University
Majeedia Hospital Delhi 0 1 0 1
Malabar Medical College Kerala 0 1 0 1
and Research Centre
Malda Medical College West Bengal 0 1 0 1
and Hospital
Manipal University Karnataka 4 23 2 29
Maulana Azad Medical Delhi 0 13 0 13
College
Maulana Azad Medical Uttar Pradesh 0 1 0 1
College
Max Super Speciality Delhi 0 3 0 3
Hospital
Mayo Institute of Uttar Pradesh 0 3 0 3
Medical Sciences
Medanta Hospital Haryana 1 1 2 4
Medical College West Bengal 0 1 0 1
Medical Sciences and Uttarakhand 0 1 0 1
Research Institute
Meenakshi Ammal Tamil Nadu 0 1 0 1
Dental College
Meerut College Gujarat Gujarat 0 1 0 1
Meerut College Uttar Uttar Pradesh 0 1 0 1
Pradesh
Metropolis Healthcare Maharashtra 0 1 0 1
Ltd
Military Hospital Meerut Uttar Pradesh 0 3 0 3
Modern Dental College Madhya Pradesh 1 1 0 2
and Research Centre
Montessori Mahila Andhra Pradesh 0 1 0 1
Kalasala
Motilal Nehru Medical Uttar Pradesh 0 3 0 3
College
Muljibhai Patel Gujarat 0 1 0 1
Urological Hospital and
Multicenter study Multicenter 0 1 0 1
Murshidabad Medical West Bengal 0 1 0 1
College
Muzaffarnagar Medical Uttar Pradesh 0 1 0 1
NDMC & Hindu Rao Delhi 0 1 0 1
Hospital
NHL Municipal Medical Gujarat 0 1 0 1
College
NIIT University Rajasthan 0 3 0 3
NIMS Medical College & Rajasthan 0 4 0 4
Hospital
115

NRS Medical College West Bengal 0 1 0 1
Nagpur University Maharashtra 0 1 0 1
National AIDS Research Maharashtra 0 2 0 2
Institute
National Centre for Cell Maharashtra 0 1 0 1
Science
National Institute for Kerala 1 0 0 1
Interdisciplinary
National Institute of West Bengal 3 18 1 22
Cholera and Enteri
National Institute of Tamil Nadu 0 1 0 1
Epidemiology (ICMR
National Institute of Karnataka 0 1 0 1
Mental Health & Ne
National Institute of Andaman & 0 1 0 1
Ocean Technology Nicobar Islands
National Institute of Assam 0 1 0 1
Pharmaceutical Edu
National Institute of Punjab 0 1 0 1
Pharmaceutical Edu
National Institute of Odisha 0 2 0 2
Science Education
National Institute of West Bengal 0 2 0 2
Cholera and Ente
National JALMA Uttar Pradesh 0 1 0 1
Institute for Leprosy and
Navodaya Medical Karnataka 0 2 0 2
College
Nilratan Sircar Medical West Bengal 0 1 0 1
College & Hospit
Nitte University Karnataka 0 1 1 2
Nizam Institute of Telangana 1 0 0 1
Medical Sciences
North Eastern Indira Meghalaya 0 3 0 3
Gandhi Regional Ins
North Maharashtra Maharashtra 0 1 0 1
University
Orchid Chemicals and Tamil Nadu 0 1 0 1
Pharmaceuticals Lt
P.D. Hinduja Hospital & Maharashtra 1 3 0 4
Medical Research
P.D.U. Govt. Medical Gujarat 0 1 0 1
College
PGIMER Chandigarh 5 16 0 21
PGIMSR Karnataka 0 1 0 1
PSG Institute of Medical Tamil Nadu 0 2 0 2
Sciences & Rese
Pachaiyappa's College Tamil Nadu 0 1 0 1
Panineeya Dental Telangana 0 1 0 1
College
116

Panjab University Chandigarh 0 6 0 6
Patel College of Gujarat 0 1 0 1
Paramedical Science and
Periyar University Tamil Nadu 0 1 0 1
Pondicherry Institute of Puducherry 1 2 0 3
Medical Science
Pondicherry University Puducherry 0 3 0 3
Pramukh Swami Medical Gujarat 1 1 0 2
College
Prathima Institute of Telangana 0 1 0 1
Medical Sciences
Presidency College Tamil Nadu 0 1 0 1
Presidency University West Bengal 0 1 0 1
Priti Medical Research Uttar Pradesh 0 1 0 1
and Charitable Trust
Pt. B D Sharma PGIMS Haryana 0 6 0 6
Public Health Delhi 0 0 1 1
Foundation of India
Pushpagiri Institute of Kerala 0 2 0 2
Medical Sciences
Quaid-e-Millath Tamil Nadu 0 1 0 1
Government Arts College
R. G. Kar Medical West Bengal 2 2 0 4
College
RD Gardi Medical Madhya Pradesh 1 10 3 14
College
RIMS Karnataka 0 2 0 2
RML Hospital Delhi 2 2 0 4
RTM Nagpur University Maharashtra 0 2 0 2
Raghavendra Institute of Andhra Pradesh 0 1 1 2
Pharmaceutical
Rainbow Childrens Telangana 1 1 0 2
Hospital
Rajah muthiah medical Tamil Nadu 0 1 0 1
college and hospit
Rajiv Gandhi Centre for Kerala 0 1 0 1
Biotechnology
Rajiv Gandhi Institute of Telangana 0 1 0 1
Medical Scienc
Rajiv Gandhi Cancer Delhi 0 1 0 1
Institute and Rese
Rama Medical College Uttar Pradesh 0 4 0 4
Rohilkhand Medical Uttar Pradesh 0 1 0 1
College
Ruhs College of Medical Rajasthan 0 1 0 1
Sciences
Rungta College of Chattisgarh 0 1 0 1
science and Technology
Rural Development Andhra Pradesh 0 2 1 3
Trust Hospital
117

S. N. M. C. Bagalkot Karnataka 0 1 0 1
S. S. Institute of Medical Karnataka 0 1 0 1
Sciences & Re
S.C.B Medical College Odisha 0 1 0 1
SDM College of Medical Karnataka 0 1 0 1
Sciences and Hosp
SRL Ltd, S. V. Road Maharashtra 0 1 0 1
SVMCH &RC Puducherry 0 1 1 2
SVS Medical College Telangana 0 1 0 1
Saifee Hospital Maharashtra 0 1 0 1
Sanjay Gandhi Post Uttar Pradesh 8 8 0 8
Graduate Institute of
Santosh University Uttar Pradesh 1 0 0 1
Sapthagiri Institute of Karnataka 0 1 0 1
Medical Science
Saveetha Medical College Tamil Nadu 0 1 0 1
& Hospital, Sa
Sawai Man Singh Rajasthan 0 3 0 3
Medical College
School of Biosciences Tamil Nadu 0 1 0 1
and Technology, An
School of Tropical West Bengal 0 4 0 4
Medicine
Seth GS Medical College Maharashtra 1 3 0 4
& KEM Hospital
Sher-e-Kashmir Jammu and 0 2 0 2
University Kashmir
Sher-i-Kashmir Institute Jammu and 2 2 0 4
of Medical Sciences Kashmir
Shivaji University Maharashtra 0 1 0 1
Shoolini University Himachal 0 1 0 1
Pradesh
Shri B. M. Patil Medical Karnataka 0 1 0 1
College
Shri Ram Murti Smarak Uttar Pradesh 0 1 0 1
Sciences
Shri Shivaji Science Maharashtra 0 1 0 1
College Department
Shri Vasantrao Naik Maharashtra 0 1 0 1
Government Medical
College
Siksha 'O' Anusandhan Odisha 0 1 0 1
University
Sindhu Mahavidyalaya Maharashtra 0 1 0 1
Center for Biotechn
Sir Ganga Ram Hospital Delhi 1 4 1 6
Smt Kashibai Navale Maharashtra 0 2 1 3
Medical College and
Society for Innovation Karnataka 0 1 0 1
and Development,
118

Sourashtra College Maharashtra 0 1 0 1
Sree Chitra Tirunal Kerala 0 1 0 1
Institute for Medica
Sri Aurobindo Institute Madhya Pradesh 1 5 0 6
of Medical Sciences
Sri Devaraj Urs Medical Karnataka 0 2 0 2
College
Sri Guru Ram Das Punjab 0 3 0 3
Sciences
Sri Narayani Hospital Tamil Nadu 0 1 0 1
and Research Center
Sri Ramachandra Tamil Nadu 1 11 0 12
Medical College and
Rese
Sri Siddhartha Medical Karnataka 1 3 0 4
College
Sri Venkateswara Andhra Pradesh 0 5 0 5
Sciences
Srimad Andavan Arts Tamil Nadu 0 1 0 1
and Science College
Sriram Chandra Bhanj Odisha 0 1 0 1
Medical College and
St John's Medical Karnataka 0 5 1 6
Subbaiah Institute of Karnataka 0 1 0 1
Medical Sciences
Subharti Medical College Uttar Pradesh 0 2 0 2
TATA Main Hospital Jharkhand 0 2 0 2
Tata Consultancy Maharashtra 0 1 0 1
Services Ltd.
Tata Medical Center Maharashtra 0 5 0 5
Tata Memorial Hospital Maharashtra 0 4 0 4
Teerthanker Mahaveer Uttar Pradesh 0 1 0 1
Medical College
Tejasvini Hospital and Karnataka 0 1 0 1
SSIOT
The Tamil Nadu Dr MGR Tamil Nadu 0 1 0 1
Medical University
The West Bengal West Bengal 0 0 1 1
University of Health
Sciences
University College of Delhi 1 5 0 6
Medical Sciences
University Puducherry 0 1 0 1
Tiruchirappalli
University of Delhi Delhi 0 1 0 1
University of Hyderabad Telangana 0 3 0 3
University of Madras Tamil Nadu 0 12 0 12
University of Mysore Karnataka 1 2 0 3
119

University of Pune Maharashtra 0 1 0 1
Unknown Maharashtra 2 4 0 6
VIT University Tamil Nadu 0 1 0 1
Vallabhbhai Patel Chest Delhi 3 5 4 12
Institute
Vananchal Dental Jharkhand 1 0 0 1
Vardhman Mahavir Delhi 4 13 0 17
Medical College &
Safdarjung Hospital
Veer Chandra Singh Uttarakhand 1 3 0 4
Garhwali Government
Vels University Tamil Nadu 0 0 1 1
Venus Medicine Himachal 2 1 0 3
Vidyasagar University West Bengal 0 4 0 4
Vision Research Tamil Nadu 1 1 0 2
Foundation
Vyas Dental College and Rajasthan 0 1 0 1
Hospital
Vydehi Institute of Karnataka 0 2 0 2
Medical Sciences
World Health Delhi 0 1 0 1
Organization
Yashoda Hospital Telangana 1 0 0 1
Yenepoya Medical Karnataka 0 2 0 2
College
120
Table A.5:
Institutions with at least one publication on AMR in animals

ARIBAS Gujarat 1
Bharathidasan University Tamil Nadu 1
CSIR-CSMCRI Gujarat 1
CSIR-Central Food Technological Research Institute Karnataka 1
Center for Disease Dynamics, Economics & Policy Delhi 1
Center for Science and Environment Delhi 1
Central Agricultural University Mizoram 1
Central Avian Research Institute Uttar Pradesh 1
Central Institute of Fisheries Technology Kerala Kerala 2
Central Institute of Fisheries Technology Maharashtra Maharashtra 1
Centre of Advanced Study Uttar Pradesh 1
Chaudhary Charan Singh (C.C.S.) University Gujarat 1
College of Veterinary Science Assam 2
College of Veterinary and Animal Husbandry Uttar Pradesh 1
College of Veterinary and Animal Sciences Kerala Kerala 1
College of Veterinary and Animal Sciences Uttarakhand Uttarakhand 1
DUVASU Uttar Pradesh 1
Dr. G. R. Damodaran College of Science Tamil Nadu 2
GADVASU Punjab 1
Guru Angad Dev Veterinary and Animal Sciences University Delhi 1
ICAR Research Complex for NEH Region Meghalaya 4
ICAR-Indian Veterinary Research Institute Uttar Pradesh 2
Indian Council of Agricultural Research Assam 3
Indian Veterinary Research Institute Arunachal Pradesh 1
Indian Veterinary Research Institute, Uttar Pradesh Uttar Pradesh 2
Indian Veterinary Research Institute, West Bengal West Bengal 2
Jawaharlal Nehru Institute of Advanced Studies Telangana 1
Karnataka Veterinary Animal and Fisheries Sciences Karnataka 2
University
Kurukshetra University Gujarat 1
Nagpur Veterinary College Maharashtra 1
Nanaji Deshmukh Veterinary Science University Madhya Pradesh 1
National Bureau of Fish Genetic Resources Uttar Pradesh 1
National Research Centre on Yak Arunachal Pradesh 1
Patna Women’s College Bihar 1
Post Graduate Institute of Veterinary Education and Research Rajasthan 1
RVS College of Arts and Science Tamil Nadu 1
Rajasthan University of Veterinary and Animal Sciences Rajasthan 1
Sher-e-Kashmir University Jammu and 2
Kashmir
121

UNESCO MIRCEN for Marine Biotechnology Karnataka 1
University of Hyderabad Telangana 1
University of North Bengal West Bengal 1
Veterinary College and Research Institute Tamil Nadu 1
West Bengal University of Animal and Fishery Sciences West Bengal 4
122
Table A.6:
Institutions with at least one publication on AMR in the environment

Annamalai University Tamil Nadu 2
BIS Group of Institutions Punjab 1
Biju Patnaik University of Technology Odisha 1
CSIR-Central Food Technological Research Karnataka 1
CSIR-Indian Institute of Toxicology Res Uttar Pradesh 2
CSIR-National Institute of Oceanography West Bengal 1
Central Leather Research Institute (CSIR Tamil Nadu 1
Central Marine Fisheries Research Instit Kerala 1
Cochin University of Science and Technol Kerala 4
College of Veterinary and Animal Husband Uttar Pradesh 1
Department of Veterinary Pharmacology an Uttar Pradesh 1
Dr. Ram Manohar Lohia Avadh University Uttar Pradesh 1
IIT Delhi Delhi 6
IIT Guwahati Assam 1
Indian Council of Medical Research West Bengal 1
Institute of Chemical Technology Maharashtra 1
Institute of Minerals and Materials Tech Odisha 1
International Centre for Ecological Engi West Bengal 1
Jain University Karnataka 1
Jamal Mohamed College Tamil Nadu 1
Jawaharlal Nehru University, Delhi Delhi 1
Jawaharlal Nehru University Uttar Pradesh 1
King Saud University Tamil Nadu 1
Madhav Institute of Technology and Scienes Madhya Pradesh 1
Mizoram University Mizoram 1
NGO Gamana Telangana 1
National Institute of Cholera and Enteri West Bengal 1
PGIMER Chandigarh 1
123

Periyar University Tamil Nadu 1
Pramukh Swami Science and H. D. Patel Ar Gujarat 1
Pune University Maharashtra 1
Sher-e-Kashmir University Jammu and 2
Kashmir
Sri Ramachandra Medical College and Rese Tamil Nadu 1
St John's Medical College and Hospital Karnataka 1
University of North Bengal West Bengal 1
Vallabhbhai Patel Chest Institute Delhi 1
Veer Bahadur Singh Purvanchal University Uttar Pradesh 1
Veer Narmad South Gujarat University Gujarat 2
Vinayaka Missions University Tamil Nadu 1
124
Table A.7:
Institutions with at least one publication on AMR in the novel agents category

AIIMS Delhi Delhi 1
Adichunchanagiri Biotechnology and Cancer Karnataka 3
Amity University Uttar Pradesh 2
Arts, Commerce and Science College Maharashtra 1
Aurigene Discovery Technologies Ltd Karnataka 1
B.J.B. Autonomous College Odisha 1
Baba Farid University of Health Sciences Punjab 1
BarodaMedical College Gujarat 1
Bhabha Atomic Research Centre Maharashtra 1
Bharathiar University Tamil Nadu 2
Birla Institute of Technology Jharkhand 1
Birla Institute of Technology & Science Telangana 1
Birla Institute of Technology and Science Pilani Goa 1
Bombay College of Pharmacy Maharashtra 2
Bose Institute West Bengal 2
C.B.S.H., G. B. Pant University of Agriculture and Technology Uttarakhand 1
CSIR - National Environmental Engineering Maharashtra 1
CSIR Institute of Genomics and Integrating Delhi 1
CSIR-Central Drug Research Institute Uttar Pradesh 1
CSIR-Central Food Technological Research Karnataka 1
CSIR-Central Institute of Medicinal and Uttar Pradesh 5
CSIR-Indian Institute of Integrative Medicine Jammu and 4
Kashmir
CSIR-Institute of Genomics and Integrative Biology Delhi 1
CSIR-Institute of Microbial Technology Chandigarh 4
CSIR-National Botanical Research Institute Uttar Pradesh 1
CSIR-National Chemical Laboratory Maharashtra 1
CSIR-National Environmental Engineering Maharashtra 1
Calcutta School of Tropical Medicine West Bengal 2
Central Institute of Freshwater Aquacul Odisha 1
Central Institute of Medicinal and Aroma Uttar Pradesh 3
Central Leather Research Institute (CSIR) Tamil Nadu 1
Central Tuber Crops Research Institute Kerala 2
Central University of Rajastan Ajmer Rajasthan 2
Chhattisgarh Dental College and Research Chattisgarh 1
Christian Medical College, Tamil Nadu Tamil Nadu 3
Coorg Institute of Dental Sciences Karnataka 1
Council of Scientific and Industrial Research (CSIR) Kerala 1
125

Defence Institute of Physiology and Allied Sciences Delhi 1
Dibrugarh University Assam 1
Doctors Diagnostic Centre Tamil Nadu 1
Dr. B.R. Ambedkar University Uttar Pradesh 1
Dr. H.S. Gour Central University Madhya Pradesh 2
East-West College of Science Karnataka 1
Entomology Research Institute Tamil Nadu 1
GITAM University Andhra Pradesh 1
Gangagen Biotechnologies Pvt. Ltd Karnataka 2
Garhwal University Uttarakhand 1
Gujarat University Gujarat 1
Gulbarga University Karnataka 1
Guru Gobind Singh Indraprastha University Delhi 1
Guru Jambheshwer University of Science and Technology Haryana 3
Guru Nanak Dev University Punjab 2
Gurukul Kangri University Uttarakhand 1
Haldia Institute of Technology West Bengal 2
Hamdard University Delhi 1
Herbicure Healthcare Bio-Herbal Foundation Not Applicable 1
IFTM University Uttar Pradesh 1
IIT Hyderabad Telangana 1
IIT Kharagpur West Bengal 10
IIT Roorkee Uttarakhand 4
IMS & Sum Hospital Medical College, S 'O Odisha 7
IPGME&R and SSKM Hospital West Bengal 1
India and M M College of Pharmacy Haryana 1
Indian Agricultural Research Institute Delhi 1
Indian Association for the Cultivation of Science West Bengal 1
Indian Council of Medical Research, Karnataka Karnataka 1
Indian Institute of Chemical Technology Telangana 1
Indian Institute of Science Karnataka 1
Indian Institute of Science Education and Research, MP Maharashtra 1
Indian Veterinary Research Institute, Uttar Pradesh Uttar Pradesh 1
Indian Veterinary Research Institute, West Bengal West Bengal 1
Institute of Advanced Study in Science and Technology Assam 1
(IASST)
Institute of Bioresources and Sustainabl Manipur 1
Institute of Nuclear Medicine and Allied Delhi 8
J N Medical College Uttar Pradesh 1
JSS University Karnataka 2
Jain University Karnataka 1
Jawaharlal Nehru Centre for Advanced Scientific Research Karnataka 18
Jawaharlal Nehru University, Uttar Prade Uttar Pradesh 3
126

Jaypee Institute of Information Technology, UP Himachal Pradesh 5
K.S.R. College of Arts and Science Tamil Nadu 1
KIIT University Odisha 3
KLE University Karnataka 1
KLE VK Institute of Dental Sciences, Belgaum Karnataka 2
Kakatiya Government Degree & P.G College Telangana 1
Karnatak University Karnataka 1
Kovai Medical Center and Hospital Tamil Nadu 1
LBS College of Pharmacy Rajasthan 1
Loyola College (Autonomous) Tamil Nadu 1
M. D. University Haryana 1
Madhav Institute of Technology and Science Madhya Pradesh 1
Madurai Kamaraj University Tamil Nadu 2
Maharshi Dayanand University Haryana 1
Mahatma Gandhi Medical College Rajasthan 1
Mahatma Gandhi Medical College and Research Institute Puducherry 1
Mahatma Gandhi University Kerala 2
Malankara Catholic College Tamil Nadu 1
Manonmaniam Sundaranar University Tamil Nadu 2
Medical College Gujarat 1
Medicinal Chemistry Department Uttar Pradesh 1
Modern College of Arts Maharashtra 1
Motilal Nehru National Institute of Technology Uttar Pradesh 1
NMIMS university Maharashtra 1
NRI college of pharmacy Andhra Pradesh 1
Nandha College of Pharmacy and Research Tamil Nadu 1
National Centre for Compositional Characterisation of Telangana 1
Materials (NCCCM)
National Chemical Laboratory Maharashtra 3
National Institute for Interdisciplinary Kerala 1
National Institute for Research in Repro Maharashtra 1
National Institute of Pharmaceutical Education Punjab 1
National Institute of Technology Gujarat Gujarat 1
National Institute of Technology Odisha Odisha 1
National Institute of Unani Medicine Karnataka 1
Natubhai V. Patel College of Pure and Applied Sciences Gujarat 1
Nirma University Gujarat 1
North Maharashtra University Maharashtra 1
North Orissa University Odisha 4
PDM College of Pharmacy Haryana 1
PRIST University Tamil Nadu 1
Padmashree Institute of Management and Sciences Karnataka 1
Panjab University Chandigarh 13
Periyar Maniammai University Tamil Nadu 1
127

Piramal Enterprises Ltd Maharashtra 1
Pondicherry University Puducherry 2
Pune University Maharashtra 1
Ranbaxy Research Laboratories Haryana 3
S L Raheja Hospital Maharashtra 1
S. S. Institute of Medical Sciences & Research Centre Karnataka 1
SASTRA University Tamil Nadu 3
SGB Amravati University Maharashtra 3
SGT University Haryana 1
SHIATS Uttar Pradesh 2
SRM University Tamil Nadu 1
SRNMN College of Applied Sciences Karnataka 1
SSN College of Engineering Tamil Nadu 1
Sanjay Gandhi Post Graduate Institute of Medical Sciences Uttar Pradesh 2
Sant Gadge Baba Amravati University Maharashtra 1
Savitribai Phule Pune University Maharashtra 1
Sheth M.N.Science College Gujarat 1
Siksha 'O' Anusandhan University Odisha 1
Sree Vidhyanikethan College of Pharmacy Andhra Pradesh 1
Sri Krishnadevaraya University Andhra Pradesh 1
Sri Ramachandra Medical College and Research Institute Tamil Nadu 4
St. Gregorios Dental College Kerala 1
St. Xavier's College Goa Goa 1
St. Xavier's College Tamil Nadu Tamil Nadu 1
Tezpur University Assam 1
Thapar University Punjab 1
Thiagarajar College Tamil Nadu 1
Tripura University Tripura 2
University of Calcutta West Bengal 4
University of Kalyani West Bengal 3
University of Lucknow Uttar Pradesh 1
University of Madras Tamil Nadu 2
University of Mysore Karnataka 3
University of Pune Maharashtra 3
Unknown Punjab 3
VHNSN College Tamil Nadu 1
VIT University Tamil Nadu 7
Venus Remedies Haryana 1
Vidyasagar University West Bengal 4
Vijaya Institute of Pharmaceutical Sciences for women Andhra Pradesh 1
Visva-Bharati University West Bengal 1
Visvesvaraya Technological University Karnataka 1
Vivekananda College Tamil Nadu 1
Yashvantrao Chavan Institute of Science Maharashtra 1
Yenepoya University Karnataka 1
128
Table A.8:
Institutions with at least one publication on AMR in the miscellaneous category

AIIMS Delhi Delhi 4
Amrita Vishwa Vidyapeetham University Kerala 1
Animal Sciences University Punjab 1
Apollo Institute of Medical Sciences and Research Telangana 1
Aravind Eye Care Madurai Tamil Nadu 1
Bhabha Atomic Research Centre Maharashtra 2
Birla Institute of Technology Jharkhand 1
Birla Institute of Technology & Science Telangana 1
Bose Institute West Bengal 2
Burdwan University West Bengal 1
CSIR - National Environmental Engineering Research Institute Maharashtra 1
CSIR Institute of Genomics and Integrative Biology Delhi 1
CSIR-Central Drug Research Institute Uttar Pradesh 1
CSIR-Central Food Technological Research Institute Karnataka 4
CSIR-Indian Institute of Chemical Technology Telangana 1
CSIR-Indian Institute of Integrative Medicine Jammu and 2
Kashmir
CSIR-Institute of Genomics and Integrative Biology Delhi 1
CSIR-Institute of Microbial Technology Chandigarh 11
Central Institute of Fisheries Education (CIFE) Maharashtra 1
Central University of Rajastan Ajmer Rajasthan 1
Centre for Cellular and Molecular Biology (CSIR) Telangana 1
Centre for DNA Fingerprinting and Diagnostics Telangana 2
Centre for Materials for Electronics Technology Maharashtra 1
Chettinad Hospital and Research Institute Tamil Nadu 1
Christ College Gujarat 1
Christian Medical College, Tamil Nadu Tamil Nadu 4
Deemed University Tamil Nadu Tamil Nadu 1
Deemed University Uttar Pradesh Uttar Pradesh 1
Department of Science & Technology Gujarat 1
Division of Avian Genetics and Breeding West Bengal 1
Dr. Baba Saheb Ambedkar Hospital Delhi 1
Eminent Biosciences Madhya Pradesh 1
GITAM University Andhra Pradesh 2
Gangagen Biotechnologies Pvt. Ltd Karnataka 1
Gauhati University Assam 1
Goa University Goa 1
129

Grant Medical College Maharashtra 1
Gulbarga University Karnataka 2
Holy Cross College Tamil Nadu 1
ICAR Research Complex for NEH Region Nagaland 1
IIT Hyderabad Telangana 1
IIT Kanpur Uttar Pradesh 2
IIT Kharagpur West Bengal 6
IIT Roorkee Uttarakhand 3
IT University Tamil Nadu 1
India Dr G R Damodaran College of Science Tamil Nadu 1
Indian Council of Medical Research Delhi 1
Indian Council of Medical Research, Andaman Andaman & Nicobar 1
Islands
Indian Institute of Advanced Research Gujarat 1
Indian Institute of Science Karnataka 4
Indian Institute of Science Education and Research, MP Madhya Pradesh 2
Indian Institute of Science Education and Research, Maharashtra 1
Maharashtra
Indian Institute of Soil Science Madhya Pradesh 1
Indira Gandhi Krishi Vishwavidyalaya Chattisgarh 1
Institute of Life Sciences Odisha 2
Institute of Nuclear Medicine and Allied Delhi 1
International Crops Research Institute for the Semi-Arid Telangana 1
Tropics (ICRISAT)
JIPMER Puducherry 1
JSS Dental College and Hospital Karnataka 1
Jawaharlal Nehru Centre for Advanced Sci Karnataka 1
Jaypee Institute of Information Technology, UP Uttar Pradesh 2
Jubilant Chemsys Ltd Uttar Pradesh 1
KIIT University Odisha 1
Kerala Veterinary and Animal Sciences University Kerala 1
Lady Doak College Tamil Nadu 1
MES Ponnani College Kerala 1
Madhav Institute of Technology and Science Madhya Pradesh 1
Madurai Kamaraj University Tamil Nadu 3
Maharshi Dayanand University Haryana 1
Manipal College of Pharmaceutical Sciences Karnataka 1
Meenakshi Ammal Dental College Tamil Nadu 1
Motilal Nehru Medical College Uttar Pradesh 1
Motilal Nehru National Institute of Technology Uttar Pradesh 2
National Bureau of Fish Genetic Resource Uttar Pradesh 1
National Centre for Veterinary Type Culture Collection Haryana 1
130

National Environmental Engineering Research Institute Telangana 1
National Institute of Immunohaemotology Maharashtra 1
National Institute of Plant Genome Resea Delhi 1
National Institute of Technology Karnata Karnataka 1
National Institute of Technology Odisha Odisha 1
Netaji Subhas Institute of Technology Delhi 2
North Maharashtra University Maharashtra 1
North-Eastern Hill University Meghalaya 1
P. M. N. M. Dental College and Hospital Karnataka 1
PGIMER Chandigarh 3
PSG College of Arts and Science Tamil Nadu 1
Pandit Bhagwat Dayal Sharma Post Graduate Institute of Delhi 1
Medical Sciences
Panjab University Chandigarh 11
Piramal Enterprises Ltd Maharashtra 1
Pondicherry University Puducherry 1
Prathima Institute of Medical Sciences Telangana 1
Presidency University West Bengal 1
Rajendra Memorial Research Institute of Medical Sciences Bihar 1
Ramananda College West Bengal 1
SASTRA University Tamil Nadu 3
SHIATS Uttar Pradesh 1
Saurashtra University Gujarat 1
Sawai Man Singh Medical College Rajasthan 1
Sri Sathya Sai Institute of Higher Learn Andhra Pradesh 1
Swami Ramanand Teerth Marathwada University Maharashtra 1
Tata Institute of Fundamental Research Karnataka 2
Tezpur University Assam 1
The Maharaja Sayajirao University of Baroda Gujarat 1
Tripura University Tripura 1
University of Allahabad Uttar Pradesh 1
University of Calcutta West Bengal 2
University of Madras Tamil Nadu 3
University of Mysore Karnataka 2
Unknown Madhya Pradesh 1
VIT University Tamil Nadu 15
Veer Surendra Sai University of Technology Odisha 1
Velammal Medical College Hospital and Research Institute Tamil Nadu 1
Vidyasagar University West Bengal 2
Visvesvaraya Technological University Karnataka 1
Yenepoya University Karnataka 2

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Scoping Report on Antimicrobial

This work is licensed under a Creative Commons Attribution 4.0 International

Figure 3.1: Carbapenem (meropenem/imipenem) resistance among four gram- 21

Scoping Report on Antimicrobial Resistance in India was prepared for the

Antimicrobial resistance (AMR) is a research in India. The aims of the

animals, including agriculture

THE ANTIMICROBIAL Escherichia coli, and Klebsiella

Gandra S et. al 2016 ICMR 2015 Carbapenem (meropenem/

obtained from ICMR for the purpose of this report.

Colistin resistance conducted in food animals, high levels

Antibiotic-resistant bacteria in the environment indicate high levels

E. coli resistance to third-

to be resistant to third-generation had Enterobacteriaceae and other

cephalosporins empiric treatment third-generation cephalosporin (Figure

Social Factors continuing medical education (Kotwani

animal protein, especially for poultry, Pharmaceutical companies can

pharmaceutical companies involved in of Gujarat, Aurangabad, Mumbai

Sites of human antibiotic

Environmental Sanitation among hospitalized patients globally

Causes of early onset

AMR Policy situation in nongovernmental initiatives such as the

There were approximately 630 of Medical Sciences, New Delhi, with

Top 10 institutions with

treatment) among food animals, àà Focusing on waste management to

Antimicrobial resistance (AMR) is a and promoting growth and preventing

animals, including agriculture aspects, policy, or regulatory

3.1. Antimicrobial al. 2015). There was a steady decrease

of healthcare expenditures (Patel et al. isolated from bloodstream infections

Gram-negative Study Year Ciprofloxacin Ceftriaxone/ Meropenem/ Piperacillin- Colistin

Gandra 2014 84% 93% 67.3% — 4.1%

obtained from ICMR for the purpose of this report.

Gandra S et. al 2016 ICMR 2015

Among gram-positive bacteria, the Streptococcus pneumoniae, which is a

Gram-negative Study Year of data Ampicillin Cefoxitin/ Linezolid Vancomycin

Percentage of resistance Gandra 2014 — 46.5% 0.6% 1.7%

The percentage of resistance to resistance decreased from 13.1% in

Bacteria Study Year Ampicillin Ceftriaxone Ciprofloxacin Tetracycline TMP/

Gandra 2014 5.3% 1.7% 29% — 4.2%

Similarly, a high proportion of Although resistance to ceftriaxone was

Finally, multidrug-resistant (MDR) options, and treatment options vary by

Study Organism Specimen % blaNDM % blaOXA-48 % blaOXA-48 &

3.1.4. Colistin resistance Figure 3.2:

Colistin is considered to be the last- Mortality associated

Antibiotic-resistant bacterial infections 3.2. Antibiotic Resistance

to 2030, it is expected that poultry broiler chickens indicates increased

Study Year(s) of Specimen Organism Findings

2014 Cloacal swab samples Not ESBL producing strains (%)

3.2.2. Antibiotic-resistant from buffaloes with mastitis isolated Antibiotic resistance in

Study Livestock Year(s) Specimen source Organism Findings

Cattle 2012, Milk samples E. coli One isolate

Cattle 2011, Raw milk E. coli Resistance %

Pigs 2011–2012, Fecal samples E. coli (n=102), ESBL producers

Pigs 2012, Rectal swabs E. coli (organized, ESBL Producers

3.2.3. Antibiotic-resistant involving tilapia fish obtained from

Study Fishery Year(s) Source Organism Findings

Tilapia fish Year not Gut content Entero- ESBL

Shellfish: 2010–2011, Gut of Vibrio species Resistance %

Source: Akiba et al. (2015).

3.3.2. Antibiotic-resistant isolates, 17.4% (40) isolates belonging