Antimicrobial resistance (AMR) occurs when bacterial, viral, fungal, parasitic and other pathogens develop mechanisms to withstand antimicrobials, rendering treatments ineffective. AMR poses a significant global challenge, with several studies providing comprehensive estimates and future forecasts of its burden across countries.
A recent Lancet study estimates that AMR caused more than one million deaths annually between 1990 and 2021. In 2021 alone, an estimated 4.71 million deaths were associated with AMR, including nearly 1.14 million directly attributed to drug-resistant infections. Forecasts suggested that by 2050, deaths associated with AMR could rise by 74.5 per cent to 8.22 million, with nearly 1.91 million directly attributable to AMR — a 67.5 per cent increase from 2021.
This steep rise in AMR could have drastic consequences, with more antimicrobials rendered ineffective, making the discovery of new, effective and safer antimicrobials more critical but highly challenging. Treating drug-resistant infections is already difficult, more expensive and often less safe, with global healthcare costs projected to increase by an additional $1 trillion by 2050.
Moreover, reduced productivity due to disability and loss of life could result in up to $3.4 trillion in gross domestic product (GDP) losses annually by 2030. Estimates from the initiative Investor Action on AMR suggested that the total global costs associated with AMR could reach $100 trillion by 2050, accompanied by a 3.8 per cent decline in global GDP. Clearly, AMR is not merely a global health challenge.
This year marked the second United Nations High-Level Meeting (UNHLM) on AMR, where member countries reviewed progress on global, regional and national efforts since the first UNHLM in 2016. They pledged to invest in sustainable tools and solutions that strengthen and accelerate multisectoral progress through a One Health approach, aiming to achieve global health equity.
Member countries committed to reducing global AMR-related deaths by 10 per cent by 2030, ensuring prudent antimicrobial use and establishing an independent panel for evidence-based action against AMR by 2025.
AMR disproportionately affects low- and lower-middle-income countries (LMICs), with over 80 per cent of AMR-associated deaths occurring in developing countries, making their voices crucial in this global forum. India’s initiatives include the establishment of a National Task Force on AMR Containment in 2010, leading to the National Policy on AMR Containment (2011) and the National Programme on AMR Containment (2013).
These culminated in the first five-year National Action Plan on AMR (NAP-AMR 2017–21), launched by the Union Ministry of Health & Family Welfare in alignment with the Global Action Plan on AMR. This was followed by NAP-AMR 2.0 in 2022, centred on the One Health approach.
Both national and global policy frameworks acknowledge the urgent need for new tools to address AMR. While safer and more effective antimicrobials are essential to improving treatment outcomes, they alone may not suffice. Accurate diagnosis using improved rapid diagnostic tools can guide prudent antimicrobial prescriptions, reducing overuse and misuse.
Vaccines can prevent infections, curbing antimicrobial use and slowing the spread of drug-resistant pathogens. Additionally, alternative therapeutic strategies such as bacteriophage therapy and microbiome-based interventions hold significant promise. Integrating these approaches — novel antimicrobials, diagnostics, vaccines and alternative therapies—offers the most effective means of addressing AMR and preventing its escalation.
While vaccines, diagnostics and new antimicrobials are essential to treat and limit transmission of drug-resistant infections, these tools alone are not sufficient. However, the primary driver of AMR remains the exposure of environmental microorganisms to sub-lethal levels of antimicrobials, fostering the evolution of drug resistance.
Resistant microorganisms can transfer their resistance genes to infectious pathogens, resulting in drug-resistant “superbugs”. A notable example is the NDM-1 gene, which encodes a metallo-β-lactamase capable of degrading last-resort carbapenem antibiotics such as meropenem and imipenem.
Major sources of antimicrobial release include hospital wastewater, pharmaceutical industry effluents and domestic sewage, compounded by indiscriminate use in agriculture and animal husbandry. Inadequate wastewater treatment exacerbates AMR in India and other LMICs. Studies have reported that 95 per cent of Escherichia coli isolates from hospital wastewater in South India and 100 per cent of those from the Cauvery river in Karnataka were resistant to third-generation cephalosporins.
Similarly, 17.4 per cent of Gram-negative pathogen isolates from the Ganga and Yamuna rivers were β-lactam resistant. Existing wastewater treatment plants (effluent treatment plants, or ETPs and sewage treatment plants, or STP) largely fail to remove antimicrobials and active pharmaceutical ingredients (API). Advanced technologies like nanofiltration, irradiation, oxidation, ozonation and electrocoagulation remain underexplored for real-world utility and are often prohibitively expensive and energy-intensive.
Hence, there is a major unmet need for new cost-effective technologies and solutions that can remove antimicrobials from wastewater, reduce their release into the environment and decelerate the emergence of drug-resistant pathogens.
At the Foundation for Neglected Disease Research (FNDR), we have developed a novel, cost-effective, customisable, eco-friendly and sustainable filtration technology to remove antimicrobials and other APIs, as well as microorganisms, from wastewater. Our technology is amenable to in-line deployment within existing ETPs and STPs, where it can yield antimicrobial- and pathogen-free treated water, safe for environmental release, without additional energy consumption.
Moreover, our technology has the added ability to remove other common water contaminants, such as heavy metals, fluoride, textile dyes, etc, making it a one-step solution that can significantly improve the efficiency of existing ETPs and STPs.
The results from lab-scale proof-of-concept studies suggest that our technology is efficient at removing diverse classes of antimicrobials, including antibiotics, antimycobacterials, antifungals, antivirals, and antimalarials, other pharmaceutical compounds, pathogens such as Escherichia coli, Enterococcus faecalis, and SARS-CoV-2, and noxious water pollutants such as heavy metals, fluoride, ammoniacal nitrogen and industrial dyes.
Subsequent evaluation of the technology in a hospital field trial revealed that it could remove 70-90 per cent of antimicrobials from diverse chemical classes, suggesting a high success rate in the real-world settings. We anticipate that the large-scale deployment of such a solution as an add-on to existing commercial, industrial and municipal wastewater treatment set-ups will help reduce AMR associated morbidity, mortality, and global socio-economic burden significantly.
The need of the hour is the expedited deployment of newer technologies, such as that developed by the FNDR team and their integration into the global policy frameworks and National Action Plans for AMR. The clock is ticking, and we must act now!
Shridhar Narayanan is a co-founder, chairman and chief executive officer at the Foundation for Neglected Disease Research (FNDR) and scientific advisor to the Indian Pharmaceutical Alliance; Bakul Piplani is a research scientist leading the grants and scientific communications efforts at FNDR; Siva Shanmugam S is a scientist leading the DMPK and Bioanalytical team at FNDR and Radha K Shandil is a co-founder, Director and Chief Scientific Officer at FNDR
Views expressed are the author’s own and don’t necessarily reflect those of Down To Earth