Antimicrobial Resistance: These Are India's Most Overused Antibiotics

India and large parts of the world are now facing a rising antibiotic resistance or antimicrobial resistance (AMR) crisis. Apart from international bodies like the World Health Organization (WHO) and older studies, the antibiotic resistance crisis was recently highlighted by a large-scale Lancet-linked study focused on India and a few other nations. This has thrust a spotlight on the misuse of commonly dispensed antibiotics in both hospital and other settings. From being available over-the-counter to getting over-prescribed for illnesses that don't necessarily need it, the AMR crisis in India is complicated and layered.

Among the most frequently used and over-prescribed antibiotics in India are azithromycin, amoxicillin, and ofloxacin, raising concerns that these very drugs may be fuelling the surge of so-called "superbugs" that are antibiotic resistant.

These drugs are not rarely prescribed or niche. In fact, they are staples of the Indian pharmaceutical landscape. Azithromycin, a macrolide, is often used empirically for respiratory infections; amoxicillin (and its combination with clavulanic acid) is a go-to for common infections; and ofloxacin, a fluoroquinolone, is widely dispensed even without prescriptions.

Overuse and inappropriate use of these agents contribute to resistance, creating dangerous selection pressure that allows superbugs to proliferate. Given how broadly these drugs are consumed, in hospitals, clinics, and pharmacies, understanding their role in India's AMR tipping point is essential.

What The New "Superbug" Studies Tell Us

A recent study published in The Lancet eClinical Medicine found extremely high colonisation by multi-drug resistant organisms (MDROs) in Indian patients within hospital settings. Other studies published in The Lancet and other journals over time have explored which superbugs are most responsible for India's AMR burden, including organisms like extended-spectrum beta-lactamase (ESBL) producing E. coli and Klebsiella, as well as carbapenem-resistant Gram-negatives and other priority pathogens.

These studies suggest a deeper problem: Widespread colonisation and possible inoculation of these bacteria, likely amplified by frequent and inappropriate antibiotic use. The biggest drivers? Some of the most common, "everyday" antibiotics in India, including azithromycin, amoxicillin and fluoroquinolones like ofloxacin.

Also Read: India's Superbug Crisis: Lancet Data Misinterpreted, Says Government Body

Why Azithromycin Is At The Centre Of Misuse

A national consumption study by Koya et al. (Lancet Regional Health - Southeast Asia) found azithromycin was the most consumed single-molecule antibiotic in India in 2019, roughly 640 million defined daily doses (DDDs), basically around 12.6% of total consumption.

Data from pharmacy-dispensing surveys show that many community pharmacies dispense azithromycin without prescription, often used for viral respiratory infections or even during Covid-19. In fact, during the COVID-19 pandemic, sales of azithromycin skyrocketed as it was widely used empirically, despite limited evidence for benefit.

This misuse creates intense selection pressure. As azithromycin use rises, resistant strains of bacteria like Salmonella, Strep. pneumoniae and even E. coli can gain a foothold, making future infections harder to treat.

Are you overusing these common antibiotics?
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Amoxicillin: A Pill In Every Hospital And Home, And Its Limits

According to India's National Antimicrobial Consumption Network (NAC-NET) data, amoxicillin combined with clavulanate (co-amoxiclav) and plain amoxicillin are among the top antibiotics consumed in hospital settings. But use has now extended beyond hospitals, entering your homes on a regular basis.

Community surveys consistently report that amoxicillin is one of the most common self-medicated antibiotics. Because amoxicillin is cheap, accessible and perceived as "safe," many people use it for conditions that don't need antibiotics, for instance, viral infections or mild illnesses.

Over-reliance on amoxicillin contributes to escalating resistance in E. coli, Klebsiella, and other Enterobacterales, especially ESBL-producing strains. These resistant bacteria are among the superbugs identified in the Lancet-linked study.

Ofloxacin And Fluoroquinolones: Potent But Over-Used

Fluoroquinolones like ofloxacin and ciprofloxacin frequently show up in pharmacy-dispensing research as antibiotics dispensed without prescription. In case you haven't caught on yet, the most common name ofloxacin goes by is Norflox.

Their broad-spectrum action makes them attractive for doctors and non-doctors alike, but misuse accelerates resistance development, especially in E. coli, Pseudomonas aeruginosa, and other problematic Gram-negative bacteria.

Fluoroquinolone resistance is particularly worrying because these drugs are often used when first-line antibiotics fail. Misuse contributes to the rise of resistant pathogens that are harder to manage, especially in hospital settings.

The Bigger Picture: Other Commonly Misused Antibiotics

While azithromycin, amoxicillin and ofloxacin are major problematic drugs, they are not the only ones.

• Third-generation cephalosporins: Drugs like cefixime and ceftriaxone are widely used, sometimes without prescription, especially for presumed bacterial infections. Consumption data indicates these are among the most used broad-spectrum antibiotics.
• Reserve antibiotics: Disturbingly, some hospital surveillance reports also record use of "reserve" or last-line drugs, such as colistin or linezolid, at certain centres. Overuse here would have dire consequences.

Buying over-the-counter antibiotics without prescriptions is fuelling the AMR crisis
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Why These Specific Misuses Fuel India's Antibiotic Resistance Crisis

Here's how misuse of these drugs is contributing to the resistance crisis:

• High volume, high misuse: Because these antibiotics are cheap, widely available and perceived as benign, they're used too often, for viral infections, minor illnesses, or without proper diagnosis.
• Selection pressure: Frequent exposure to these drugs gives resistant strains a survival advantage; resistant pathogens multiply and spread.
• Community carriage: As shown in the recent studies, resistant bacteria are already widely carried in patients before even hospitalisation, suggesting community-level transmission catalysed by overuse.
• Healthcare impact: Overuse has made common antibiotics less reliable, forcing doctors to rely on broader-spectrum or more toxic drugs, thereby driving costs, side effects, and hospital stays.

Also Read: What Are Superbugs? The Bacteria Behind India's Antibiotic Resistance Crisis, Explained

What Needs To Change: Stewardship, Regulation And Awareness

Given the scale and impact of this misuse, here are critical steps to address the problem:

For Clinicians And Hospitals:

• Strengthen Antimicrobial Stewardship (AMS): Use culture-based prescribing, de-escalation, and monitor local resistance patterns (antibiograms).
• Screen patients for MDRO carriage, especially pre-procedure, to guide prophylaxis and reduce empiric over-prescribing.

For Pharmacists And Regulators:

• Enforce prescription-only rules, especially for key antibiotics like fluoroquinolones and macrolides.
• Restrict over-the-counter sales of broad-spectrum antibiotics without proper medical oversight.

For The Public:

• Never demand antibiotics for viral infections.
• Complete a full antibiotic course when prescribed and don't save leftovers.
• Practice good hygiene, vaccinations, and sanitation to reduce infections and the need for antibiotics.

For Government And Policymakers:

• Expand surveillance networks (AMRSN, NCDC) to better track antibiotic consumption and resistance.
• Invest in diagnostics that allow rapid, affordable bacterial identification and sensitivity testing.
• Launch sustained public-health campaigns on the dangers of antibiotic misuse.

The Lancet-linked study showing 83% colonisation by resistant bacteria in Indian hospital-setting patients is a clarion call. While many superbugs receive attention, we cannot ignore the role of the everyday antibiotics like azithromycin, amoxicillin, and ofloxacin in fuelling this crisis. These commonly used medicines are not only over-consumed but often misused, creating resistant strains that threaten modern medicine itself. Addressing antibiotic misuse requires coordinated action like better prescribing, stricter regulation, public education, and stronger surveillance. The future of effective antibiotics depends on preserving the power of these foundational drugs, before it's too late.

Disclaimer: This content, including advice, provides generic information only. It is in no way a substitute for a qualified medical opinion. Always consult a specialist or your own doctor for more information. NDTV does not claim responsibility for this information.

References:

1. Koya SF, et al. Consumption of systemic antibiotics in India in 2019. The Lancet Regional Health - Southeast Asia. 2022.

2. Kotwani A, et al. Over-the-Counter Sale of Antibiotics in India: A Qualitative Study of Providers' Perspectives across Two States. Antibiotics (Basel). 2021 Sep 17;10(9):1123.

3. Gandra S, Sulis G, et al. COVID-19 boosted excess sale of antibiotics in India. SciDev.Net / Gavi, the Vaccine Alliance. 2 Sept 2021.

4. Sulis G, et al. Sales of antibiotics and hydroxychloroquine in India during the COVID-19 pandemic: an interrupted time-series analysis. PLOS Medicine. 2021;18(9):e1003682.

5. National Centre for Disease Control (NCDC). National Antimicrobial Consumption Network (NAC-NET) Report 2023. Government of India. 2025.

6. Al Masud A, et al. Assessing community antibiotic usage and adherence as per standard treatment guidelines: a cross-sectional study in India. Sustainability: ScienceDirect. 2025.

7. Mittal N, Tayal A, Kumar S, et al. Longitudinal Trends in In-Patient Antibiotic Consumption According to the WHO Access, Watch, Reserve (AWaRe) Groups and Cost: Analysis at a NAC-NET site in North India over 7 Years (2017-2023). Antibiotics (Basel). 2024;13(7):673.