The story so far: The Central Drugs Standard Control Organisation (CDSCO) has warned against the indiscriminate, repeated, or prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs) and antibiotics, linking inappropriate use to avoidable renal complications and chronic kidney disease (CKD).

In its September 21 circular, it also reminded doctors, pharmacists, hospitals, and the public that these medicines are subject to prescription and other regulatory safeguards.

What does the latest directive mean?

The CDSCO circular is, in significant part, a reminder that existing rules already require medical supervision for these medicines and doesn’t amount to any new ban on painkillers or antibiotics.

Most NSAIDs are classified under Schedule H of the Drugs Rules, 1945. Most antibiotics are under Schedule H1. These medicines are therefore not meant to be sold at retail without a prescription from a Registered Medical Practitioner.

Schedule H1 medicines also carry a specific warning that they should be taken only on and according to medical advice.

The regulator has asked the public not to take NSAIDs or antibiotics indiscriminately, repeatedly or for prolonged periods without medical advice.

“Antibiotics should not be self-medicated or used for illnesses where they are not clinically indicated,” it said.

Also, doctors have been asked to prescribe them only when clinically justified, in the appropriate dose and for the appropriate duration, and to follow antimicrobial stewardship principles. Pharmacies, hospitals, and healthcare institutions have also been put on notice.

The kidney warning is particularly relevant to NSAIDs. These drugs can reduce blood flow to the kidneys and are associated with acute kidney injury, particularly among people who already have kidney disease, diabetes, or hypertension. Longer-term use has also been associated with CKD occurrence or progression.

Importantly, the warning does not mean that all painkillers or antibiotics are inherently unsafe. The concern is inappropriate selection, dose, duration, and unsupervised use.

How extensive is antibiotic misuse?

There is no single national figure that captures all inappropriate antibiotic use in India. Available studies, however, show that self-medication remains a significant problem.

A systematic review covering 66 Indian studies and nearly 30,000 participants estimated overall self-medication at 64.4%, although this included medicines generally and not antibiotics alone. Analgesics, antipyretics, antibiotics, and cough remedies were among the commonly self-medicated drug categories.

A community study from South-East Delhi found that 35% of 200 participants reported antibiotic self-medication. Fever, cold, and flu were common reasons, while pharmacies were the main source of antibiotics.

While these studies cannot be interpreted as a national prevalence estimate and represent different populations and locations, together they illustrate why prescription enforcement and antibiotic stewardship remain concerns.

What does antibiotic misuse do?

Antibiotics work against bacterial infections. They do not treat viral illnesses such as most common colds and influenza.

When antibiotics are used unnecessarily, incorrectly or for an inappropriate duration, bacteria can be exposed to the drug without being eliminated. Resistant organisms can then survive and multiply. This contributes to antimicrobial resistance (AMR).

The consequences extend beyond the individual who takes the antibiotic. Resistant organisms can spread to other people and through healthcare and environmental pathways.

WHO estimates that bacterial AMR was associated with more than 4.7 million deaths globally in 2021. In 2023, approximately one in six laboratory-confirmed bacterial infections globally was resistant to antibiotics. WHO says misuse and overuse of antimicrobials are important drivers of the problem.

What does WHO say about antibiotic use?

WHO has increasingly moved towards antimicrobial stewardship — ensuring that antimicrobials are used only when necessary and that the right drug, dose and duration are selected.

Its AWaRe classification divides antibiotics into three groups: Access, Watch and Reserve. Access antibiotics are generally preferred for common infections because they have a narrower spectrum and lower resistance potential. Watch antibiotics have greater resistance potential and therefore require more careful use. Reserve antibiotics are intended for infections caused by multidrug-resistant organisms when other options are inadequate.

WHO’s analysis of 2022 antibiotic-use data found that only about one in three reporting countries/territories/areas met the target of having at least 70% of antibiotic consumption from the Access group. WHO has called for stewardship policies to reduce unnecessary antibiotic use and encourage Access antibiotics when they are clinically appropriate.

WHO’s 2025 global AMR surveillance report, based on more than 23 million laboratory-confirmed cases reported by countries, also underlines the continuing global burden of resistance and the need for better surveillance.

Which drugs are commonly misused, and who is most vulnerable?

NSAIDs are among the medicines of concern because they are widely used for headaches, fever, body pain, arthritis, dental pain, and other painful conditions.

Common NSAIDs include ibuprofen, diclofenac, naproxen, and similar anti-inflammatory painkillers. Their risks become more important with prolonged or high-dose use and in people with kidney disease, diabetes, hypertension, dehydration or other risk factors.

Indian pharmacovigilance data, although based on reported adverse events rather than population prevalence, provide an important signal: in one analysis of NSAID-associated CKD reports, 82% of cases were among people aged 40–80 years, with diclofenac implicated in 43% of the reports.

For antibiotics, children are an important vulnerable group, largely because parents or caregivers may administer medicines based on previous prescriptions or advice from pharmacies and family members. The recent Indian meta-analysis found substantial antibiotic self-medication among children.

Older adults and people with chronic diseases also require particular caution because kidney function may already be reduced and multiple medicines may be involved.

What measures is the government bringing in?

India has been working on AMR for more than a decade. The National Programme on AMR Containment was launched in 2013, with surveillance, monitoring of antimicrobial consumption, infection prevention and control, and promotion of rational antimicrobial use among its objectives.

India launched its National Action Plan on Antimicrobial Resistance 2.0 (NAP-AMR 2025–2029) in November 2025. It adopts a One Health approach, bringing human health together with animal, agricultural, and environmental sectors. It includes surveillance, antimicrobial stewardship, infection prevention and control, research and monitoring.

The government has also used the Drugs Rules to control antibiotic sales. Schedule H1 requires records of the supply of listed medicines, including details of the prescriber and patient, with records maintained for three years.

There is also a recent regulatory development in August 2026, when CDSCO issued a draft notification proposing four additional drugs for inclusion in Schedule H1.

Why have rules not worked so far?

The central difficulty is that regulation has existed for years, but implementation has been uneven.

India’s NAP-AMR documentation itself records earlier CDSCO awareness and enforcement drives concerning Schedule H and H1 medicines, including restrictions on selling antimicrobials without prescriptions. Yet studies continue to document antibiotic self-medication and access through pharmacies.

Similarly, antimicrobial stewardship programmes have been part of India’s AMR strategy since the first National Action Plan. The 2017–2021 plan called for stewardship programmes, treatment guidelines, multidisciplinary stewardship committees, and training.

The continuing problem, therefore, is less about the absence of rules and more about translating those rules into routine practice — ensuring that prescriptions are actually required at the point of sale, that doctors prescribe antibiotics appropriately, that patients do not demand or reuse medicines, and that hospitals monitor antibiotic consumption. 

Although the incidence of malaria fell by nearly a quarter between 2000 and 2015, the trend has reversed over the past decade, with global incidence rising by 8.5% since 2015. Experts say the growing threat of resistance to anti-malarial medicines could complicate efforts to eliminate the disease and reverse gains.

India currently holds about 1.4% of the global malaria burden, marking a decline from previous decades. Estimated cases in the country fell from 6.4 million in 2017 to nearly two million in 2023, while malaria-related deaths declined by about 68% during the same period, leading to India’s move from the WHO’s High Burden to the High Impact list.

Much of the progress has been driven by improvements in diagnosis, treatment and vector control, along with the efforts of community health workers. Suresh Kumar D., senior specialist in infectious diseases, Apollo Speciality Hospitals, Chennai, said door-to-door screening and early diagnosis by Accredited Social Health Activists (ASHAs) played a crucial role in reducing transmission, particularly in rural areas.

Challenges ahead

However, experts say the gains still remain fragile. Transmission persists in tribal and forest regions where access to diagnostics and medicines remains inadequate. India also continues to carry a substantial burden of Plasmodium vivax, accounting for nearly 46% of the global burden of the species. The country’s malaria case mix comprises approximately 57% P. falciparum and 43% P. vivax.

While P. falciparum remains responsible for most severe and fatal infections, P. vivax poses a different challenge. “Vivax may be less deadly, but it relapses and continues silently seeding transmission,” Dr. Suresh said.

Resistance to frontline medicines

For the past two decades, malaria treatment has largely relied on artemisinin-based combination therapies (ACTs), which pair a fast-acting artemisinin drug with another medicine that helps clear the remaining parasites. However, resistance to these therapies is emerging as one of the biggest concerns in malaria control.

According to Melissa Sathyan, consultant in internal medicine, Rela Hospital, Chennai, resistance to artemisinin and some of the partner drugs used in ACTs has been reported primarily in Southeast Asia and parts of Africa. The greatest concern remains P. falciparum, which is responsible for the majority of severe malaria cases.

Partial resistance to artemisinin has been linked to mutations in the parasite’s kelch13 (K13) gene. Dr. Suresh said mutations such as R561H, first reported in Rwanda, have spread into neighbouring regions including Tanzania, while other K13 variants have expanded across the Great Rift Valley. At least eight African countries have reported confirmed or suspected resistance.

Though these mutations have not emerged as a major problem in India, the risk of spread cannot be discounted. P. Praveen Kumar, consultant in general medicine, SRM Prime Hospital, Chennai, said there was also increasing concern over reduced responsiveness of P. vivax parasites to certain therapies.

Contributing factors

Several factors are contributing to the emergence of resistant strains, including incorrect use of anti-malarial medicines, poor adherence to treatment, circulation of counterfeit or substandard drugs, and historical use of artemisinin monotherapy before combination therapies became standard. Weaknesses in vector control and growing insecticide resistance further complicate the picture.

For patients, the consequences can be severe. Delayed parasite clearance, prolonged illness, treatment failure and the need for second-line therapies can increase healthcare costs and the risk of severe malaria and death, Dr. Sathyan noted.

Climate change also adds to the challenge. The spread of Anopheles stephensi, a mosquito species adapted to urban environments, along with changing climatic conditions, could accelerate transmission.

Need for stronger surveillance and strategies

Despite the threat posed by resistance, ACTs continue to be recommended by the WHO and India’s national guidelines as first-line treatment for uncomplicated malaria. Severe malaria is treated with intravenous artesunate followed by oral ACTs.

Experts said newer drug combinations and alternative treatment strategies were being evaluated in response to evolving resistance patterns.

For severe malaria, intravenous artesunate remains the preferred standard of care. For uncomplicated P. vivax malaria, chloroquine and primaquine continue to be widely used. Primaquine is particularly important because it targets hypnozoites , dormant forms of the parasite in the liver that can trigger relapses.

Future approaches may involve rotating different first-line therapies across regions and employing triple ACT combinations, which pair artemisinin with two partner drugs, thereby making it more difficult for parasites to overcome treatment. Approved malaria vaccines are also being introduced in high-risk regions as part of broader control strategies.

Surveillance would be central to containing resistance. Routine therapeutic efficacy studies and molecular surveillance to detect K13 mutations, along with monitoring insecticide resistance, are becoming increasingly important.

Operational surveillance and India’s test-track-treat strategy had been key to managing local outbreaks. Experts also underscored the importance of early diagnosis, prompt treatment, insecticide-treated bed nets, indoor residual spraying and community awareness programmes.

Research priorities include the development of next-generation anti-malarial drugs with mechanisms different from those of artemisinin and continued efforts to develop vaccines. Ensuring the quality of medicines and sustaining investments in community health worker networks will also be critical, particularly as the remaining pockets of transmission are concentrated in hard-to-reach regions.

With India aiming to eliminate malaria by 2030 and the global burden showing signs of resurgence, experts say sustained vigilance and innovation will be essential to prevent drug resistance from eroding decades of progress.

Published – June 17, 2026 04:25 pm IST

Image used for representative purpose only.
| Photo Credit: G. N. Rao

For the first time, Indian scientists have reported antimicrobial resistance (AMR) gene profiles in poultry from Kerala and Telangana, and have cautioned that this emerging resistance may be aggravated by the depleting antibiotics repertoire.

Poultry is a major source of AMR, because industrial farming, with modern practices, widely uses antibiotics. India and China are major producers of meat and have hotspots of AMR in their countries.

This has been stated in a recent paper titled ‘The antimicrobial resistance profile in poultry of Central and Southern India is evolving with distinct features’, published in Comparative Immunology, Microbiology and Infectious Diseases, by the Drug Safety Division, Indian Council of Medical Research-National Institute of Nutrition, Hyderabad.

Speaking about the study, Shobi Veleri, one of the authors of the paper, said that while Central and Southern India were predicted as emerging hotspots for AMR in poultry, there was no data available to substantiate this.

“To this end, we collected chicken faeces from poultry farms in these regions and isolated genomic DNA. The samples exhibited a high prevalence of gram-negative and anaerobic species. These deadly species have an extra layer of cell membrane protection against drugs that could kill them. AMR acquired by them poses an additional challenge for medical treatment of serious infectious diseases like pneumonia, cholera, food poisoning etc.,’’ Dr. Veleri said.

High-priority pathogens, like E. coli, Clostridium perfringens, Klebsiella pneumonia Staphylococcus aureus, Enterococcous faecalis, Pseudomonas aeruginosa and Bacteriodes fragiles that pose challenges for antibiotic treatment in India were also detected in the poultry samples, and were carrying AMR genes. 

This is a red flag for urgent intervention to stop the spread of AMR in the ecosystem, the paper noted.

Respiratory infections (Pneumonia, bronchitis), urinary tract infections, gastrointestinal infections, intra-abdominal infections, and several clostridial infections commonly seen in India are caused by gram-negative and anaerobic species. 

Infections of AMR pathogens increase public health risk and the likelihood of mortality arising from limited drug options and consequent health complications.

The study further found that southern India had a higher abundance of AMR genes compared to central India. E. coli was significantly more prevalent in the southernmost zone of India compared to other sites.

Also, the ICMR data had many common AMR profile features of the European Union (EU) poultry farms but lacked mcr-1, the gene that renders resistance to colistin, the last resort antibiotic in the essential drugs list of the World Health Organization. This is a recently-emerged AMR gene in E. coli. Similarly, a newly-emerged resistance gene, optrA, detected in EU was undetected in Indian poultry samples, whereas qnr, which is highly present in EU, is emerging in south Indian samples in low levels.

The data reveals the extent to which the AMR gene has evolved in central and southern India, and it is comparable to EU data but its severity is less than it is in the EU, the report said. Thus, now India has a window of opportunity to control AMR spread in the food chain, the scientists noted, while seeking urgent government intervention to ensure the safety of the public.

The recommendation to the Drugs Consultative Committee (DCC) is aimed at curbing the growing antimicrobial resistance which is now recognised as a public health threat globally. 
| Photo Credit: Getty Images/iStockphoto

The Drugs Technical Advisory Board (DTAB), the highest statutory decision-making body on technical matters related to drugs in the country, has recommended the inclusion of all antibiotics in the definition of new drugs in the New Drugs and Clinical Trial (NDCT) Rules, 2019.

The recommendation to the Drugs Consultative Committee (DCC) is aimed at curbing the growingantimicrobial resistance which is now recognised as a public health threat globally. 

According to Rule 122 E of the Drug and Cosmetic Rules 1945, a new drug can be one which has not been used in the country and has not been recognised as effective and safe by the licensing authority for the proposed claims. It could also be an approved drug with modified or new claims including indications, dosage, and new route of administration. 

If brought into the new drug bracket, the manufacturing, marketing, and sale of antibiotics will be documented. Also, the manufacturing and marketing clearance will have to be obtained from the Central government instead of State drug administration, and patients will be able to buy antibiotics only on prescription. 

The board is also looking at amending the labelling requirements under the Drugs Rules, 1945 and adding a blue strip or box for antimicrobial products. It has recommended that no antimicrobials should be sold by the traders to the non-pharmaceutical industries who do not hold requisite licences.

A recently released report by the Indian Council of Medical Research’s Antimicrobial Resistance Surveillance Network said that drug-resistant and difficult to treat urinary tract infections, blood stream infections, pneumonia, and typhoid are among the diseases that are showing resistance to commonly used antibiotics in India.

Meanwhile, in a recent meeting, DTAB was apprised that antimicrobial resistance has been recognised as a serious and growing threat to public health globally.

“The problem of antimicrobial resistance has been highlighted as a global health priority in multiple high-level platforms and in view of this it was proposed to include all antibiotics in the definition of “new drug’’ in New Drugs and Clinical Trial Rules, 2019,” noted the minutes of the meeting.

DTAB added that antimicrobial resistance can be caused due to misuse of antibiotic, antiviral, antifungal, etc. and accordingly recommended that the matter may be deliberated in the DCC initially.

Fungal infections are evolving and becoming resistant to the medicines used to treat them, causing what some researchers are calling a “silent pandemic” that needs to be addressed urgently. According to molecular biologist Norman van Rhijn from the University of Manchester in the UK, the threat of fungal pathogens and antifungal resistance is being overlooked in global health discussions. Without urgent attention and action, some particularly nasty fungal infections, which already infect 6.5 million a year and claim 3.8 million lives annually, could become even more dangerous, he warned, as per Science Alert. 

The biologist, along with an international group of scientists, is urging government, research communities and the pharmaceutical industry to “look beyond just bacteria”. Fungal infections are left out of too many initiatives to tackle antimicrobial resistance, the researchers said, per Science Alert. Without urgent attention, fungal infections could become even more dangerous, they said. 

“The disproportionate focus on bacteria is concerning because many drug resistance problems over the past decades were the result of invasive fungal diseases, which are largely under-recognized by the community and governments alike,” Norman van Rhijn and his colleagues, who hail from institutions in China, the Netherlands, Austria, Australia, Spain, the UK, Brazil, the US, India, Turkiye, and Uganda, said. 

Fungal diseases such as Aspergillus fumigatus, which affects the lungs, and Candida, which causes yeast infections, are considered the most dangerous. People with weakened immune systems and older adults are at the highest risk, per the outlet. 

Scientists explained that compared to bacteria and viruses, fungi are more complicated organisms, which makes it harder and more expensive for scientists to develop a medicine that kills the cells of fungi without damaging other important cells in the body. Currently, there are only four classes of antifungal drugs, and resistance to them is increasing. 

“To treat deep or invasive fungal infections, only four systemic antifungal classes are available and resistance is now the rule rather than the exception for those currently available classes,” the researchers wrote. 

Also Read | China’s Gigantic Hydroelectric Dam Has Earth-Shifting Capabilities, Scientists Say

The team said that it is concerned that agricultural practices are contributing to the problem. They explained that fungicides used in farming can cause cross-resistance in the fungi that affect humans. They suggest that the world needs a balance between protecting crops and treating fungal infections. 

“Antifungal protection is required for food security. The question is, how do we balance food security with the ability to treat current and future resistant fungal pathogens?” the researcher wrote. 

The team recommends a global agreement to limit certain antifungal drugs to specific purposes, as well as collaborative regulations to balance food security with health.

This week a prize was announced that is likely to have far-reaching implications in the world of health care. Despite its importance most of the community is unaware of the event. The winner of the Longitude prize is poised to spearhead a revolution in the field of infection management and global efforts to tackle antimicrobial resistance. The £8million ( ₹85 crore) Longitude Prize on Antimicrobial resistance (AMR), first announced in 2014, revealed its winner at an event in London’s Science Museum. The PA-100 AST System from Sysmex Astrego is a high-tech, transformative, rapid, point-of-care test for UTIs (Urinary Tract Infection).

Rational use of antibiotics — choosing the appropriate antibiotic for the correct patient at the optimal time — is fundamental in saving lives and combating the superbug crisis. Rapid diagnostics are poised to be crucial in this effort. The winner of the Longitude Prize is set to spearhead the list of emerging rapid diagnostic technologies in a transformative manner. The applications for the Longitude Prize bring hope, suggesting that through collective action, we can look forward to a future protected from the threats of antimicrobial resistance.

The crisis is imminent: Antibiotic-resistant infections killed nearly 1.3 million people globally in 2019 and are on course to cause 10 million deaths a year by 2050, outstripping deaths caused by cancer. The global economy may lose up to 4 trillions by 2030 and up to 100 trillions by 2050 due to the AMR crisis.

What does the prize mean?

Most advanced tests in medical practice today are PCR-based, but the PA-100 AST System from Sysmex Astrego has developed a transformative technology based on a phenotypic test. This test identifies the bacteria causing the urinary tract infection and performs antibiotic susceptibility testing (AST) to determine the effective antibiotic for the specific patient in under 45 minutes.

The test uses a single-use cartridge, the size of a smart phone. Less than half a millilitre of the urine is added to this cartridge. Bacteria in the urine is trapped in over 10,000 microfluidic traps in parallel arrays and exposed to five different antibiotics at five different concentrations. The cartridge is inserted into a reader instrument, the size of a shoe box, where bacterial growth is monitored by phase-contrast imaging. The reader provides a report , “sensitive” or “resistant” for each antibiotic in 30-45 minutes. This supports doctors and health workers in their clinical decision making at the point of care, and opens up the significant possibility of previously “retired” first-line antibiotics coming back into use for the majority of patients.. Accurate, rapid diagnosis of bacterial infections that help doctors and health workers manage and target antibiotics, will slow the development and spread of antibiotic resistant infections, improve healthcare and save potentially millions of lives.

The test represents a huge advance over the current turnaround time of 2-3 days. The test will help doctors prescribe the right antibiotic at the right time, rather than waiting for 3 days and resorting to empirical antibiotic prescription. The test can be performed in a doctors clinic rather than sending the urine sample to a laboratory. When a patient with symptoms of urinary infection visits a doctor, if the new technology is used , the doctor will know within 45 minutes ,whether the patient has urinary infection or not and if there is an infection which antibiotic will work. The test is transformative, accurate, and affordable for patients worldwide.

Currently there are two types of tests available to diagnose urinary infection.

The first one is the urine dipstick test that can be done as a point-of-care test. Point-of-care diagnostic tests are tests that can be performed in the clinic, emergency departments, hospital wards, or pharmacy counters, without the need to send the sample to a laboratory. The advantage of the dipstick is that results are available in a couple of minutes, which helps doctors decide whether to start antibiotics or not. Unfortunately accuracy is not more than 50-60%. Even if the doctor carries out a dipstick despite its limitations, the test doesn’t help the doctor choose the right antibiotic.

For this, the urine sample must be sent to the laboratory for culture. The culture results take a minimum of 2-3 days. But the doctor cannot wait 2-3 days to start an antibiotic. So, even if the doctor sends a urine sample for culture, they still have to start an antibiotic empirically, based on educated guesswork, before the culture results are ready. By this time, the patient has already completed a full or half course of antibiotics. Such blind antibiotic prescriptions are a major cause of the antibiotic resistance crisis, especially in countries like India. A transformative, rapid point of care diagnostic test that is accurate and affordable has the potential to revolutionise urinary tract infection treatment in India and worldwide. Current urinary tract infection management in most cases is based on a 50:50 rationale. Only 50% of patients with symptoms of urinary infection have an actual infection, and the accuracy of a urine dipstick is 50-60%.

In India, every year, millions of patients with urinary tract infections visit doctors or pharmacies seeking treatment. These infections result in significant loss of lives, burden the healthcare system, and have a socio-economic impact. In 20-30% of sepsis patients, the infection originates from the urinary tract. Up to two in five people who develop severe sepsis will lose their lives. Hence, rapid and accurate point-of-care tests for urinary tract infection can save millions of lives worldwide, especially in India. The solution is a rapid, accurate, and affordable test that can help the doctor diagnose urinary infection accurately and provide information on the correct antibiotic that can cure the infection.

What is the Longitude Prize?

In 1714, the British government announced the Longitude Prize to solve the longitude problem, literally. In the 18th century, thousands of ships were lost at sea because sailors couldn’t determine the position of the ship at sea. If a ship doesn’t know where it is, it risks being shipwrecked.

To determine the position of a ship, both latitude and longitude are needed. Latitude was easy to measure by observing the sun, moon, and stars, but longitude was a mystery. The British government announced the Longitude Prize for an invention that helps calculate longitude. John Harrison, a watchmaker, invented an ingenious device that could calculate longitude perfectly and won the prize.

300 years after the first Longitude Prize, the Britain launched a second Longitude Prize. The public was asked to vote for a major challenge that needed an immediate solution, such as global warming, food shortage, and water shortage. The public voted for Anti Microbial Resistance. A ten million pound Longitude Prize was announced in 2014. Of this, £ 2 million was awarded to various innovators to refine their technology. The final winner receives £ 8 million.

The Longitude Prize on AMR intends to incentivise the creation of new diagnostic tests that, in a matter of minutes, can identify whether an infection is bacterial, and if so, the right antibiotic to prescribe to slow the spread of antibiotic resistant infections. The goal is to replace the 2–3-day lab test process that doctors and patients must currently endure, and end “just in case” prescribing that is prevalent as a result, which promotes the development of antibiotic resistance.

More often than not, the experience for patients with a fever is to get tested and treated for a typhoid infection. The test is a rapid blood test called the Widal test. The subsequent treatment usually consists of tablets, typically in urban areas, or injections in rural ones.

Typhoid spreads through contaminated food and water and is caused by Salmonella typhiand other related bacteria. Also known as enteric fever, it presents with a high fever, stomach pain, weakness, and other symptoms like nausea, vomiting, diarrhoea or constipation, and a rash. Some people, called carriers, may remain symptom-free and shed the bacteria in their stool for several months to years.

These symptoms mimic those of malaria, dengue, influenza, and typhus, to name a few, each with different treatment modalities. If left untreated, typhoid can be life-threatening. Per the World Health Organisation, 90 lakh people are diagnosed worldwide with typhoid every year and 1.1 lakh die of it. A small 2023 study reported the burden to be 576-1173 cases per 100,000 child-years (one child year is one child being followed up for one year) in urban areas and 35 per 100,000 child years in rural Pune.

How is typhoid fever diagnosed?

The gold standard for diagnosing typhoid — in addition to a detailed medical history and a thorough examination — is to isolate the bacteria from a patient’s blood or bone marrow and grow them in the lab. Stool and urine samples can also yield the same but with lower sensitivity.

However, performing culture tests in smaller clinical settings presents practical problems. Cultures are time-consuming and skill- and resource-intensive. Prior antibiotic treatment can also affect the results of cultures — a common issue due to the indiscriminate use of antibiotics in India. Some PCR-based molecular methods are known to be better but are limited by cost; the need for specialised infrastructure and skilled personnel; and the inability to retrieve live bacteria for further tests.

Against this backdrop, in India, clinicians use the Widal test extensively to diagnose typhoid in both public and private sectors.

As with other infections, our immune system produces antibodies in the blood against the bacteria, causing enteric fever. The Widal test rapidly detects and quantifies these antibodies. It’s a point-of-care test and doesn’t need special skills or infrastructure. Developed in the late 1800s by a French physician, it is no longer used in many countries because of its flaws — flaws that are rendered by the scale of the test’s use in India to be abusive.

Why is the Widal test inappropriate?

A single positive Widal test report doesn’t necessarily mean a typhoid infection is present, and a negative report doesn’t confirm the disease’s absence. To diagnose an active infection, clinicians must test at least two serum samples taken at least 7-14 days apart, so that they may detect a change in concentrations of the antibodies. But getting two samples is rarely feasible and time-consuming.

Second, in areas with high and continuous typhoid burden, certain levels of antibodies against the bacteria may already be present in the blood. Without knowing the baseline cut-off, it isn’t possible to correctly interpret the test. A related issue is that different manufacturers of the test specify different cut-off values in their kits’ user manuals.

Third, the reagents used in the Widal test to reveal the presence of various antibodies can cross-react with antibodies produced against infections by other bacteria, viruses or parasites, or even in typhoid-vaccinated individuals, leading to false positives. Prior antibiotic therapy can also affect antibody levels and yield a false negative.

Correct diagnosis and appropriate treatment of enteric fever are important because serious complications, like severe intestinal bleeding or perforation, can develop within a few weeks if the disease is mismanaged. False negatives can thus delay diagnosis and lead to fatal outcomes.

What are the consequences of the test’s use?

Because of the Widal test’s propensity for erroneous results, the actual burden of typhoid in India remains obfuscated. A lack of awareness of the proper time at which to collect a blood sample, along with a lack of standardisation of kits and poor quality-control compound the problem.

Further, a single test costs a couple hundred rupees. Patients in many States have also reported being charged Rs 500 to Rs 4,000 per dose of antibiotic injections by local healthcare providers following a typhoid diagnosis based on a single Widal test. Patients in both urban and rural areas have reported selling assets to receive these antibiotics.

The irrational use of antibiotics is a major cause of antimicrobial resistance (AMR). Bacteria have also been known to be able to transmit AMR between strains and species, and they are not limited by geographical borders. This is why the threat of AMR in one country represents the threat of AMR everywhere. Some strains of Salmonella are also resistant to multiple drugs. Continued irrational use of the Widal test, which facilitates unnecessary use of antibiotics, will therefore only make it more and more difficult to control this preventable disease while adding to the financial woes of the patients already suffering.

What do we need instead of the Widal test?

We need to discover better point-of-care tests that can replace the Widal test. And until they’re available, clinicians can consider using best-practice heuristics that provide a rational diagnosis and subsequent treatment options based on the regional data of effective antibiotics available against the bacteria.

These options should be coupled with ensuring adequate and safe food and water and functional sanitation to address the disease’s root cause.

Improving access to better diagnostic tests could also address this problem. Doing a blood or bone marrow culture is often not feasible as it requires laboratory infrastructure that most parts of the country lack. Healthcare workers can instead benefit from a ‘hub and spoke’ model, with sample collection sites at the periphery and district hospitals and medical colleges as the hubs that process samples. The latter facilities could also serve as research centres that generate regional prevalence and susceptibility data.

Next, we need better surveillance to stay on top of the AMR caused by the overuse of the Widal test. The Indian Council for Medical Research publishes an annual report highlighting the typhoid bacteria’s resistance patterns. As per the last report, in 2021, the number of samples tested to report susceptibility ranged from one from the ‘East’ region to 126 samples from the ‘North’.

Finally, as typhoid also has symptom-free carriers, constant environmental vigilance and data-sharing are imperative.

Dr. Vasundhara Rangaswamy is a microbiologist and a rural physician. Dr. Parth Sharma is a public health physician, writer, and researcher.