Introduction: Fixed Dose Combination (FDC) is highly popular in the Indian pharmaceutical market and has been particularly flourishing in the last few years. Though rationality status is not clear, the pharmaceutical industry has been manufacturing and marketing FDCs.

Antimicrobial resistance (AMR) is an important public health concern globally. For India, undoubtedly, AMR has had profound impact on its health & socioeconomic parameters. Several hospital and community-based surveys have indicated alarming rise in incidence of multidrug resistant microbes, especially ‘superbugs’, having direct links with antibiotic use/misuse. Additionally, paucity in data with regards to quantification of AMR crisis & its determinants has been concerning. However, the national commitment to address AMR has steadily increased of late, with an oft-restated realization – it is time to act. Recent initiatives like National Policy for Containment of AMR (2011), Chennai Declaration (2012), Anti-microbial Resistance Surveillance and Research Network (2013), The Red Line Campaign (2016), National Action Plan (NAP) for AMR (2017), ICMR Treatment Guidelines for Antimicrobial Use in Common Syndromes (2019) are promising measures expected to have positive impact on both clinical and economic outcome in India. This paper provides a snapshot of major strategies proposed in recent years, including educational and awareness initiatives, infection control guidelines, audit and feedback, antimicrobial stewardship, surveillance projects etc. It also identifies technical challenges & opportunities for improved AMR mitigation in India.

Background Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action. Objectives To review the current situation with respect to AMR in India and initiatives addressing it. Identifying areas where more information is required will provide a call to action to minimize further rises in AMR and to improve patient outcomes. Methods National AMR initiatives, antibiotic use and prescribing in India, and availability of susceptibility data, in particular for the key community-acquired respiratory tract infection (CA-RTI) pathogens (Streptococcus pneumoniae and Haemophilus influenzae) were identified. National and international antibiotic prescribing guidelines for specific CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) commonly used locally were also reviewed, plus local antibiotic availability. Insights from a local clinician and clinical microbiologist were sought to contextualize this information. Conclusions Many initiatives have been launched since AMR was recognized as a national priority and organizations such as the Indian Academy of Paediatrics and the Global Antibiotic Resistance Partnership have worked to build awareness. The Indian Ministry of Health and Family Welfare published a 5 year national action plan on AMR. However, the burden of infectious disease and consumption of antibiotics in India is high. There have been national surveillance studies generating local data along with international studies such as Survey of Antibiotic Resistance (SOAR) and Antimicrobial Testing Leadership and Surveillance (ATLAS). For common RTIs, clinicians use a range of international and national guidelines. However, a more standardized inclusive approach to developing local guidelines, using up-to-date local surveillance data from community-acquired infections, could make guidelines more locally relevant. This would encourage more appropriate antibiotic prescribing and improve adherence. This would, in turn, potentially limit AMR development and improve patient outcomes.

An increase in the daily dose of amoxicillin from 45 mg/kg to 90 mg/kg was introduced in late 2000 to respond to increasing presence of penicillin-resistant Streptococcus pneumoniae (PRSP) in Acute Otitis Media (AOM) and in other respiratory infections. The basis for this recommendation is a well understood mechanism of resistance among PRSP as well as established safety profile of amoxicillin with known tolerance to high doses. The addition of a standard dose of clavulanic acid provides protection against resistance present in other pathogens involved in AOM and other respiratory infections. A formulation of high dose of amoxicillin with standard dose of clavulanic acid has been developed to meet the increasing needs for efficacy against bacteria with growing antibiotic resistance. While, on the one hand, there is continued empirical use of standard/lower dose of amoxicillin (45 mg/kg/day) or a second- or third-generation cephalosporin in AOM, on the other hand, there is evidence of a rise in intractable cases (relapses or first-line therapy failures). In addition to this, an evolving disease bacteriology and regional variation in antibiotic susceptibility are determinants of clinical outcome in AOM. The current paper discusses the unmet areas and explains rationale behind guideline-directed empirical high-dose amoxicillin supported with clavulanic acid in AOM.

Soil-Transmitted Helminths (STH) or geohelminths are an important cause of morbidity worldwide. A large proportion of the infection burden occurs in India, including STH infections due to roundworms (Ascaris lumbricoides), whipworms (Trichuris trichura) and hookworms (Necator americanus or Ancyclostoma duodenale). Apart from direct health impacts, they are also implicated in anaemia, nutritional deficiencies and delayed cognitive development in children. They also have been shown to have detrimental impact on economic development and future income earning potential. The current global strategy on STH control is through increased utilisation of Preventive Chemotherapy (PC) for at-risk population, comprising mainly pre-school and school age children. This is crucial for India, as there can be significant proportion of untreated subjects in the community, who may act as a reservoir of infection for treated subjects to get re-infected. Additionally, inculcating healthy behaviour modifications and adopting WASH interventions meant a major shift in social and cultural norms in many societies. Overall, the multifaceted nature of STH control in India requires concerted efforts and significant mobilisation of human and financial resources. In this regard, several recent initiatives including Swachh Bharat Abhiyan, Nirmal Gram Puraskar, Water Sanitation and Hygiene (WASH) interventions, Clean India: Clean schools etc., have brought a positive change, apart from the provision of deworming for morbidity control through National Deworming Day. In this paper, authors have narrated major initiatives in recent years that are expected to bring a lasting solution to the problem of STH infection in India.