At the height of the COVID-19 pandemic, while the world masked up and stayed home, groups of scientists chased the coronavirus in an unlikely place - wastewater. Their efforts paved the way for a new era of disease monitoring, using sewage as a reservoir of information about pathogens ranging from viruses to antibiotic-resistant bacteria.
This method holds promise in combating one of the gravest threats to global health - Antimicrobial Resistance (AMR). Antibiotic resistance, a subset of AMR, is already rendering critical treatments ineffective, leaving infections like tuberculosis (TB) - once manageable—difficult and expensive to treat. The rise of multidrug-resistant TB (MDR-TB), which infects nearly half a million people annually, is a grim harbinger of a future where medicines may routinely fail.
Without urgent action, AMR could transform even minor infections into life-threatening conditions. Surveillance systems are one of our most powerful tools to counter this crisis.
What is AMR surveillance and why is it important?
Imagine going to the doctor for a simple infection, only to find out that the antibiotics you’ve taken before no longer work. That’s the scary reality of AMR and just the tip of the iceberg, and why keeping an eye on it—through AMR surveillance—is so critical.
Surveillance acts like a ‘radar’ and an early warning system, constantly monitoring which pathogens (bacteria, viruses, and fungi) are developing resistance to which drugs. It helps make timely public health decisions.
For instance, the 2016 outbreak of ceftriaxone-resistant Salmonella Typhi in Pakistan, was identified through AMR surveillance, which led to the implementation of appropriate control measures to contain the outbreak.
AMR Surveillance systems like WHO’s Global Antimicrobial Resistance Surveillance System (GLASS) track this at a global level by assessing the spread of AMR. The system helps in guiding patient care, informing local, regional, and national authorities, and guiding public health policy.
In India, the Indian Council of Medical Research (ICMR) plays a key role, with the Antimicrobial Surveillance & Research Network (AMRSN) gathering data from hospitals and pathology labs across the country. From identifying that 50% of Klebsiella pneumoniae bacteria from bloodstream infections are resistant to carbapenems (a last-resort antibiotic) to reporting that 73% of Escherichia coli causing Urinary Tract Infections (UTIs) were resistant to third-generation cephalosporins (commonly prescribed antibiotics), AMRSN has been underscoring the severity of AMR in hospitals.
Here’s how specific AMR genes are screened in hospitals: pathology labs collect samples (blood, urine, sputum, faeces) from infected patients, and these samples are tested using standard biochemical tests to determine antimicrobial susceptibility - they’re either resistant or susceptible to treatment.
Further testing includes looking at the shape, size, genes, and behaviour of these pathogens. This data is then entered into a shared portal and is validated by experts in regional centers. This data is then compiled to show which antibiotics are becoming less effective and where resistance is emerging. The information is shared with health authorities and hospitals to guide treatment policies, monitor trends, and support new guidelines.
Tracking how pathogens become resistant to medicines designed to treat them, monitoring these changes over time, and identifying particularly harmful ones in specific areas are crucial for adjusting treatment plans, issuing travel advisories, and making vaccine strategies.
Challenges with AMR surveillance in India
The journey to building a smooth-sailing, robust surveillance system is rife with challenges. Despite having good hospitals in Indian surveillance networks, ensuring high-quality, consistent data remains a significant challenge.
Gathering reliable data requires standardised methods, well-trained staff, and proper tools across different regions. However, limited resources, uneven infrastructure, and inconsistent data recording practices make AMR surveillance particularly difficult.
Even the best tertiary care hospitals in India do not have Hospital Information Systems (HIS) to systematically collect and manage AMR data. This makes it difficult to correlate AMR rates with antimicrobial consumption rates and clinical outcomes.
Microbiologist Shraddha Karve from Ashoka University and part of the Alliance for Pathogen Surveillance (APSI) consortium in India, highlights another barrier: outdated formats and inaccessible data. “Bugs evolve faster than data” she notes, stressing the need for real-time, user-friendly tools to track AMR trends.
Innovations in AMR tracking system
Shraddha’s team has developed a web application inspired by Switzerland’s ANRESIS model which pools data from multiple hospitals, presenting it in an intuitive format: a color-coded table.
Each cell, where pathogens and antibiotics intersect, reflects resistance levels—green for low, yellow for intermediate, and red for high resistance—accompanied by percentages. For example, if a cell says 30% in red, the samples are resistant, and the antibiotic may not work in many cases. Doctors can use this guide to make swift decisions and know what antibiotics to avoid. This accessible visualization can enable doctors to make informed decisions quickly.
Beyond data visualization, genomic tools are reshaping AMR research. Sequencing microbial DNA can uncover resistance genes and their mechanisms, such as whether they reside on plasmids, or mobile genetic elements that spread resistance among bacteria. Training hospital staff to use these tools and integrating rapid, cost-effective sequencing into AMR surveillance will be critical for containing outbreaks.
For this reason, researchers like Shraddha work closely with hospitals in India, collect and study this data, and also train medical teams to extract and sequence microbial DNA. Using rapid and cost-effective sequencing will help control their spread. “These bugs are dangerous and we don’t want them to be transported outside an ICU,” said Shraddha.
Global collaborations are also advancing the field. In 2016, the Vivli initiative brought together pharmaceutical companies to share raw AMR surveillance data on an open platform. One project explores how factors like C-section rates, education levels, and workforce participation influence resistance patterns by gender, offering a novel perspective on targeted interventions.
Getting out of the grip of the AMR crisis
Outsmarting rapidly evolving superbugs demands close collaboration among clinicians, scientists, and epidemiologists. Innovation in point-of-care diagnostics—testing for infections directly at the patient’s location—shows immense promise, especially for critically ill patients who need swift and accurate treatments.
New nanomotion technology platforms offer a game-changing approach to finding the most effective antibiotic for treating an infection. Unlike conventional methods that depend on monitoring bacterial growth over 24 hours, these advanced platforms can deliver results within 2–4 hours, dramatically reducing delays in critical care decisions.
However, surveillance and diagnostics alone cannot solve the AMR crisis. Promoting vaccination and hygiene practices are equally important in preventing the spread of resistant pathogens.
The typhoid outbreak in Pakistan provides a compelling case wherein vaccination campaigns successfully curtailed the spread of drug-resistant Salmonella Typhi. Similarly, a study in Malawi demonstrated that a single vaccine dose was 78.3% effective in protecting children against resistant typhoid strains.
Building a robust defense against AMR requires a multi-pronged strategy. Surveillance systems must identify and track resistance patterns, while vaccination, hygiene, and educational outreach work to reduce the prevalence of infections. Together, these measures create a layered approach to addressing AMR.
AMR is not a problem of the future—it is an urgent crisis today. Like a ten-headed monster, it requires coordinated, immediate action across all sectors of science, medicine, and public health. The fight against AMR will demand every resource in our arsenal, deployed with frightening urgency to safeguard the future of healthcare.
Edited by Sarah Hyder Iqbal and Parth Sharma.
Image by Janvi Bokoliya.
