Antibiotics Are Not Everyday Medicines - Pulmonologist Dr Vijay Kumar Agrawal

A cold, a sore throat or a mild fever often brings a familiar suggestion: “Take an antibiotic.” Someone recommends azithromycin, an old prescription is reused, or tablets are bought without a medical consultation. When the illness improves, the drug gets the credit, although a viral infection may have resolved on its own. “This is how a valuable prescription medicine gradually becomes an everyday household remedy. The consequences go much beyond unnecessary spending,” warns Dr Vijay Kumar Agrawal, Director & HOD, Pulmonology & Sleep Medicine and Senior Consultant, Critical Care Medicine, Yatharth Hospital, Faridabad.

In a conversation with The Health Outlook, Dr Agarwal, examines why antibiotics are being overused, how resistance is fast spreading and what needs to be done to preserve these life-saving medicines.

Q: How serious is the antibiotic misuse problem?

Dr Agrawal: According to WHO’s 2025 surveillance report, approximately one in six laboratory-confirmed bacterial infections covered by its global analysis in 2023 was resistant to antibiotic treatment. This refers to the infections studied, not to one in six people or episodes of illness. WHO also reports an estimated 1.14 million deaths directly attributable to bacterial antimicrobial resistance worldwide in 2021.

Indian research highlights the importance of respiratory prescribing. A study published in PLOS ONE in 2019, using private-sector outpatient data from 2013–2014, estimated 519 million antibiotic prescriptions in the population studied; 55% were associated with respiratory diagnoses. These older findings are not a current national count, and they do not establish that every prescription was inappropriate. They nevertheless identify a major opportunity to improve practice.

The pandemic illustrated the scale of precautionary prescribing. WHO reported in 2024 that approximately 75% of hospitalised COVID-19 patients in the international data assessed received antibiotics, although only 8% had bacterial co-infections requiring them. Prescribing “just in case” can become a widespread practice when uncertainty replaces clinical judgement.

Q. Does every fever or cough require an antibiotic?

Dr Agrawal: No. Fever and cough do not automatically mean that an antibiotic is required. Influenza, for example, is a viral infection. Antibiotics do not kill influenza viruses. The same applies to many common respiratory viral infections.

An antibiotic becomes relevant when there is a suspected or confirmed bacterial infection, or when a bacterial complication develops. The decision should be based on the clinical picture and, where required, appropriate investigations.

Q. Why do people continue to take antibiotics for viral illnesses?

Dr Agrawal: One reason is the expectation of a quick recovery. Patients often feel that an antibiotic is a stronger medicine and will make them better faster.

There is also a common tendency to reuse an old prescription or take a tablet recommended by a friend or relative. Sometimes people stop the medicine as soon as they feel better, while others take antibiotics even when they were never needed in the first place.

This creates a cycle of unnecessary antibiotic exposure.

Q. What happens when antibiotics are taken unnecessarily?

Dr Agrawal: Unnecessary antibiotics can cause side effects and disturb the normal bacteria that live in our body. More importantly, repeated and inappropriate use contributes to antimicrobial resistance.

When bacteria are exposed to antibiotics unnecessarily or improperly, resistant strains can emerge. These bacteria can become increasingly difficult to treat.

Q. Does every fever or cough require an antibiotic?

Dr Agrawal: As a pulmonologist, I consider respiratory illness a crucial starting point for public education. The common cold, influenza and many uncomplicated upper respiratory infections are viral. Antibiotics do not treat these viruses. Routine antibiotic treatment is also generally inappropriate for uncomplicated acute bronchitis. Yellow or green sputum alone does not establish a bacterial infection.

Bacterial pneumonia, selected COPD exacerbations and infections in vulnerable patients may require antibiotics. The decision depends on examination, severity, underlying conditions and relevant investigations. Persistent cough may need assessment for asthma, tuberculosis or another cause rather than repeated antibiotic courses. Patients should receive symptom-care advice and clear instructions about when to return for reassessment.

Q: Why does misuse continue in India?

Dr Agrawal: Antibiotics are often obtained without a valid prescription, despite existing prescription controls. Their availability without medical authorisation should not be confused with legal over-the-counter status. Weak enforcement, leftover medicines and informal advice make self-medication easy.

Costly consultations, distant clinics and limited follow-up also influence behaviour. Doctors face crowded practices, diagnostic uncertainty and pressure from patients expecting medicine at every visit. In hospitals, broad-spectrum treatment may continue without regular review. These pressures require better access and clinical support alongside accountability.

Pharmacists have an important role in checking prescriptions, explaining treatment instructions and directing patients towards appropriate care. Refusing an unauthorised sale is more useful when accompanied by a practical referral. Public messaging should explain that recovery after taking a medicine does not prove the medicine was necessary.

Q: How can we protect advanced antibiotics?

Dr Agrawal: Carbapenems such as meropenem and polymyxins such as colistin are valuable options for selected serious infections. They should not be chosen simply because they appear stronger or more expensive. Colistin can cause significant kidney toxicity and requires careful monitoring.

WHO’s AWaRe framework groups antibiotics into Access, Watch and Reserve categories. Carbapenems are generally watch agents, while colistin and polymyxin B are reserve medicines. Hospitals need defined prescribing and review safeguards for these drugs, supported by microbiology and experienced clinical advice.

Such safeguards must allow immediate appropriate treatment in life-threatening infection. Cultures should be obtained when feasible without delaying emergency therapy, followed by reassessment as results become available. Persistent illness may require drainage of an infected collection, removal of an infected device or reconsideration of the diagnosis rather than another medicine.

Q: What is the link between antibiotics and animals and the environment?

Dr Agrawal: Many antibiotic classes used in veterinary care overlap with those important in human medicine. Treating sick animals appropriately is necessary; routine use for growth promotion or to compensate for unhygienic farming conditions is the concern. WHO recommends restricting medically important antibiotics used for growth promotion and routine disease prevention in healthy animals without a relevant diagnosis.

India prohibited the manufacture, sale and distribution of colistin and its formulations for food-producing animals, poultry, aquafarming and animal feed supplements in July 2019. Enforcement must extend through supply chains to actual farm practices. Better housing, vaccination, biosecurity and veterinary access can reduce dependence on medicines.

Resistant bacteria and their genes can spread through animal contact, food handling, manure and contaminated water. Antibiotic residues are a related but separate concern. Hospital sewage, farm runoff and pharmaceutical effluent also require oversight. Coordinating human, animal and environmental health—the One Health approach—is essential.

Q: What measures does the government need to take to curb misuse of antibiotics?

Dr Agrawal: Enforce prescription rules. Strengthen inspection of retail and online dispensing, verify prescriptions and act against repeated violations, including inappropriate access to advanced injectable antibiotics. Also, improve access to care and diagnostics. Affordable primary care, district microbiology services and reliable specimen transport can reduce self-medication and diagnostic guesswork. Restrictions must not prevent necessary treatment.

Healthcare facilities should maintain local prescribing guidance, review broad-spectrum treatment and audit antibiotic use. Smaller centres need access to shared specialist support.

It’s time to invest in prevention and oversight. Fund sanitation, vaccination, infection control, farm biosecurity and wastewater management. Track human and veterinary antibiotic use and publish progress against clear responsibilities.

Q. What role do doctors and hospitals have in reducing antibiotic misuse?

Dr Agrawal: Doctors must record the working diagnosis, antibiotic choice, dose, route and review plan. Use current guidance and local susceptibility patterns rather than habit.

Also, choose and reassess carefully. Prefer the narrowest effective treatment and use combinations only when indicated. Review empirical therapy, commonly within 48–72 hours, and narrow, change or stop it when justified. A positive culture may reflect colonisation rather than infection. Avoid unnecessary duration. Use the shortest effective evidence-based course, review intravenous-to-oral conversion and prevent prolonged surgical prophylaxis. Explain clinician-directed changes to the patient. Last but not least, communicate and prevent infection. Explain why an antibiotic is unnecessary when appropriate, provide symptom care and return precautions, and maintain hand hygiene, safe device care and environmental cleaning.

Q. What is the message you would like patients to remember?

Dr Agrawal: Do not start an antibiotic for a cold, cough, fever or loose stools based on an old prescription, a relative’s advice or an online recommendation. Also, do not demand the strongest medicine or an injection. Accept that appropriate care may involve no antibiotics after medical assessment.

Moreover, take the prescribed dose at the advised intervals and for the duration recommended. Do not share, save or extend treatment yourself. Follow revised instructions if the clinician changes or stops it after reassessment.

One must report allergies and other medicines. Breathlessness, confusion, chest pain, dehydration, worsening illness or a severe allergic reaction require prompt medical attention. Keep recommended vaccinations up to date and ask about safe disposal of unused tablets.

That is how we protect both today’s patients and those who will depend on these medicines tomorrow.