Antimicrobial resistance (AMR) has become a critical threat to global health, eroding the effectiveness of life-saving treatments and jeopardising the foundations of modern medicine. To strengthen evidence and guide policy, the World Health Organization (WHO) established the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015. It is the first global collaborative effort to standardise AMR surveillance.
The Global Antibiotic Resistance Surveillance Report 2025 draws on more than 23 million bacteriologically confirmed infections reported by 104 countries in 2023, offering adjusted global and regional estimates of resistance across 93 infection type-pathogen-antibiotic combinations and assessing the maturity of national surveillance systems.
Expanding Global Surveillance
Since its inception, GLASS participation has increased four-fold, with 104 countries, covering over 70 per cent of the global population, reporting in 2023 compared to just 25 countries in 2016. This upward trend reflects rising awareness of the importance of sharing AMR data as a collective public health good. Yet, regional gaps persist: participation remains lowest in the Americas (20 per cent) and Western Pacific (37 per cent), while South-East Asia (90.9 per cent) and East Mediterranean regions (76.2 per cent) report the highest levels. By the end of 2024, 130 countries, including three territories and areas, were enrolled in GLASS, marking substantial expansion in global engagement.
Between 2016 and 2023, the number of infections with Antimicrobial Susceptibility Test (AST) results reported to WHO per million population rose globally for most infection types. AST reports for urinary tract infections increased by a median of 26 per cent annually, for bloodstream infections by 20 per cent, and for gastrointestinal infections by 11.4 per cent. These increases suggest growing surveillance capacity and broader inclusion of healthcare facilities. However, coverage of urogenital gonorrhoea infections remains low.
However, less than half of the reporting countries have established all WHO-recommended surveillance components, and the global score for data completeness remains only 53.8 per cent. Sub-Saharan Africa, Central Asia, and Latin America still face major diagnostic and data coverage gaps, underscoring the need for strengthened digital and laboratory infrastructure.
Global Resistance Levels and Regional Variation
In 2023, about one in six bacterial infections worldwide were resistant to antibiotics, with urinary tract infections being the most affected (1 in 3), followed by bloodstream infections (1 in 6). Gastrointestinal infections showed resistance in 1 in 15 cases and urogenital gonorrhoea in 1 in 125 cases. Resistance was highest in South-East Asia and the Eastern Mediterranean region (1 in three infections), followed by Africa (1 in 5), while Europe and the Western Pacific showed lower levels. The global median was 17.2 per cent.
Analysis of 93 infection type-pathogen-antibiotic combinations reveal widespread resistance to essential first-choice, second-choice, and last-resort antibiotics through substantial regional and pathogen-specific differences. Among the bloodstream infections, Gram-negative bacteria, such as Escherichia coli and Klebsiella pneumoniae, are resistant to fluoroquinolones and third-generation cephalosporins—the first-choice treatment for these infections. Globally, resistance to third-generation cephalosporins was 44.8 per cent for E. coli and 55.2 per cent for K. pneumoniae, exceeding 70 per cent in parts of the African region.
Resistance to carbapenems, a key group of broad-spectrum ‘Watch’ antibiotics, reached 54.3 per cent in Acinetobacter species, while K. pneumoniae bloodstream infections resistant to carbapenems were reported at 41.2 per cent in the South-East Asia region. Methicillin-resistant Staphylococcus aureus (MRSA) continued to pose major challenges, with global resistance in bloodstream infections at 27.1 per cent and the highest levels, 50.3 per cent, in the Eastern Mediterranean region. Non-typhoidal Salmonella bloodstream infections showed 18 per cent global resistance to ciprofloxacin, peaking at 36.2 per cent in the European region.
In gastrointestinal infections, fluoroquinolone resistance in Shigella species was reported at 29.7 per cent globally, but reached an alarming 75.5 per cent in the South-East Asia region. For urinary tract infections, resistance among E. coli and K. pneumoniae to third-generation cephalosporins, fluoroquinolones, and cotrimoxazole exceeded 30 per cent globally. Neisseria gonorrhoeae showed near-universal fluoroquinolone resistance at 75 per cent and although ceftriaxone resistance remained low at 0.3 per cent, its emergence, particularly in the Eastern Mediterranean region at 2.5 per cent, threatens the last effective empirical treatment for gonorrhoea.
Rising Threat from Gram-negative Pathogens
Between 2018 and 2023, resistance increased in 40 per cent of pathogen-antibiotic combinations, with annual rise between 5 per cent and 15 per cent. Increasing resistance to ‘Watch’ antibiotics, particularly carbapenems and fluoroquinolones, among E. coli, K. pneumoniae, Acinetobacter spp., and Salmonella spp., is a growing concern. These antibiotics are essential for treating severe infections, and rising AMR is limiting empirical therapeutic choices and driving a shift from oral to intravenous treatments, including greater reliance on second-choice and last-resort antibiotics.
Carbapenem-resistant K. pneumoniae and Acinetobacter spp. are associated with fatality rates exceeding 30 per cent. Third-generation cephalosporin-resistant E. coli and MRSA, though less lethal, are characterised by high incidence and morbidity, contributing to over 10,000 cases and more than a year of disability per million population. The treatability of infections by carbapenem-resistant Acinetobacter spp. and E. coli remains low to moderately low, with prevention proving difficult. Rising resistance in fluoroquinolone-resistant non-typhoidal Salmonella poses additional challenges, as its transmission is widespread. The limited antibiotic development pipeline heightens the urgency for new treatment options.
Limited Surveillance and Diagnostic Capacity
Countries with weaker AMR surveillance report higher resistance, with a Pearson correlation coefficient, r= –0.74. This pattern may reflect both genuinely higher resistance in settings with limited capacity and biases due to data derived predominantly from tertiary hospitals treating severe cases.
[Pearson correlation coefficient, denoted as r, is a statistical measure of the strength and direction of the linear relationship between two quantitative variables. It ranges from -1 to +1, where +1 indicates a perfect positive linear relation, whereas -1 indicates a perfect negative linear relation, and 0 indicates no linear relation at all.]
In many low-resource settings, insufficient diagnostic infrastructure restricts the ability to generate representative, reliable AMR data. For instance, only 1.3 per cent of clinical the laboratories in sub-Saharan Africa perform bacteriological testing. Of these, just 18 per cent have access to automated AST. Limited access to molecular diagnostics further hampers the detection of resistance mechanisms. As a result, clinicians often rely solely on empirical treatment without the confirmation of local resistance patterns, leading to inappropriate antibiotic use and accelerating resistance. In such contexts, broad-spectrum ‘Watch’ antibiotics, such as carbapenems, are frequently prescribed pre-emptively, despite limited evidence of their effectiveness. Strengthening diagnostic and surveillance systems is, therefore, essential for generating actionable, representative data and guiding appropriate antibiotic use.
Disproportionate Impact on Low- and Middle-Income Countries
AMR disproportionately affects low and middle-income countries (LMICs) and those with fragile health systems. There is a strong inverse correlation between the universal health coverage (UHC), service coverage index, income classification, and median AMR in bloodstream infections (Pearson r = –0.77). This pattern indicates that socioeconomic inequities and weak health systems contribute to a syndemic in which AMR exacerbates existing vulnerabilities.
In LMICs, intensive care units and neonatal wards, surgical settings are increasingly affected by infections caused by carbapenem-resistant K. pneumoniae and Acinetobacter spp., where treatment options are limited. Over-reliance on broad-spectrum ‘Watch’ antibiotics has been identified as a key driver of resistance. WHO’s Global Surveillance AMU showed that ‘Access’ antibiotics (recommended as first-choice treatments) accounted for only 52.7 per cent of global antibiotic use in 2022, far below the 70 per cent target set in the 2024 United Nations General Assembly political declaration on AMR. ‘Watch’ antibiotics comprised 45.3 per cent of use, exceeding 70 per cent in nearly one-third of countries, while ‘Reserve’ antibiotics were seldom used and accounted for only 0.3 per cent use.
As resistance to affordable first-line antibiotics such as third-generation cephalosporins rises, clinicians are compelled to use carbapenems, and when these fail, they turn to ‘Reserve’ antibiotics. However, these drugs are often unaffordable, inconsistently available, and require diagnostic confirmation that is rarely feasible in resource-limited settings. Many LMICs report no use of ‘Reserve’ antibiotics, not due to lack of clinical need, but because of systemic barriers to access.
Priorities for Global Action
The 2025 GLASS report emphasises that sustained global and national efforts are essential to curb AMR. Countries must overcome the barriers to data collection, improve the representativeness of surveillance, and ensure timely sharing of the data with GLASS. Participation must be expanded, particularly in underrepresented regions and core laboratory and digital infrastructure must be strengthened to close the gaps in global coverage.
Countries are urged to implement integrated, context-specific intervention packages that include infection prevention and control, water, sanitation and hygiene, vaccination, antimicrobial stewardship, and strengthening of laboratory services. Resistance trends in Gram-negative pathogens necessitates urgent action to reduce the use of ‘Watch’ antibiotics and increase ‘Access’ antibiotics to 70 per cent by 2030, in accordance with the 2024 UN political declaration on AMR. Research and development of new antibiotics particularly against the carbapenem-resistant pathogens, must be prioritised.
To ensure accurate surveillance, countries must integrate AMR monitoring into routine clinical practice, develop nationally representative systems, strengthen diagnostic capacity, and invest in robust digital information platforms. By 2030, at least 80 per cent of the countries are expected to achieve quality-assured diagnostic capacity for bacteriology and mycology, as committed in the 2024 declaration.
Finally, addressing AMR requires strengthening of health systems, expanding universal health coverage, and equitable access to essential medicines. Global financing mechanisms, including the Pandemic Fund and global financing mechanisms, along with domestic investment, are also vital to sustain progress.
Findings of the Data Collection from India
The Global Antibiotic Resistance Surveillance Report 2025 by the WHO highlights India’s significant role in the growing global AMR crisis. India is identified as one of the biggest contributors to this alarming pattern, reflecting the country’s heavy antibiotic use, persistent infections, and limited treatment coverage. Nearly half of the articles on bloodstream infections in the report originated from China, India, and Pakistan, while 42 per cent of those on urinary tract infections were from India, Iraq, Iran, and Pakistan.
According to the report, India procured 80 per cent of the full courses of studied antibiotics, but managed to treat only 7.8 per cent of its estimated cases. The study further found that carbapenem-resistant Gram-negative bacterial infections, which are resistant to last-line antibiotics, remain a severe concern in India. Treating such infections is particularly difficult as only a small proportion of patients receive appropriate therapy.
The country faces multiple challenges in combatting AMR, including over-the-counter availability of antibiotics, overcrowded health facilities, poor sanitation, and misuse in agriculture and poultry farming. Over-prescription of antibiotics in rural clinics further aggravates the problem. Socio-economic inequalities and climate change add to the burden.
Experts suggest that improved infection prevention and control, access to clean water and sanitation, and vaccination coverage could mitigate the effects of excessive antibiotic use in low-income settings like India. The report underscores that strengthening India’s surveillance systems and ensuring rational antibiotic use are essential to curb the country’s growing AMR crisis.
Conclusion
The Global Antibiotic Resistance Surveillance Report 2025 has presented a comprehensive picture of the growing AMR crisis, revealing extensive resistance, increasing trends among key Gram-negative pathogens, and persistent inequities in surveillance and access to treatment. The report underscores that combating AMR demands coordinated global action rooted in robust surveillance, equitable access to diagnostics and medicines, and sustained political commitment. Without decisive intervention, antibiotic resistance threatens to erode decades of medical progress and compromise the effectiveness of modern healthcare worldwide.
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