A
patient enters a clinic with a sore throat, a mild fever, and three days of
fatigue. The clinician conducts a brief examination. No throat swab is taken.
No rapid antigen test is performed. No laboratory culture is requested. Within
four minutes, an amoxicillin prescription is written, and the encounter is
over. This sequence is not exceptional. It is, by a substantial margin, the
dominant pattern of antibiotic prescribing across the world. Between 40 and 70
percent of all antibiotic prescriptions globally are written without a
confirmed bacterial diagnosis, for conditions that are either viral in origin,
self-limiting, or for which no pathogenic organism has been identified at all
(USPTO, 2024). The consequences of this practice are not confined to the individual
patient receiving an unnecessary prescription. They are collective, cumulative,
and catastrophic, and they are now arriving at a scale that the clinical
community and the policymakers who govern it can no longer defer addressing.
Antimicrobial
resistance is among the greatest public health threats of the twenty-first
century. It is not a future risk. It is a present one, shaped in clinics,
pharmacies, and drug shops every day, by prescribers responding to patient
pressure, managing diagnostic uncertainty, and operating within systems that
provide neither the time nor the tools required to make evidence-based
decisions. This article examines the mechanisms by which unnecessary antibiotic
prescribing occurs, what the cumulative evidence establishes about its
consequences, and why South Asia, Nepal included, sits at the epicentre of a
resistance crisis that its regulatory frameworks, healthcare infrastructure,
and clinical culture are not currently equipped to manage.
The Scale of the
Problem: Numbers That Cannot Be Ignored
Antibiotics
are the most prescribed class of drugs in the world, representing a global
market of between twenty-five and thirty billion United States dollars
annually. They are also the most misused. Between 40 and 70 percent of all
antibiotic prescriptions are wrongly prescribed, dispensed for conditions in
which they have no clinical effect because no bacterial pathogen is present
(USPTO, 2024). In the United States alone, the Centers for Disease Control and
Prevention estimate that more than 60 million antibiotic prescriptions are
written annually for viral influenza, a condition for which antibiotics are
entirely ineffective. The CDC's 2025 antibiotic stewardship update reported an
overall outpatient antibiotic prescribing rate of 752 prescriptions per 1,000
patient population in 2024, noting persistent inappropriate prescribing for
respiratory conditions including acute bronchitis and viral upper respiratory
infections, and documenting that approximately 75 percent of sinusitis visits
resulted in an antibiotic prescription despite most cases of acute
uncomplicated sinusitis resolving without one (CDC, 2025).
These
figures describe one of the most heavily regulated and resource-rich health
systems in the world. In low- and middle-income countries, where regulatory
enforcement is weaker, diagnostic capacity is thinner, and patient populations
are larger, the proportions are worse. A 2024 analysis published in PMC found
that in Southeast Asia, including Bangladesh, between 20 and 50 percent of
community antibiotic use is inappropriate, with suboptimal healthcare standards
and unregulated pharmacy sales driving the excess (PMC, 2024). A nationwide
survey in Nepal found that 79 percent of patients had purchased antibiotics
over the counter without a prescription, and that 42.9 percent of patients
surveyed believed that fever, an inherently non-specific symptom that may have
viral, inflammatory, or environmental causes, could and should be treated with
antibiotics (Scientific Reports, 2021).
Why Clinicians
Prescribe What They Know They Should Not
The
clinician who prescribes an antibiotic without a bacterial diagnosis is not, in
most cases, ignorant of the guidelines. A 2025 systematic review of qualitative
studies on factors influencing physicians' antimicrobial prescribing decisions,
published in PMC, identified the most common drivers of inappropriate
prescribing as time pressure, patient or carer demand for antimicrobials,
diagnostic uncertainty, and insufficient access to rapid point-of-care testing
(PMC, 2025). The same review noted that many physicians acknowledge clinical
guidelines while simultaneously deviating from them under the combined weight
of these pressures. This is not a characterization of incompetent practice. It
is a characterization of a system that has placed prescribers in conditions
under which evidence-based restraint is structurally difficult to maintain.
Patient
pressure is measurable and consequential. A peer-reviewed experimental study
examining antibiotic prescribing decisions among hospital-based physicians
found that patient expectation for antibiotics has a statistically significant
association with prescribing behaviour, and that patients actively direct
clinical encounters toward bacterial diagnoses and antibiotic prescriptions
through priming and nudging strategies during history taking and examination
(PMC, 2022). This pressure is not overt in most cases. It manifests as the
patient who emphasizes the severity or duration of symptoms in terms that
suggest bacterial infection, or who notes that they were given antibiotics for
the same symptoms in a previous encounter. Clinicians operating under time
pressure, with limited diagnostic infrastructure, and with a professional
incentive to avoid patient dissatisfaction, respond to this pressure at rates
the evidence consistently documents as significantly higher than clinical
guidelines would sanction.
Diagnostic
uncertainty is perhaps the most clinically legitimate driver of inappropriate
prescribing, and simultaneously the one most amenable to systemic correction. A
clinician who cannot distinguish a bacterial from a viral upper respiratory
infection on clinical examination alone, because the two presentations can be
clinically indistinguishable, and who has no access to a rapid antigen test or
C-reactive protein point-of-care assay, faces a genuinely difficult decision.
The consequences of under-treating a bacterial infection are visible and
immediate. The consequences of over-treating a viral infection with an
antibiotic are invisible at the individual level, distributed across the
population, and delayed by months or years. Systems that do not provide rapid
diagnostic tools are systems that have made the wrong prescribing decision
structurally more likely. The clinical behaviour is a symptom. The system is
the disease.
The Resistance
Arithmetic: What Unnecessary Prescribing Is Producing
The
Global Research on Antimicrobial Resistance Project, whose findings were
published in The Lancet in September 2024, produced the most
comprehensive analysis of bacterial antimicrobial resistance trends yet
assembled. Its findings are unambiguous. If resistance continues to follow
historical trends from 1990 onward, bacterial antimicrobial resistance will
cause 39 million deaths between 2025 and 2050, equivalent to three deaths every
minute (Wellcome, 2024). AMR-associated deaths, in which drug-resistant
infection contributes to but does not directly cause death, could reach 169
million over the same period. The analysis found that AMR-attributable deaths
in people aged 70 and older increased by more than 80 percent between 1990 and
2021, and projects that countries in South and Southeast Asia and sub-Saharan
Africa will bear a disproportionate share of this mortality (CIDRAP, 2024).
The
economic consequences are commensurate with the clinical ones. The Center for
Global Development's 2025 analysis estimated current direct healthcare costs
associated with antimicrobial resistance at USD 66 billion per year,
representing 0.7 percent of global health expenditure. Under a
business-as-usual resistance trajectory, these costs are projected to rise to
USD 159 billion, while the global economy would be USD 1.7 trillion smaller by
2050 in an accelerated resistance scenario (Center for Global Development,
2025). The World Bank has estimated that unchecked AMR could reduce global
gross domestic product by 3.8 percent annually by 2050 and push 28 million
people into poverty. These are not projections from theoretical models with
disputed assumptions. They are conservative estimates from institutions with
strong incentives to produce credible rather than alarming figures.
The
specific mechanisms by which unnecessary antibiotic prescribing contributes to
these outcomes are well understood. Every antibiotic course, whether clinically
justified or not, creates selective pressure that favours the survival of
resistant bacterial strains. Resistance genes are then propagated through
direct transmission between individuals, through environmental pathways
including wastewater and agricultural runoff, and through the food chain via
antibiotic use in livestock. The WHO's Global Antibiotic Resistance
Surveillance Report 2025 documented rising resistance rates across multiple
pathogen and antibiotic combinations in all surveyed regions, including
increasing fluoroquinolone resistance in gonorrhea and rising carbapenem
resistance in Klebsiella pneumoniae, drugs that are among the last effective
options for treatment of the infections they target (WHO, 2025).
South Asia: Where the
Crisis is Most Acute and Least
Addressed
South
Asia is the region where the antimicrobial resistance crisis is most acute,
most consequential, and most inadequately governed. The reasons are not
difficult to identify. The region carries one of the highest burdens of
infectious disease globally, creating genuine and high clinical demand for
antimicrobials. It has among the highest rates of antibiotic consumption in the
world, driven by a combination of legitimate clinical need, inappropriate
prescribing, self-medication, and virtually unregulated over-the-counter
pharmacy sales. And it has among the weakest regulatory and stewardship
infrastructure to manage the consequences.
In
Nepal, the situation is particularly well documented and particularly stark. A
qualitative study published in the BMJ Global Health, drawing on interviews
with patients, clinicians, and drug dispensers across eastern, western, and
central Nepal, found that drug shops are the primary location where patients
engage with health services, and that over-the-counter antibiotic sales are the
norm rather than the exception (BMJ Global Health, 2021). Dispensers at drug
shops, who are frequently not licensed pharmacists and who operate under no
meaningful regulatory oversight, supply antibiotics on patient request without
diagnostic evaluation of any kind. A separate Nepalese survey found that the
majority of healthcare workers demonstrated knowledge of antibiotics and
antimicrobial resistance, meaning the problem is not one of professional
ignorance but of a system in which clinical knowledge cannot be translated into
appropriate prescribing behaviour because the structural conditions, time,
diagnostics, regulation, and enforcement do not support it (Scientific Reports,
2021).
The antibiotics
most frequently dispensed over the counter in South Asian drug shops are
broad-spectrum agents, the very antibiotics that resistance specialists most
urgently wish to preserve for severe and confirmed bacterial infections. A 2024
review published in Frontiers in Public Health found that notably higher rates
of antibacterial usage were observed in BRICS countries, with India among the
most significant consumers, and documented that about 80 percent of
antimicrobials in middle- and low-income countries are used in the community,
with between 20 and 50 percent of that use being inappropriate (Frontiers in
Public Health, 2024). The patients purchasing these antibiotics are not acting
irrationally within their own informational context. They have learned, correctly,
that visiting a drug shop is faster, cheaper, and less procedurally demanding
than visiting a healthcare facility, and that the drug shop will provide the
antibiotic the facility might have declined to prescribe after examining them.
The system has taught them this, and the system must answer for it.
Stewardship: What It
Requires and Why It Is Failing
Antimicrobial
stewardship, defined as the coordinated effort to promote appropriate
antibiotic use, is the primary global response to address the AMR crisis. Guided by the WHO’s 2015
global action plan, most nations now maintain national strategies. The United
Nations General Assembly adopted a political declaration on antimicrobial
resistance in 2024, including a target that 70 percent of antibiotics used
across sectors should come from the Access group of antibiotics, those
considered first-line and least likely to generate resistance. The distance
between these targets and current practice is vast. A 2026 analysis in PLOS
Medicine noted that clinicians routinely operate under time pressure,
diagnostic uncertainty, and patient expectations, conditions that foster
decision fatigue and reliance on trial and error and educated guesses, and that
even well-designed clinical decision support tools risk being sidelined when
implemented without complementary behavioural, organizational, and policy
interventions (PLOS Medicine, 2026).
The
stewardship framework itself is sound. The implementation is not. Barriers
documented in the peer-reviewed literature across multiple settings and health
system types include diagnostic uncertainty driven by absence of rapid
point-of-care testing, knowledge gaps and misconceptions about antimicrobial
resistance among both clinicians and patients, patient expectations that
antibiotics will be prescribed, commercial pressures on pharmacy staff whose
income is linked to sales volume, defensive prescribing linked to fear of
patient deterioration and associated liability, and absence of electronic
prescribing systems that could flag inappropriate prescriptions before they are
dispensed (PMC, 2025). In South Asian settings, add to these the near-total
absence of enforced prescription requirements for antibiotic dispensing, the
prevalence of counterfeit and substandard antibiotic formulations that fail to
achieve therapeutic concentrations and thereby accelerate resistance without
achieving clinical effect, and the political economy of pharmaceutical
distribution in which manufacturers, distributors, and dispensers all have
financial incentives that run directly against restriction of antibiotic sales.
What Evidence-Based
Action Actually Requires
The
prescription for this crisis is not complicated to describe, though it is
demanding to implement. Rapid diagnostic testing must be made available as a
first-line tool in primary care settings across South Asia, not as a specialist
or hospital resource but as a routine component of the primary care encounter.
The investment required for point-of-care testing infrastructure in
high-burden, low-resource settings is modest relative to the cost of the
resistance it would prevent. Countries that have integrated rapid antigen
testing and C-reactive protein measurement into primary care antibiotic
decision-making have demonstrated measurable reductions in inappropriate
prescribing without increases in adverse patient outcomes.
Regulatory
enforcement of prescription requirements for antibiotic dispensing must be
treated as a public health priority rather than a low-level commercial
compliance matter. In Nepal and across South Asia, the gap between the written
regulation and the practice of unregistered drug shops dispensing
broad-spectrum antibiotics on request is not a gap that more guideline
documents will close. It requires inspection, enforcement, licensing
consequences, and sustained political will of a kind that has not yet been
applied to this problem at anything approaching the scale the evidence demands.
Medical
education must explicitly address the social and psychological dynamics of
antibiotic prescribing, not only the pharmacological and microbiological ones.
Clinicians who understand that patient pressure is a documented and measurable
driver of inappropriate prescribing, and who have been trained in the
communication strategies that allow them to manage that pressure without
sacrificing patient satisfaction or relationship, prescribe more appropriately
than those who have not. This is not a soft skills addendum to clinical
training. It is a core clinical competency with direct population-level
consequences.
Conclusion: The
Post-Antibiotic Era is not a Metaphor
The
WHO has warned of a post-antibiotic era in which common infections and minor
injuries that have been treatable for decades become untreatable again. This is
not a hypothetical scenario from a distant future. Drug-resistant typhoid is
already requiring meropenem, a last-resort antibiotic, in young patients in
South Asia. Drug-resistant gonorrhea strains resistant to all available
antibiotic classes have been documented on multiple continents.
Carbapenem-resistant organisms, for which treatment options are limited to a
handful of highly toxic and extremely expensive drugs, are increasingly
prevalent in intensive care units across the region.
Every
unnecessary antibiotic prescription written today contributes, in a measurable
if individually small way, to the conditions that produce these outcomes. The
clinician who prescribes amoxicillin to satisfy the patient with a viral sore
throat is not acting maliciously. But the act is not clinically neutral, and
the cumulative effect of millions of such acts, repeated daily across every
health system in the world, is the resistance crisis the evidence has been
quantifying for two decades and which policymakers have, in the same two
decades, failed to address with the urgency its mortality projections warrant.
The
arithmetic is available to anyone who reads it. Thirty-nine million deaths
attributable to antimicrobial resistance between 2025 and 2050. One hundred and
sixty-nine million deaths in which resistance is a contributing factor. USD 66
billion per year in current direct healthcare costs, rising to USD 159 billion
under business as usual. The question is not whether the evidence is sufficient
to justify urgent action. It clearly is. The question is whether the political
will, the regulatory apparatus, the clinical culture, and the healthcare
infrastructure will be assembled in time to act on it. That is a question the
practitioners and policymakers reading this article have the capacity, though
not yet the demonstrated collective will, to answer.
