Recommendations
1. Avoiding emergence. Effective interventions for rationalising antimicrobial consumption include stewardship programmes to educate healthcare personnel and prevent excessive use of Antimicrobial, awareness campaigns, as well as enhanced immunisation programmes [15]. Price policies and behavioural approaches (e.g. delayed prescriptions) are increasingly considered as potential tools to decrease unnecessary consumption [15].
2. Avoiding spread. Large scale implementation of strategies for early detection of resistant microbial infections and enhanced hospital-based care with complete course of treatment can effectively preventing and control transmission in larger population [25]. Local physicians through CME can be trained to properly consult patients to take full course of antibiotics, they can also be trained to handle resistant cases (i.e. by referring them to higher centre of care) [26], [27]. Another strategy to increase complete use of antibiotics can be implementing the five WHO principles on hand washing, coupled with goal setting, incentives or accountability [15].
3. Encouraging R & D. With limited research and development pharmaceutical industries in India have been marketing for ages old antimicrobial drugs – most of which have developed resistance and proved to be in-effective [1], [5], [28]. There is need to boost expenditure on research that will develop plants based indigenous antimicrobial drugs to prevent or cure infectious conditions [29], [30]. Also, there is need to invent newer treatment regimens that can be more effective and simultaneously more cost-effective than antibiotics use [31].  
According to several research studies, particularly the one conducted in Boston, after three billion years of bacterial evolution, the world’s infecting bacteria had almost no antibiotic resistance genes, but a half century of antibiotic use then spread many into more than a quarter of them [32]. People or animals receiving Antimicrobial as well as countries that use more Antimicrobial have been found to have more antibiotic resistant bacteria [33]. From all we know, the progression of antibiotic resistance would appear to be ultimately some cumulative function of how many bacteria have encountered an antibiotic [34].
4. Innovative policy supporting intersectoral coordination. The existing national policy on antimicrobial resistance has been formulated in 2011 [35]. Antimicrobial resistance is a serious threat to global public health that requires action across all government sectors and society and is driven by many interconnected factors [5]. Single, isolated interventions have limited impact and coordinated action is required to minimize the emergence and spread of antimicrobial resistance [1]. Therefore, it is crucial to alter the existing policy to encourage inter-sectoral coordination between different ministries concerning health like – ministry of chemical and fertilisers which regulates the pharma industry, ministry of health and family welfare which monitors the quality and cost of drugs. However existing policy do not encourage practice of inter disciplinary work. Hereby we recommend the due policy change in that will ultimately favours the inter sectoral coordination and also encourages the linkages between the existing research and development and drug procurement through proper channel. Also considering cost component, there is strong need to re-design pharmaceutical policy that will provide free and quality drugs, so that over the counter drug purchase can be controlled and this will be a greater measure to combated anti-microbial resistance.
5. Multidisciplinary approach to control progression of antibiotic resistance. Antimicrobial resistance (AMR) is a global health and development threat [5]. It requires urgent multi-sectoral action in order to achieve the Sustainable Development Goals (SDGs) [5]. To control this serious public health issue and to save human and animal lives; multi-disciplinary approaches across health care settings as well as environment and agriculture sectors are required [36].
Use of Antimicrobial in food animal production in inappropriate over dosage has aggravated the issue [8]. Also use of antimicrobial should be limited for the treatment of severely infected animals’ birds and should not be used for non-therapeutic purposes like - convert feed to muscle [37], growth promotion [38], or to cope up with load on transportation and situation of crowding and poor hygiene [37], [38]. Wherever possible other modes of preventing infection should be adopted. Third generation cephalosporins, fluoroquinolones, other antimicrobial used for controlling diseases, should be limited for treating refractory infections in individual animals [5]. Policy recommendations from FAAIR can be adopted to limit antimicrobial administration to animals only on prescription by a veterinarian [39]. To assess the human health risk and inform public health policy, quantitative data on antimicrobial use (in-depth measurements) in agriculture should be made available by pharmaceutical manufacturers, importers and end users [8], [40], [41]. Regulatory agencies should consider the ecology of antimicrobial resistance –the processes of spread and complex interactions between bacteria – both pathogens (disease causing) and non-pathogens (commensals), food animals, humans, and their environments [39]. Surveillance programs for antimicrobial resistance should be harmonized to permit integrated analysis of human and animal data [39].
6. Restrict over the counter purchase (OCT) of drugs and controlling hospital acquired infections. India has one of the highest rates of antimicrobial resistance (AMR) worldwide [42]. Despite being prescription drugs, antibiotics are commonly available over-the-counter (OTC) at retail pharmacies [42]. Further rampant urbanization and unregulated industrialization have failed to provide quality of life to the overall human population [43], resultantly most of Indians live in poverty. All these factors contribute to the lack of knowledge about proper use of medicines among urban poor population and inadequate guidance to use antibiotics by physicians.
Some of the unhygienic practices at hospitals and health care facilities also contributes to AMR due to hospital acquired infections [36]. Therefore, restricting OCT by pharmacists and a few precautions for hospital-based workers such as —practicing simple control measures such as the hand hygiene changing gloves after examining the patient, can be monumental in controlling the spread of resistant bugs, as well as hospital-acquired infections [37], [44]. There are few studies that shows that only 30 per cent of doctors and health workers do hand wash after they examine each patient [45]; this increases the spread of resistant microbes to other ill patients with poor immunity. The current policy brief therefore recommends the policy change in existing guidelines that assures the standard operating procedures are being practiced among health care workers in health care facilities that ultimately controls hospital acquired infections and spread of resistant microbes.
Figures and Tables
Figure 1. Key facts about anti-microbial resistance