The Lancet ERCP Data Controversy Highlights The Limitations of India’s AMR Surveillance
India’s AMR surveillance network is primarily built on a few dozen tertiary-care hospitals. The problem is not the quality of data from these tertiary centres; it is the narrowness of the sample. A surveillance system built only on a few dozen largest hospitals cannot speak for the entire country
Antimicrobial resistance has once again taken centre stage in India after the publication of a recent paper in The Lancet reporting alarmingly high resistance rates among patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). While the headline numbers are scientifically accurate for this very specific group of high-risk patients, the manner in which some media platforms interpreted the data as reflective of “India’s national antibiotic resistance level” has understandably created confusion. The real issue, however, is not The Lancet paper. The real issue is India’s long-standing gap in generating truly representative national antimicrobial resistance (AMR) data. This moment should compel us to reflect on where our surveillance stands and what must change.
What The Lancet ERCP study actually examined
ERCP is a specialised diagnostic and therapeutic procedure used for diseases of the bile duct, pancreas and liver. Patients undergoing ERCP often have prolonged illness, multiple healthcare exposures and high likelihood of harbouring resistant organisms. The Lancet study evaluated pre-procedural samples from such individuals to understand colonisation with resistant bacteria. This distinction between colonisation and infection is crucial. Colonisation means the organism is present on or inside the body without causing disease; infection means it is causing clinical illness. Colonisation rates in high-risk hospitalised groups are always higher than infection rates in the general population.
The study described the presence of extended-spectrum beta-lactamase-producing bacteria, known as ESBLs, which are organisms resistant to many commonly used antibiotics. It also reported the proportion of carbapenem-resistant Enterobacterales, or CRE, which represent the most difficult-to-treat gram-negative bacteria. The resistance percentages were unquestionably high, but they were high because the cohort itself was medically complex and predisposed to colonisation. Several countries participated in the multicentric study, each contributing their own ERCP-linked datasets. What the paper showed was real and scientifically valid for this specific population. What was not valid was the leap made by some media outlets that this was “India’s national resistance rate”. No such extrapolation was ever justified.
This episode illustrates a deeper structural problem. Without a comprehensive national AMR surveillance framework that reflects tertiary, secondary and primary healthcare settings, any isolated dataset — especially one involving high-risk patients — can be misinterpreted in public discourse.
Limitations of the NCDC, ICMR surveillance networks
India’s two main antimicrobial resistance surveillance pillars are coordinated by the National Centre for Disease Control (NCDC) and the Indian Council of Medical Research (ICMR). These networks have made significant contributions over the years, but they share a fundamental limitation: they are driven primarily by a few dozen tertiary-care hospitals. Most of these institutions are large, complex, referral-level centres where antibiotic pressure and resistant organisms are naturally more prevalent. Their data is invaluable, but it cannot and does not represent the entire country.
The NCDC network oversees sentinel laboratories across the country and provides annual national antimicrobial resistance summaries. The ICMR network has built one of India’s strongest technical AMR platforms, generating high-quality data on priority pathogens and advancing laboratory capacity. Yet, both networks draw their evidence almost entirely from tertiary hospitals. The secondary and primary care levels — which together represent the true breadth of India’s healthcare delivery — remain largely outside the surveillance lens, though efforts to include secondary hospitals have recently begun.
The problem is not the quality of data from these tertiary centres; it is the narrowness of the sample. A surveillance system built only on a few dozen of India’s largest hospitals cannot speak for the entire country. Particularly so when India has a vast network of district hospitals, sub-district hospitals, community health centres and an enormous private sector that collectively manage millions of patients each year.
GLASS and how other countries contribute national data
The WHO Global Antimicrobial Resistance Surveillance System was created to harmonise AMR reporting worldwide. Countries participating in GLASS generally submit antimicrobial susceptibility testing data — AST data — generated in routine clinical microbiology laboratories. AST data represent the percentage of isolates resistant or susceptible to specific antibiotics and are the backbone of national antimicrobial resistance estimates.
Most countries contributing to GLASS use data already produced in their accredited hospital laboratories as part of routine patient care. They do not create parallel, grant-dependent systems collecting data from a tiny number of elite institutions. They extract, standardise and submit what already exists in hundreds of laboratories across their health network. This is what makes their national antimicrobial resistance pictures more representative.
India, in contrast, contributes data almost exclusively from the limited number of tertiary-care institutions included under NCDC and ICMR networks. This creates the impression — incorrect but understandable — that India’s AMR levels are among the world’s highest, because the only datasets we produce at scale come from hospitals with the sickest patients.
The untapped resource
India has one of the world’s largest networks of accredited hospitals and laboratories. NABH accreditation certifies quality systems in hospitals, and NABL accreditation certifies laboratory competence, including microbiology laboratories performing antimicrobial susceptibility testing (AST). Hundreds of NABH hospitals across the country house NABL-accredited microbiology laboratories, producing high-quality AST data every single day. These datasets already exist, already follow international quality standards and already sit on the laboratory computers in structured digital formats. Yet India’s national surveillance system does not routinely collect or integrate this enormous body of free, validated data. Instead, India continues to rely on the antimicrobial resistance (AMR) picture generated from only a few dozen hospitals, despite multiple experts — including me — raising this gap repeatedly with national authorities over more than a decade.
This is among the most surprising aspects of the Indian AMR landscape. When so many countries with far fewer accredited laboratories are able to supply their routine antimicrobial susceptibility testing data to GLASS, India, with its wide network of NABL-accredited facilities, continues to overlook this treasure trove of information.
Why the ERCP dataset cannot serve as a national estimate
The Lancet ERCP dataset is scientifically sound for its purpose. It describes colonisation in a very high-risk group undergoing an invasive procedure. But colonisation patterns in such a population cannot be used to estimate resistance levels in community populations or even in routine hospital settings. National estimates must come from a broad, representative surveillance system, not from a procedure-linked cohort. The problem is not with The Lancet paper; the problem is that India does not yet have a surveillance system capable of providing an alternative narrative grounded in comprehensive, nationwide evidence.
The way forward
India urgently needs to expand AMR surveillance beyond tertiary hospitals. Secondary hospitals must be systematically integrated, not through small pilot projects but through a sustained national programme. Primary-care centres, which cannot perform microbiology testing themselves, should refer samples to nearby NABL-accredited laboratories. Most importantly, the enormous body of antimicrobial susceptibility testing (AST) data already generated in NABH-NABL hospitals must be incorporated into national surveillance. Including these datasets would cost the country nothing while immediately giving India one of the world’s largest and most accurate AMR evidence bases.
India’s antimicrobial resistance challenge is real, but so is its surveillance opportunity. The Lancet ERCP controversy should not merely spark debate; it should become the catalyst for finally building a truly national AMR surveillance system — one that reflects the India where patients actually live, seek care and receive treatment.
Freatured image credit: NIAID/Unsplash
