Mapping the AMR Infection Landscape in Bihar: Implications for Strengthening Policy and Clinical Practice

Background: Antimicrobial resistance (AMR) poses a significant threat to public health, especially in low- and middle-income countries (LMICs), where surveillance infrastructure is underdeveloped. Bihar, India's third most populous state and one of its least-resourced states, has remained largely absent from national AMR monitoring initiatives. Methods: This study aimed to characterize the AMR infection landscape across five public tertiary care hospitals in Bihar over three years (2022-2024) and to assess the feasibility of integrating digital workflows for real-time microbiological reporting. Standardized antimicrobial susceptibility testing (AST) was performed on >48,000 urine, pus, and blood samples using CLSI guidelines. Facility-level data were digitized into an open-source AMR reporting system, enabling automated antibiogram generation. Results: The findings revealed substantial resistance: high resistance to beta-lactams, carbapenems, and fluoroquinolones across pathogens. For instance, E. coli sensitivity to nitrofurantoin varied from 86.5% at NMCH (Patna) to 44.7% at JLNMCH (Bhagalpur), while cephalosporin sensitivity in Klebsiella spp. dropped below 2% in several hospitals. MRSA prevalence exceeded 65% in two facilities, far above the national average of 47.8%. Digital integration led to a four-fold increase in culture testing in all facilities and improved data completeness and turnaround times. Spatial analysis and microbiology laboratory assessment revealed significant geographic disparities in diagnostic access, with facilities in remote districts facing delays of over four hours for basic testing. Conclusions: Our study is the first study from India to create such a broad, facility-associated AMR picture over time at a state level. Policy implications include the need for a state-level AMR surveillance dashboard, alignment of procurement with facility-specific resistance patterns, and routine stewardship audits. Clinically, this study demonstrates the utility of localized antibiograms for guiding empirical therapy in resource-limited settings. This study provides a scalable framework for embedding AMR surveillance into routine health system workflows in LMICs.