A nursing station in the children’s ward at Patan Hospital in Lalitpur, Nepal.

Dr Piyush Rajbhandari heads the microbiology lab at Patan Hospital in Lalitpur, Nepal. He and his team provide the hospital’s doctors with patient-specific antibiotic sensitivity and resistance data to enable them to make evidence-based decisions when prescribing antibiotics.

A view over a football match—in precious open space—and thecity of Kathmandu, Nepal beyond, as seen from the Swayambhu temple complex, an important Buddhist pilgrimage site. Rapid urbanisation and development pose hygiene and sanitation challenges and facilitate the rapid spread of illnesses. Pharmacies have proliferated in the city, but regulation and oversight have not kept pace. They are typically the first port of call for people who are unwell, and frequently dispense antibiotics without diagnostic tests or prescriptions.

A caliper being used to measure the extent to which various antibiotics (in discs) are effective against a bacterial culture from a patient in the microbiology lab at Patan Hospital in Lalitpur, Nepal. Measurements are referenced against a standard chart, and information on sensitivity and resistance will inform doctors’ decisions about which antibiotics, if any, should be prescribed.

Five year-old Aadee Poudel daubing coloured powder on the face of his father, Arjun Poudel, on the day of the Holi festival of colour at their home in Kathmandu, Nepal. At the end of 2021 Aadee was bitten by a dog and received rabies vaccinations as a precaution. The injection site became infected, leading to a long struggle with a pathogen that was found to be resistant to 12 of 13 major antibiotics. Though the boy is finally well again, Arjun says he is still small for his age as a result of the protracted illness.

Five year-old Aadee Poudel (centre) with his brother, Aarush, and mother, Santoshi, at their home in Kathmandu, Nepal. At the end of 2021 Aadee was bitten by a dog and received rabies vaccinations as a precaution. The injection site became infected, leading to a long struggle with a multidrug-resistant pathogen that was found to be resistant to 12 of 13 major antibiotics. Santoshi lost her job as a result of having to take so much time off work to care for him.

Three year-old David, who was fighting a multidrug-resistant urinary tract infection, at Patan Hospital in Lalitpur, Nepal. He was being treated with colistin, an antibiotic of last resort. According to his grandfather, he had been in hospitals for most of the past six months.

The bed where Anupama Gurung’s grandfather succumbed to an infection from multi-drug resistant Escherichia coli at the family’s home in Kathmandu, Nepal. The experience was formative in his granddaughter, Anupama Gurung’s, decision to make antimicrobial resistance (AMR) the focus of her work.

Research Associates, Anupama Gurung (left) and Ashok Chaudhary, preparing samples for PCR analysis at the Centre for Molecular Dynamics in Kathmandu, Nepal. The focus of Gurung’s work is antimicrobial resistance (AMR), which is a major but under-recognised threat to global health and food security.

Subheshwar Jadaw advising a customer at his pharmacy in Lalitpur, Nepal, as pharmacist, Malashree Thapa, takes another customer’s blood pressure. The sale of antibiotics without a prescription is widespread in Nepal and contributes to the development of antimicrobial resistance (AMR). Jadaw, who says he trained as a Community Medicine Assistant, says that pharmacies routinely advise and provide medication to customers who cannot afford to see a doctor, or who do not want to pay for and wait for diagnostic tests. He says that although he always requests that patients take a full course of antibiotics, some refuse to, and insist on purchasing fewer pills than recommended.

A fruit stall in Lalitpur, Nepal. Research by the Kathmandu Research Institute for Biological Sciences found a high prevalence of antimicrobial resistant (AMR) bacteria on fresh produce in the city. While specific sources of this are difficult to determine given the wide variety of origins and paths to market of the fresh produce available in the city, it is known, for example, that some types of fruit trees are routinely sprayed with antibiotics to control certain bacterial diseases.

Santosh Khanal (centre) and Sudeep KC, doctoral candidates at Tribhuvan University, sampling water from the Dhobi Khola, a tributary of the Bagmati River, in Kathmandu, Nepal. The two are studying the patterns and prevalence of antimicrobial resistant (AMR) bacteria and AMR genes in wastewater and river water in the Kathmandu valley. Their sampling regimen includes sewage, rivers and hospital and pharmaceutical company wastewater.

A view over an informal settlement on the Manohara River in Kathmandu, Nepal. The Manohara, which flows into the Bagmati River, which in turn meets the Ganges, is severely polluted, including with untreated sewage and hospital wastewater. Both contain antibiotic residues and AMR genes which make their way into the water table, soils and ultimately animals and humans, contributing to the phenomenon of antimicrobial resistance (AMR). Crop fields and gardens can be seen, which have periodically been flooded by the river.

Sita Gurung in front of her home in an informal settlement along the Bagmati River in Kathmandu, Nepal. Across the river, multi-storey residential and commercial buildings can be seen. The Bagmati, which flows into the Ganges, is severely polluted, including with untreated sewage and hospital wastewater. Both contain antibiotic residues which make their way into the water table, soils and ultimately animals and humans, contributing to the phenomenon of antimicrobial resistance (AMR). Sita uses water from the river in her vegetable garden.

Sita Gurung watering her vegetables with water from the Bagmati River at her home in an informal settlement along the Bagmati in Kathmandu, Nepal. The Bagmati River, which flows into the Ganges, is severely polluted, including with untreated sewage and hospital wastewater. Both contain antibiotic residues which make their way into the water table, soils and ultimately animals and humans, contributing to the phenomenon of antimicrobial resistance (AMR).

Layers at a poultry farm in Chaling on the outskirts of Bhaktapur, Nepal. As is common in Nepal, where the sale and use of veterinary antibiotics is unregulated, the owner says he has sometimes treated his chickens with antibiotics without veterinary advice. The misuse and overuse of antibiotics in poultry is a major contributing factor to the emergence of antimicrobial resistance (AMR), and to the prevalence of AMR genes in the environment.

A crate of empty poultry medication bottles, including antibiotics, purchased and used by the owner of a poultry farm in Ramkot on the western fringe of Kathmandu. As is typical, he says that when he has sick birds he first purchases antibiotics and treats the birds on the basis of past experience. Only when that fails does he consult a veterinarian. The misuse and overuse of antibiotics in poultry is a major contributing factor to the emergence of antimicrobial resistance (AMR), and to the prevalence of AMR genes in the environment.

A terraced wheat field in front of a chicken egg producer in a fast-growing mixed residential area in Ramkot on the western fringe of Kathmandu, Nepal. According to owner the farm has about 6000 birds and produces 1950 eggs per day, the majority of which are sold in the city. (The wheat field is not part of the farm.)

A customer purchasing eggs at a farm in Ramkot on the western fringe of Kathmandu, Nepal. Lack of knowledge of waiting times that should be observed between administering antibiotics and consuming meat or eggs means that produce is frequently sold before antibiotics and their residues have been fully metabolised.

Dr Nabaraj Shrestha, a veterinarian specialising in poultry, during a visit to farms in Ramkot on the western fringe of Kathmandu, Nepal.