Fighting Antimicrobial Resistance: How Nepal’s Dhulikhel Hospital Is Leading the Way

Roberto Posada, MD, second from left, attends antibiotic stewardship rounds with Nepali colleagues at Dhulikhel Hospital.

At my first meeting with the staff at Dhulikhel Hospital in Nepal, Suman Shahukhala, a pharmacist, showed me bacteria growing from a urine sample of a patient who came in very ill. The bacteria was E. coli, and it was resistant to all antibiotics available in Nepal except colistin.

Discovered in the 1940s, colistin fell out of favor in the 1980s because it caused dangerous side effects in some people, and by the 1980s there were less risky alternatives available. However, in this case the pharmacist had no option but to advise the treating physicians to use colistin, despite its serious side effects.

The next bacteria he showed me, from a different patient, was even worse. In that case the organism was resistant to all antibiotics available; there was no drug at all that could be used. That patient had little hope of recovery from their serious infection.

Antimicrobial resistance is a growing global crisis, and Nepal is no exception. The misuse and overuse of antibiotics have led to drug-resistant bacteria, making common infections harder to treat. With limited health care infrastructure and increasing infection rates, Nepal faces a serious public health threat from antimicrobial resistance. Luckily, I am privileged to partner with a dedicated team at Dhulikhel Hospital, committed to reducing antibiotic resistance,  and to keeping their patients and communities safer.

Why Antimicrobial Resistance Is a Major Concern

When antibiotics don’t work, infections last longer and become more severe. Conditions like pneumonia and urinary tract infections, which were once easily treatable, are harder to manage, leading to higher mortality rates.

Patients with drug-resistant infections often need extended hospital care, additional tests, and more expensive medications. Many medical procedures rely on antibiotics to prevent infections. When antibiotics fail, the success of surgeries and treatments like chemotherapy is at risk.

These issues put a strain on both families and Nepal’s already overburdened health care system. In addition, drug-resistant bacteria can spread quickly in hospitals and communities, endangering vulnerable groups like newborns, the elderly, and those with weakened immune systems.

How Dhulikhel Hospital Is Combating Antimicrobial Resistance

To tackle this crisis, Dhulikhel Hospital, in collaboration with the Arnhold Institute for Global Health at Mount Sinai and the AMPATH Nepal Partnership, has launched an Antimicrobial Stewardship Program. This initiative ensures responsible antibiotic use to prevent resistance while providing the best possible treatment for patients. Key strategies of the program include providing more resources to clinicians to support their decision-making and creating systems to monitor antibiotic use. The program was created by the team from Dhulikhel Hospital, with Mount Sinai experts joining as advisors as they roll it out.

As a result of the program, one new resource available to Dhulikhel’s clinicians is an antibiogram—a report used at Mount Sinai’s hospitals and many others, that tracks local antibiotic resistance patterns—to help clinicians make informed treatment decisions and monitor changes in resistance over time. Dhulikhel Hospital is also developing guidelines for treating common infections like pneumonia and urinary tract infections. These guidelines help doctors select the most effective antibiotics while avoiding unnecessary use of drugs that we need to save for complex or very serious infections. Regular training sessions are also being held for doctors, nurses, and pharmacists to promote responsible antibiotic prescribing and use.

The hospital also has started an antibiotic stewardship committee that conducts weekly hospital rounds. This team of experts—including doctors, nurses, pharmacists, and microbiologists— helps physicians choose the right antibiotic, in the right dose, for the right duration, preventing unnecessary antibiotic use and slowing down resistance development.

To monitor and regulate antibiotic use, the hospital now classifies certain powerful antibiotics as “restricted,” meaning they require approval before use. This ensures these lifesaving drugs are only prescribed when absolutely necessary, reducing the risk of resistance.

The Team Behind the Initiative

The Antimicrobial Stewardship Program at Dhulikhel Hospital was established by Prakash Sapkota, MD, and is led by Nabin Simkhada, MD, both from the Department of Internal Medicine. The team includes specialists from anesthesiology, obstetrics and gynecology, pharmacy, microbiology, and nursing. Sujan Pathak, MD, serves as the research assistant for the project. Key collaborators from Mount Sinai include myself, Roberto Posada, MD, and my colleague Mary Boyle, MD, MPH. We are both pediatric infectious disease specialists.

Why This Matters

Antimicrobial resistance is a serious threat, but with immediate action, we can slow its spread and preserve the effectiveness of lifesaving antibiotics. The Antimicrobial Stewardship Program at Dhulikhel Hospital is a crucial step toward responsible antibiotic use, improving patient outcomes, and safeguarding future generations against untreatable infections.

Roberto Posada, MD, is Professor of Pediatrics, Medical Education, and Global Health at the Icahn School of Medicine at Mount Sinai.