Biofilm-Associated Antibiotic Resistance in Indian Clinical Isolates of Klebsiella pneumoniae: A Systematic Review With a Post Hoc Meta-Analysis of blaNDM Prevalence

This review aimed to systematically examine biofilm production and antibiotic resistance in Klebsiella pneumoniae isolates from Indian health care settings. An extensive literature search was conducted across scholarly databases for studies published in the past decade reporting biofilm formation and carbapenem resistance in Indian isolates of K. pneumoniae. Studies were screened, and data were extracted from eligible studies. Ten studies met the inclusion criteria, representing diverse Indian clinical settings. For the association between biofilm formation and carbapenem resistance, only two studies met the criteria for quantitative pooling. Due to the very small number of studies, substantial methodological differences, and wide variability in effect estimates, a formal meta-analysis was not performed. Instead, a qualitative synthesis was conducted, which indicated a trend toward higher carbapenem resistance among strong biofilm producers. Separately, a post hoc meta-analysis was performed for blaNDM prevalence. Four studies contributed data to this analysis, yielding a pooled prevalence of 43% (95% CI: 30%-58%). Across studies, resistance genes were identified for 12 antibiotic classes, including carbapenemases (blaNDM and blaOXA-48), extended-spectrum β-lactamases (ESBLs) (blaCTX-M and blaTEM), aminoglycoside-modifying enzymes (rmtB and armA), and efflux pump regulators. Our results suggest an association between strong biofilm formation and carbapenem resistance in Indian K. pneumoniae isolates. The widespread presence of resistance genes across multiple antibiotic classes underscores the urgent need for surveillance and targeted infection-control strategies. The high prevalence of blaNDM among Indian clinical isolates highlights the clinical threat posed by these organisms in India.