J. Microbiol. Infect. Dis., (2026), Vol. 16(2): 101–106

Research Article

10.5455/JMID.2026.v16.i2.6

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Clinical practices and treatment preferences of meropenem in the management of multidrug-resistant infections in Indian settings

Manjula Suresh^* and Krishna Kumar Manjunath

Department of Medical Services, Micro Labs Limited, Bangalore, India

*Corresponding Author: Manjula Suresh. Department of Medical Services, Micro Labs Limited, Bangalore, India.
Email: drmanjulas [at] gmail.com

Submitted: 16/12/2025 Revised: 14/04/2026 Accepted: 28/04/2026 Published: 01/06/2026

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ABSTRACT

Background: Antimicrobial resistance, particularly due to multidrug-resistant (MDR) gram-negative pathogens, poses a major therapeutic challenge in India. Despite several clinical studies on the effectiveness of meropenem in various infections, there is a dearth of studies among clinicians.

Aim: To evaluate expert opinion on the clinical use of meropenem in the management of MDR infections in Indian clinical settings.

Methods: This cross-sectional study employed a 23-item, multiple-choice questionnaire to gather expert opinions from clinicians with MDR management experience in Indian settings. The questionnaire covered current practices, clinical observations, and perceived efficacy of meropenem for managing MDR infections. Descriptive statistics summarize the data, with categorical variables shown as percentages.

Results: This study included 412 respondents. Approximately 40% of clinicians reported that 21%–30% of patients with infections preferred meropenem. The majority of participants (72.82%) reported a preference for meropenem in meningitis, ventilator-associated pneumonia (VAP), and bloodstream infections. Nearly 81% of clinicians indicated that meropenem was the preferred drug of choice for treating gram-negative MDR pathogens. More than half of the participants (51.7%) reported that their preferred intravenous dose of meropenem was 1 g administered in two to three divided doses for treating MDR, extensively drug-resistant, or pandrug-resistant infections, while 46% preferred a dose of 2 g in two to three divided doses. Most participants (60.92%) indicated a preference for meropenem–sulbactam in complex infections such as complicated intra-abdominal infections, meningitis, and complicated urinary tract infections (cUTIs).

Conclusion: This study highlights the widespread use of meropenem in the management of severe MDR infections, particularly meningitis, VAP, and bloodstream infections. Meropenem remains the preferred agent for gram-negative MDR pathogens, with most clinicians favoring standard intravenous dosing of 1–2 g in divided doses. Its frequent use in cUTIs and its preference for meropenem–sulbactam in complex infections further underscore its clinical importance.

Keywords: Antimicrobial resistance, Infections, Meningitis, Meropenem, Multidrug-resistant.

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Introduction

Antibiotics remain a cornerstone of modern medical practice for bacterial infection treatment. However, their widespread and often inappropriate use has substantially contributed to the escalating burden of antimicrobial resistance (AMR) (Atta et al., 2024). AMR has emerged as a major global public health challenge, compromising the effective management of infectious diseases. It has been projected that AMR could account for up to 10 million deaths annually worldwide by 2050 if current trends persist (Pulingam et al., 2022). The 2022 Global AMR and Use Surveillance System report further underscores the alarming resistance rates observed among commonly encountered bacterial pathogens (Antimicrobial resistance, 2025).

The impact of AMR is more pronounced in low- and middle-income countries, including India, where the problem is exacerbated by high antimicrobial consumption, limited regulatory oversight, and variable infection prevention and control practices (Bhattacharjee et al., 2025). India bears a substantial AMR burden and was reported to have the 57th highest age-standardized mortality rate associated with AMR in 2021 (Institute for Health Metrics and Evaluation, 2024). These factors pose a serious threat to effective infection management and public health outcomes.

Multidrug-resistant (MDR) infections represent a critical subset within the broader context of AMR and are associated with increased morbidity, mortality, prolonged hospital stays, and higher health care costs. The World Health Organization has recognized the emergence and spread of MDR bacterial pathogens as a major global health concern (Kumar et al., 2013). MDR is defined as resistance to at least one antimicrobial agent in 3 or more categories. Extensively drug-resistant (XDR) organisms remain susceptible to only one or two antimicrobial classes, whereas pandrug-resistant (PDR) organisms exhibit resistance to all available antimicrobial agents (Tanwar et al., 2014). The increasing prevalence of MDR, XDR, and PDR pathogens has necessitated greater reliance on last-line antimicrobial agents, particularly carbapenems, for the management of severe and life-threatening infections.

Meropenem, a broad-spectrum carbapenem antibiotic, plays a pivotal role in treating infections caused by resistant bacterial pathogens. As a β-lactam antibiotic, meropenem exerts its bactericidal effect by inhibiting bacterial cell wall synthesis (Nicolau, 2008). It demonstrates potent activity against several gram-positive, gram-negative, and anaerobic organisms and is particularly effective against resistant gram-negative bacteria. Its antimicrobial spectrum includes clinically important pathogens such as Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii, making it a key therapeutic option in settings where alternative treatments are limited (Steffens et al., 2021; Grewal, 2024).

Despite its widespread clinical use, clinical practices, dosing preferences, and perceived outcomes of meropenem use among clinicians in India remain limited. Therefore, the present study aimed to assess clinician-reported practices and opinions regarding the use of meropenem in the management of antibiotic-resistant infections, with a specific focus on MDR, XDR, and PDR pathogens in Indian clinical settings.

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Materials and Methods

A cross-sectional study was conducted among clinicians specializing in managing MDR infections in major Indian cities from June 2024 to December 2024.

Questionnaire

The questionnaire booklet titled MEROTRACK (Clinical Perspectives on Anti-Infectives and the Role of Meropenem) was sent to the doctors who were interested in participating in this study. The 23-item questionnaire explored key aspects, including clinical practices, treatment preferences, and perceived efficacy of meropenem in MDR management. Reliability, as determined by a split-half test (coefficient alpha), was adequate but should be improved in future versions of the questionnaire. A study of criterion validity was undertaken to test the questionnaire and develop methods of testing the validity of measures of physicians’ perspectives. However, the extraneous variables in this include the clinician’s experience and the use of newer drugs. The two criteria used were the perspectives of the doctors from the clinical practice and the assessment of an external assessor and statistician.

Participants

A convenient sampling technique was used, and an invitation was sent to 450 clinicians from various specialties, intensivists, infectious disease specialists, and general physicians who have expertise and ≥3 years of clinical experience in treating MDR in both ICU and non-ICU settings across India in the month of March 2024 for participation in this Indian survey. Approximately 412 clinicians from major cities of all Indian states, representing the geographical distribution, shared their willingness to participate and provide necessary data. Clinicians were instructed to complete the questionnaire independently without consulting their colleagues. Written informed consent was obtained from each participant before the study began.

Statistical analysis

Data were analyzed using descriptive statistics. For multiple-response (“select all that apply”) questions, percentages were calculated per respondent based on the total number of respondents for each item. As respondents could select more than one option, the totals may exceed 100%. This approach was applied consistently across all figures and tables. Categorical variables were presented as percentages to provide a clear understanding of their distribution. The frequency of occurrence and the corresponding percentage represent the distribution of each variable. Tables were generated using Microsoft Excel (version 2409, build 16.0.18025.20030) to present the findings in a structured format.

Ethical approval

The study was conducted in accordance with the Bangalore Ethics, an independent ethics committee recognized by the Indian Regulatory Authority, the Drug Controller General of India.

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Results

The study included 412 clinicians, and approximately 27% reported that the leading cause of healthcare-associated infections in hospitals is insufficient hand hygiene practices. Approximately 28% of clinicians in the Indian context opined that the most significant barrier to effective infection control programs is the lack of trained health care professionals. Approximately 73.54% of the respondents selected “all of the above,” indicating that a combination of factors drives the emergence of MDR organisms in India. Individually, 13.83% of the respondents identified unregulated over-the-counter sales and inappropriate prescription of antibiotics, 7.77% reported inadequate infection prevention and control practices (including poor hand hygiene and lack of isolation protocols), and 4.85% attributed it to the widespread use of antibiotics for growth promotion and disease prevention in livestock. A significant proportion of participants (72%) responded that the challenges faced by antimicrobial stewardship programs in India are the lack of standardized treatment protocols across different states, insufficient laboratory support for antibiotic sensitivity testing, and the over-the-counter, unregulated sale of antibiotics. Approximately 43% of the participants reported that pathogens (MDR, XDR, or PDR) were commonly observed in the 46-to 60-year age group.

Approximately 35% of the clinicians stated that respiratory tract infections are the most commonly encountered MDR organisms. Approximately 46% of the respondents reported that P. aeruginosa, K. pneumoniae, A. baumannii, E. coli, and Staphylococcus aureus are MDR, XDR, or PDR pathogens that are often seen in clinical practice. According to 35% of the respondents, penicillin has the highest rate of resistance. The cornerstone strategy for preventing the spread of antibiotic resistance in healthcare settings is the isolation of patients with drug-resistant infections, as reported by 42% of clinicians, while 32% reported that frequent changing of antibiotics was the cornerstone strategy. As reported by 47% of the respondents, approximately 11%–20% of patients in routine clinical settings experience XDR or PDR infections, whereas 34% of respondents estimated the proportion to be <10%, indicating variability in clinician-reported burden across settings. Approximately 40% of clinicians reported preferring meropenem in approximately 21%–30% of patients with suspected or confirmed MDR, XDR, or PDR infections (Table 1).

The majority of participants (72.82%) reported that they preferred meropenem for meningitis, ventilator-associated pneumonia (VAP), and bloodstream infections (Fig. 1). Almost 81% of clinicians indicated that meropenem is the preferred drug of choice for treating gram-negative MDR pathogens. More than half of the participants (52%) reported that the preferred dose of intravenous meropenem for treating most MDR, XDR, or PDR infections was 1 g administered in two to three divided doses, while 46% reported a preferred dose of 2 g in two to three divided doses (Table 2). Clinician-reported estimates of clinical response to intravenous meropenem showed variability, with 38.59% of respondents reporting that 41%–50% of patients with MDR, XDR, or PDR infections achieved clinical improvement, while 35.68% reported response rates of 21%–30%. Fewer clinicians reported lower response rates (11%–20%: 19.42%; <10%: 5.83%), indicating heterogeneity in perceived treatment outcomes.

Approximately 35% of the participants stated that 21%–30% of patients with sepsis are treated every month. Approximately 60% of the participants reported that they encounter carbapenem-resistant Enterobacteriaceae only occasionally in their clinical practice. Approximately 37% of clinicians reported using meropenem in 11%–25% of their patients with complicated urinary tract infections (cUTIs), while 34% reported using meropenem in 26%–50% of such patients (Table 3).

Approximately 37% of the participants indicated that they prefer meropenem in 26%–50% of patients with nosocomial pneumonia. Nearly 37.14% of respondents reported that they prefer meropenem when clinically indicated in approximately 26%–50% of patients with nosocomial pneumonia, while smaller proportions reported use in 11%–25% (29.85%), <10% (13.35%), and 51%–75% (19.17%). The majority of participants (60.92%) indicated that they prefer meropenem–sulbactam for conditions such as complicated intra-abdominal infections, meningitis, and cUTI (Table 4).

Table 1. Distribution of responses on the preference for meropenem use in clinical practice when indicated for infections.

Fig 1. Distribution of responses to clinician-reported indications for meropenem use in clinical practice.

Table 2. Distribution of responses on the preference of IV meropenem dosage to treat most MDR, XDR, or PDR infections.

Table 3. Distribution of responses on the proportion of patients with complicated cUTI in whom meropenem is preferred when indicated.

Table 4. Distribution of responses to meropenem + sulbactam preference in different indications.

According to 42% of clinicians, meropenem was observed to be effective against extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae. Moreover, the respondents identified multiple factors that may limit the rational use of antibiotics, with over-the-counter availability of antimicrobials without a prescription being the most commonly reported (51.94%), followed by limited access to rapid diagnostic tests (22.33%), restrictive treatment guidelines (16.5%), and patients’ preference for traditional medicine (8.74%), suggesting both system-level and behavioral contributors.

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Discussion

This study highlights the role of meropenem for treating severe bacterial infections, particularly those caused by MDR and XDR pathogens, in India. Meropenem was reported to be preferred in the management of infections in the present study. In line with this, a previous study by the current authors and Pandit et al. (2025) stated that meropenem is predominantly used for various infections, such as sepsis (73.8%), complicated intra-abdominal infections (54.96%), lower respiratory tract infections (50.8%), and urinary tract infections (48.4%) (Manjula et al., 2025; Pandit et al., 2025).

In the current survey, most clinicians preferred meropenem for meningitis, VAP, and bloodstream infections. Baldwin et al. (2008) reported that meropenem is the only carbapenem approved for bacterial meningitis (Baldwin et al., 2008). In VAP, Hurst and Lamb (2000) demonstrated that meropenem is significantly more effective than ceftazidime-based treatments in nosocomial lower respiratory tract infections (Hurst and Lamb, 2000). Mohr (2008) highlighted meropenem’s effectiveness against ESBL-producing bacteria, making it particularly valuable in serious systemic infections (Mohr, 2008). Patel et al. (2010) concluded that meropenem is preferred as an appropriate empiric antibiotic choice for gram-negative bloodstream infections in Indian settings (Patel et al., 2010).

Meropenem was the preferred drug of choice for treating Gram-negative MDR pathogens. Similar results were shown in an Indian study, which found that 77% of clinicians indicated meropenem as their preferred treatment for Gram-negative MDR pathogens (Manjula et al., 2025). Jones et al. (2002) demonstrated that meropenem is the preferred drug for treating gram-negative MDR pathogens in India due to its high efficacy (99.1% susceptibility) compared with other antimicrobials (Jones et al., 2002).

The present survey reported that the preferred intravenous meropenem dose was 1 g administered in two to three divided doses for most MDR, XDR, or PDR infections. The Infectious Diseases Society of America recommends 1 g intravenous every 8 hours for standard meropenem regimens, with adjustments based on clinical severity and local susceptibility patterns (Tamma et al., 2024). Pharmacokinetic evidence indicates that 1 g meropenem intravenously every 8 hours, especially when administered as an extended infusion, achieves target drug exposure against Gram-negative organisms in severe sepsis and septic shock (Kothekar et al., 2020). The majority of participants in the current study indicated the use of meropenem in patients with cUTIs. Similarly, Lopatkin et al. (1999) reported an 88.9% bacteriological efficacy of meropenem for cUTIs (Lopatkin et al., 1999). Sivanandy et al. (2024) and identified meropenem as having the highest cure rate, at 91.4%, among treatments for cUTIs (Sivanandy et al., 2024).

In the present study, a majority of participants (60.92%) reported a preference for meropenem–sulbactam across multiple clinical indications, including complicated intra-abdominal infections, meningitis, and cUTIs, as indicated by the selection of “all of the above,” suggesting a broad-spectrum perceived utility of this combination. Similarly, a cross-sectional study by the current authors reported that 43% of clinicians preferred meropenem–sulbactam for the treatment of complicated intra-abdominal infections, meningitis, and cUTI (Manjula et al., 2025). Wiseman et al. (1995) concluded that meropenem is effective in treating intra-abdominal infections, meningitis, and urinary tract infections, with efficacy comparable to other treatment options (Wiseman et al., 1995).

The key strength of this study lies in its large and diverse clinician sample, which provides a comprehensive overview of clinical practices and treatment preferences for meropenem in the management of MDR infections across Indian settings. The survey offers valuable insights into various risk factors for MDR, preferred clinical indications, dosing practices, and treatment outcomes in routine clinical practice. Furthermore, the inclusion of resistance-related context enhances the clinical relevance of the findings. However, this study has several limitations. As a survey-based analysis, it relies on self-reported clinician responses, which may be influenced by recall and response biases, as well as selection and social desirability biases. The study did not capture patient-level clinical or microbiological outcomes, which limited the ability to link prescribing patterns with objective treatment effectiveness. In addition, regional variations in resistance patterns, institutional antimicrobial stewardship practices, and long-term outcomes were not assessed, which constrains broader interpretability.

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Conclusion

This study describes clinicians’ reported treatment preferences for meropenem in the management of infections caused by MDROs. Meropenem is commonly used for indications such as meningitis, ventilator-associated pneumonia, bloodstream infections, and cUTIs, particularly in the context of suspected or confirmed gram-negative MDR pathogens. Most respondents reported using conventional dosing regimens of 1–2 g of meropenem in 2–3 divided doses. In addition, a notable proportion of clinicians indicated a preference for combination regimens, including meropenem and sulbactam, for certain severe infection scenarios. These findings underscore the importance of generating region-specific real-world data and highlight the need for larger, multicentric studies integrating microbiological and clinical outcomes to guide Antimicrobial stewardship practices across diverse health care settings.

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Acknowledgments

We would like to thank all the clinicians who contributed to this study.

Conflict of interest

Both authors are employees of Microlabs Limited. This affiliation is disclosed as a potential conflict of interest. The study was an expert-opinion survey among clinicians, all of whom provided informed consent. No external funding was received. Therefore, no conflict of interest influenced the conduct, analysis, or reporting of the study.

Funding

None.

Authors' contributions

Both authors contributed equally to this study.

Data availability

Blinded data will be made available to the authors upon request.

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