Resistance in children's infections rose everywhere, fastest in Gram-negatives and resource-limited settings

Design

Multiregional surveillance study with spatiotemporal forecasting to 2035

Population

106,581 bacterial isolates from children aged 0–18 years in 82 countries, 2004–2022

Primary outcome

Resistance trends to WHO AWaRe antibiotic groups

Effect

ICU Watch-group resistance 15% to 33%; projected 2035 carbapenem resistance 35% (Klebsiella), 82% (A baumannii)

This surveillance study analysed 106,581 bacterial isolates, one per child, from children in 82 countries in a global surveillance database between 2004 and 2022, grouping resistance by the WHO AWaRe antibiotic categories. Almost half the children were under 3.

Resistance rose in every region, with higher levels and faster growth in resource-limited settings. Mean resistance was 36% to Access antibiotics, 22% to Watch and 13% to Reserve. In intensive care units, Watch-group resistance rose from 15% to 33%, and in children under 3 from 12% to 32%. Klebsiella species rose fastest, particularly against third- and fourth-generation cephalosporins and carbapenems in Southeast Asia, Eastern Europe and the Western Pacific. Models project carbapenem resistance of 35% in Klebsiella and 82% in Acinetobacter baumannii by 2035.

For paediatricians in India this describes the ward many already work on, where empirical cephalosporins fail in neonatal and paediatric sepsis. The data come from a surveillance network of submitted isolates rather than a population sample, and forecasts carry uncertainty. The direction is consistent with other sources.

• Base empirical choices for severe sepsis and pneumonia on your own unit's antibiogram, reviewed at least yearly.
• Send cultures before the first antibiotic dose wherever possible, so therapy can be narrowed.
• Use Access-group antibiotics first for common community infections, keeping Watch and Reserve drugs for where they are needed.
• Review every Watch or Reserve prescription at 48 to 72 hours against culture results.
• Expect carbapenem-resistant Klebsiella in intensive care; infection control measures matter as much as drug choice.

Why it matters

It suggests empirical cephalosporins and carbapenems in sick children will keep losing ground over the next decade.

Don't overread it

Isolates were submitted to a surveillance network, not sampled from whole populations, and the 2035 figures are model projections.

The statistics, in plain English

A 95% uncertainty interval of 29% to 40% for Klebsiella carbapenem resistance in 2035 is the range the model considers plausible. Projections assume current trends continue; changes in prescribing or infection control could alter them.

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