What You Need to Know
NDM-CRE incidence among children more than quadrupled (IRR, 4.24) and passed KPC as the most common carbapenemase in pediatric isolates.
Infants had the highest incidence, and most children with CP-CRE had serious underlying conditions such as cardiovascular disease, neurocognitive conditions or cancers.
ICU stays (40%) and healthcare outside the United States (37%) were the most common exposures, which supports admission screening for children with prior healthcare abroad.
Across the study period, estimated national pediatric CRE incidence increased 51% (incidence rate ratio [IRR], 1.51; 95% CI, 1.22-1.88), and CP-CRE incidence increased 92% (IRR, 1.92; 95% CI, 1.25-2.99).¹ Increases in the 29-state open cohort were similar, and infants had the highest incidence rates of any pediatric age group.1
NDM-CRE incidence more than quadrupled over the study period (IRR, 4.24; 95% CI, 2.07-9.16).1 NDM surpassed KPC as the most prominent carbapenemase among pediatric isolates, and the authors identified this shift as the primary driver of rising pediatric CP-CRE incidence.1 NDM enzymes are not inhibited by avibactam, vaborbactam, or relebactam, removing several agents commonly used against KPC producers.
Risk Factors and Healthcare Exposures in Children With CP-CRE
For children with incident CP-CRE identified from January 2023 through March 2024, investigators completed medical chart reviews for 109 of 129 patients. Fourteen percent of reviewed patients had no healthcare risk factors. Among those with risk factors, 75% had an underlying medical condition.1
Condition profiles differed by age. Cardiovascular disease was the most common condition among infants and toddlers (64%), while neurocognitive conditions (49%) and malignancies (41%) predominated among older children.1
Across all age groups, the most common exposures were intensive care unit hospitalization (40%) and healthcare received outside the United States (37%).1 The authors concluded most pediatric CP-CRE cases occurred in children with serious underlying medical conditions receiving high-acuity care. Because NDM-CRE has few treatment options, they proposed admission screening for patients with prior healthcare exposure outside the United States, along with strengthened infection prevention practices.1
The CDC previously estimated approximately 12,700 CRE infections and 1,100 deaths in the United States in 2020 and has warned the rise in NDM-CRE threatens to increase those totals.3 In its 2025 analysis, the agency urged clinicians to test promptly for carbapenemase mechanisms when CRE is detected and to select therapy based on the specific resistance mechanism.2,3 CDC also flagged limited clinical laboratory capacity for carbapenemase testing, suggesting surveillance data likely underestimate the true burden.2
References
1.Rankin DA, Stahl AL, Ali M, et al; Pediatric CRE Investigation Group. Carbapenemase-producing carbapenem-resistant Enterobacterales among children in the United States, 2019-2024. J Pediatric Infect Dis Soc. Published online November 4, 2026. doi:10.1093/jpids/piag115
2.Rankin DA, Stahl A, Sabour S, et al. Changes in carbapenemase-producing carbapenem-resistant Enterobacterales, 2019 to 2023. Ann Intern Med. Published online September 23, 2025. doi:10.7326/ANNALS-25-02404
