Global Study Finds Rising Antimicrobial Resistance in Children

A new global surveillance study has found that antimicrobial resistance (AMR) in children rose across all regions from 2004 to 2022, with the steepest increases in resource-limited settings, intensive care units, and children younger than 3 years.¹ The findings, published July 20 in JAMA Pediatrics, forecast continued increases in resistance to Watch- and Reserve-group antibiotics through 2035, driven largely by Gram-negative pathogens.¹

Researchers analyzed 106,581 isolates from 106,581 children aged 0 to 18 years across 82 countries using the Antimicrobial Testing Leadership and Surveillance database, applying the World Health Organization's Access, Watch, and Reserve (AWaRe) antibiotic classification system.²¹ Nearly half of participants, 47%, were 0 to 2 years old, and 55% were male.¹

JAMA Pediatrics study of more than 100,000 isolates forecasts resistance trends through 2035

Resistance to Access-group antibiotics, first-line agents for common infections, was highest overall at a mean of 36%, compared with 22% for Watch-group antibiotics and 13% for Reserve-group antibiotics, those reserved for multidrug-resistant infections.¹ In intensive care units, Watch-group resistance more than doubled, rising from 15% to 33% over the study period, with the sharpest increase among children aged 0 to 2 years, from 12% to 32%.¹ Resistance also rose substantially in children with sepsis, from 15% to 30%, and respiratory infections, from 12% to 29%.¹

Acinetobacter baumannii carried the highest overall resistance among the pathogens studied, exceeding 55% across every AWaRe category by 2022.¹ Klebsiella species showed the fastest resistance growth, particularly to third- and fourth-generation cephalosporins and carbapenems in Southeast Asia, Eastern Europe, and the Western Pacific.¹ Resistance disparities between high- and low-income countries widened considerably over the study period, particularly in children aged 0 to 2 years.¹

First author Yanhong Jessika Hu, MD, PhD, MPH, and colleagues noted that their findings were “broadly comparable with the WHO’s Global Antimicrobial Resistance and Use Surveillance System (GLASS) 2022 country ranges (cephalosporin resistance, 33%-100%; carbapenem, 23%-100%), with lower pediatric point estimates expected given case-mix and setting.” They added that the “projections align with those of WHO models predicting disproportionate increases in multidrug-resistant infections in resource-limited settings, where children face the dual problems of high AMR and limited access to effective antibiotics.”

“These results have clear policy and practice implications. Children remain underrepresented in global AMR strategies despite distinct resistance patterns. Our findings highlight the need for tailored AMS, targeting sepsis and respiratory infections, especially in settings with potentially weaker oversight (eg, emergency departments),” Hu et al wrote.

Forecast Points to Continued Rise Through 2035

Researchers used spatiotemporal models to project resistance trends forward to 2035.¹ Resistance to Access antibiotics is projected to stabilize or decline, but resistance to Watch and Reserve antibiotics is expected to keep climbing, especially among Gram-negative pathogens, part of a broader trend of rising carbapenem-resistant infections already being tracked in adult populations.¹ By 2035, carbapenem resistance is projected to reach 35% in Klebsiella species and 82% in A baumannii, both substantial increases from current levels of 15% and 51%, respectively.¹

The study's authors noted several limitations, including that the surveillance database is not population-based and may be subject to site-selection bias, and that forecasts assume current trends continue without accounting for future changes in stewardship, treatment, or health system disruption.¹ To improve data access, the authors developed an interactive platform called AMR in Kids to support surveillance and country-level analysis, particularly in high-burden, low-resource settings.¹

The authors said children remain underrepresented in global AMR strategies despite showing distinct resistance patterns from adults, and called for antimicrobial stewardship efforts tailored to sepsis and respiratory infections, particularly in settings like emergency departments where oversight may be weaker.¹ The findings add to a summer of AMR-focused coverage, including efforts to accelerate discovery of new antibiotics against WHO priority pathogens. The study was funded by an impact award from the Wellcome-funded AMR Surveillance Open Data Re-use Challenge.¹

References

1. Hu YJ, Qiu H, Harwell JI, et al; Bryant PA. Childhood antimicrobial resistance with global forecasts. JAMA Pediatr. Published online July 20, 2026. doi:10.1001/jamapediatrics.2026.2808

2. World Health Organization. The WHO AWaRe (Access, Watch, Reserve) antibiotic book. Updated December 9, 2022. Accessed July 28, 2026. https://www.who.int/publications/i/item/9789240062382