Sharon Nachman, MD, on How Pediatric AMR Forecasts Should Change Prescribing

A recent publication of a JAMA Pediatrics study forecasting rising antimicrobial resistance (AMR) analyzed 106,581 pediatric bacterial isolates from 82 countries between 2004 and 2022 and found AMR rising across all regions, with the steepest increases in resource-limited settings, ICUs, and children under 3. Using the WHO's Access, Watch, Reserve (AWaRe) classification, researchers found Access-group resistance averaged 36%, Watch-group 22%, and Reserve-group 13%, with ICU resistance to Watch-group antibiotics more than doubling (15% to 33%) and even sharper increases in sepsis and respiratory infections; Acinetobacter baumannii had the highest overall resistance (over 55% across every AWaRe category), while Klebsiella species showed the fastest growth, especially for carbapenems in Southeast Asia, Eastern Europe, and the Western Pacific.

Forecasting models project Access-antibiotic resistance will stabilize, but Watch- and Reserve-group resistance will keep climbing, with carbapenem resistance projected to reach 35% in Klebsiella and 82% in A baumannii by 2035—prompting the authors to call for stewardship efforts targeted at ICUs and respiratory/sepsis care and for closing the surveillance and clinical-trial gap that leaves children underrepresented in global AMR strategy despite showing resistance patterns distinct from adults.

Sharon Nachman, MD, is chief of the Division of Pediatric Infectious Disease at Stony Brook Children's Hospital and chair of the IMPAACT Network, which has directed pediatric and maternal HIV and tuberculosis clinical trial research for more than a decade. She has led more than 25 clinical trials in pediatric infectious disease, including as protocol chair or vice chair on 20 of them.

Nachman spoke with Contagion following the study’s forecasts in children through 2035, offering a pediatric ID specialist's perspective on what the projections mean for prescribing today.

Contagion: The study projects carbapenem resistance in Klebsiella spp could reach 35% in children globally by 2035, and A baumannii could hit 82%. As a pediatric ID specialist, what does this trajectory mean practically for empiric therapy decisions you're making today, and at what point does a resistance forecast like this actually change how you prescribe now rather than later?

Sharon Nachman, MD: First, local data matter most to the prescribing physician. Knowing the local resistance profile helps guide antibiotic treatment. The second is understanding whether the patient has traveled and when and where. Third is being aware of recent antibiotic use in the patient and their household contacts. Taken together, these factors inform current prescribing choices and will also help design the right treatments for our patients going forward.

The steepest increases in Watch- and Reserve-group resistance are concentrated in ICUs, children aged 0 to 2, and patients with sepsis and respiratory infections. What does this combination of factors tell you about where stewardship interventions need to be targeted?

Nachman: It helps to understand who is prescribing antibiotics and where. ICUs see our sickest patients and are on the front line of tracking which pathogens are circulating and what to prescribe, which is why involving infectious disease physicians and stewardship expertise in those choices matters now and will continue to matter.

Rising resistance in children with respiratory infections also means our messaging about using vaccines to prevent bacterial infections needs to be reemphasized. Recent data showing RSV monoclonal antibodies in young infants help prevent downstream bacterial infections suggest we already have new tools to use, and we should push ahead with them.

The study draws a sharp distinction between resource-limited and higher-income settings, but the data also show carbapenem resistance in A baumannii climbing steeply in North America and Western Europe, not just in Southeast Asia or Africa. How should US-based clinicians be thinking about AMR as a domestic pediatric problem, and is the field doing enough to treat it as one?

Nachman: I think about rising resistance as a truly global issue. Some pathogens may have settled into a particular location or niche, but ignoring the fact that pathogens travel with people and that we are a global community is a critical gap in developing plans to identify and treat them. What we really need is good pharmacokinetic and safety data on newer antibiotics across the lifespan so that when a drug is needed, we know the correct dose and safety profile for children, starting with our youngest and most fragile patients.

The study notes children are consistently underrepresented in AMR surveillance, in clinical trials for Reserve-group antibiotics, and in global AMR action plans despite having distinct resistance patterns from adults. From your vantage point leading a pediatric ID program, what does it actually cost children when the field defaults to adult data, and what would it take to change this?

Nachman: When therapies are approved for adults with no plan for eventual use in children, it harms them. Safety and pharmacokinetic studies need to happen in children across all ages while a treatment or antibiotic is still in phase 3 in adults. We don't need a separate phase 3 efficacy study in children, since there's no data suggesting a pathogen responds differently to an antibiotic in a child compared with an adult. What we do need is to know the correct dose based on real data rather than guesswork. Yes, these studies aren't cheap, but misdosing an antibiotic, or not having it available when needed, costs more in the long run.

What's the one antibiotic, or antibiotic class, you're most worried about losing in pediatric patients within the next decade, and why?

Nachman: There are too many choices to give this one answer. I worry about overuse of ceftriaxone and cephalosporins generally in emergency departments. These are our workhorse antibiotics, and they're too often given when a narrower-spectrum medication might have been the better choice. I also worry about the quinolone class, which is used heavily in adult patients, pushing resistance among pathogens with downstream implications for children.

Transcipt edited for clarity.

Reference
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