Abstract
Importance
Antimicrobial resistance (AMR) threatens effective treatment of severe childhood infections, but multiregional data about pediatric AMR remain limited.
Objective
To assess geographic and temporal AMR trends among children for World Health Organization (WHO) priority pathogens using the WHO Access, Watch, and Reserve (AWaRe) antibiotic classification.
Design, Setting, and Participants
This multiregional surveillance study analyzed pediatric bacterial isolates from the Antimicrobial Testing Leadership and Surveillance (ATLAS) database between January 2004 and December 2022. The analysis included 106 581 isolates from 106 581 children aged 0 to 18 years in 82 countries. Data were analyzed from February 2024 to April 2026.
Exposures
Resistance to AWaRe-categorized antibiotics in WHO priority bacterial pathogens.
Main Outcomes and Measures
Temporal trends in resistance were evaluated using linear and nonlinear models, by geographic region, age, setting, and infection. Spatiotemporal generalized additive models were applied to estimate resistance trajectories and forecast to 2035.
Results
Of 106 581 children included in this study, 47% were aged 0 to 2 years, 35% were aged 3 to 12 years, and 18% were aged 13 to 18 years; 58 620 (55%) were male. From 2004 to 2022, pediatric AMR increased in all regions, with consistently higher resistance levels and faster growth in resource-limited settings. Resistance to any Access-group antibiotic was highest overall at a mean of 36% (range, 2%-66%), with resistance to Watch-group antibiotics at a mean of 22% (range, 1%-47%) and Reserve-group antibiotics at a mean of 13% (range, 0%-30%). Resistance to antibiotics in the Watch and Reserve groups increased most rapidly in intensive care units, wherein Watch-group antibiotic resistance increased from 15% (517/3564) to 33% (2910/8748) (
P
< .001), especially in those aged 0 to 2 years (12% [325/2649] to 32% [1257/3959];
P
< .001) and those with sepsis (15% [298/2030] to 30% [1409/4705];
P
< .001) and respiratory infections [12% [657/5324] to 29% [3311/11507];
P
< .001).
Acinetobacter baumannii
had the highest overall resistance (more than 55% in every AWaRe category), while
Klebsiella
species increased fastest, particularly to third- or fourth-generation cephalosporins and carbapenems in Southeast Asia, Eastern Europe, and the Western Pacific. Projections suggested stabilization of resistance to Access antibiotics but continued increases in resistance to antibiotics in the Watch and Reserve groups, especially in Gram-negative pathogens. By 2035, carbapenem resistance was projected to be 35% (95% uncertainty interval [UI], 29%-40%) in
Klebsiella
species and 82% (95% UI, 77%-85%) in
A baumannii
.
Conclusions and Relevance
Pediatric AMR increased in all regions across the study period, driven primarily by escalating resistance among Gram-negative pathogens responsible for sepsis and pneumonia. These trends threaten the effectiveness of empiric therapy for severe childhood infections, particularly in settings with limited alternative treatment options.