Global Pediatric AMR Rises Across AWaRe Antibiotic Classes
Key Takeaways
- In this global pediatric surveillance analysis, resistance was observed across all 3 World Health Organization access, watch, and reserve (AWaRe) groups, with access antibiotics carrying the highest overall burden.
- Lower-resource countries had overall resistance ranging from 65% to 78%, while some of the sharpest recent increases were reported in higher-resource regions including North America and Europe.
- From 2018 to 2022, Klebsiella resistance to watch drugs in Africa rose from 29% to 49%, and Klebsiella resistance to reserve drugs rose from 0% to 43% in Southeast Asia and from 0% to 33% in Africa.
- By 2022, more than 55% of Acinetobacter baumannii specimens were resistant to every drug category.
- Reserve-drug resistance rose from 9% to 32% in intensive care units and from 2% to nearly 20% in emergency departments between 2004 and 2022.
Hu and colleagues conducted an observational surveillance analysis of antimicrobial resistance (AMR) using the Antimicrobial Testing Leadership and Surveillance (ATLAS) database in a JAMA Pediatrics analysis. The dataset included bacterial isolates from 106,581 children, 55% boys, across more than 80 countries between January 2004 and December 2022. Resistance trends were examined by region, medical setting, pathogen type, age group, and the World Health Organization (WHO) access, watch, and reserve (AWaRe) categories. This design allowed comparison of pediatric resistance patterns across multiple clinical contexts.
Across the study period, mean resistance was 36% (range 2%-66%) for access antibiotics, 22% (1%-47%) for watch antibiotics, and 13% (0%-30%) for reserve antibiotics. Access resistance was highest in the youngest children, whereas watch and reserve resistance peaked in adolescents. The age pattern suggested that pediatric AMR pressure differed by drug class rather than rising uniformly across childhood.
Lower-resource settings carried the heaviest overall burden, while North America and Europe were among the higher-resource regions with sharper recent increases. Klebsiella resistance rose in Africa and Southeast Asia, Acinetobacter baumannii showed the broadest resistance burden by 2022, and Staphylococcus aureus moved in the opposite direction with declining access resistance outside Southeast Asia. Reserve-drug resistance also extended beyond intensive care units, indicating that the clinical setting mattered as much as the organism.
Because the analysis was surveillance-based and observational, it described where resistance was being detected rather than why those patterns emerged. Resistant infections identified outside intensive care settings did not prove community acquisition, even if they suggested earlier encounters in children's care pathways.
The reported pattern was one of pediatric AMR varying across AWaRe class, region, age, pathogen, and care setting rather than following a single global trajectory. In the model-based outlook through 2035, access resistance may level off or ease, while watch and reserve resistance were projected to keep rising, with Acinetobacter baumannii and Southeast Asia remaining especially pressured. Overall, the analysis pointed to sustained pediatric resistance pressure concentrated differently across drug classes and clinical settings.
Clinician Questions
Which pediatric age groups had the highest resistance within the AWaRe categories?
In pediatric antimicrobial resistance within the World Health Organization access, watch, and reserve categories, access-group resistance was highest among children aged 0 to 2 years at 33%, whereas watch-group and reserve-group resistance were highest among adolescents aged 13 to 18 years at 28% for both.
What did rising reserve-antibiotic resistance outside ICUs suggest in pediatric care settings?
Rising resistance to reserve antibiotics in both intensive care units and emergency departments suggested that highly resistant infections were being encountered earlier in children's care pathways. The surveillance analysis did not show that those infections were acquired in the community.
Did any pediatric bacterial pathogen show declining resistance rather than rising resistance?
Staphylococcus aureus was the reported countertrend in pediatric AMR, with resistance to access antibiotics declining over time in every region except Southeast Asia.
What did the 2035 model project for pediatric access, watch, and reserve resistance?
Projections based on prior trends suggested that pediatric resistance to access antibiotics may level out or decrease over the next decade, while watch and reserve resistance may continue to rise. The projected burden remained especially pronounced for Acinetobacter baumannii and in Southeast Asia, and those estimates were forecasts rather than observed future data.