Antibiotic resistance among critically ill children is projected to keep rising through 2035, curtailing the potential of antibiotics for sepsis and severe infections, according to a study published July 20 in JAMA Pediatrics.
Researchers analyzed 106,581 pediatric bacterial isolates collected between 2004 and 2022 from 82 countries, then forecast resistance trends to 2035:
- Carbapenem resistance among critical pathogens in children roughly doubled over the study period, from 9% to 17%, and this is projected to reach 21% by 2035.
- Resistance to third- and fourth-generation cephalosporins rose from 16% to 31% and is predicted to hit 36% by 2035.
For U.S. health systems, the figures are starker:
- Carbapenem resistance among critical pathogens in North America is projected to increase from 10% in 2021 to 50% by 2035 — one of the steepest relative increases in the study, even as absolute rates stay below those in Southeast Asia and Africa.
For the purposes of monitoring drug resistance, the World Health Organization classifies antibiotics among three categories: access, watch and reserve. Access is for first- and second-line antibiotics for common infections. Watch is for severe cases with higher resistance potential, and reserve is for last-resport antibiotics.
The threat is concentrated among the highest acuity of pediatric cases, according to the report. Resistance climbed most steeply in watch and reserve categories. Those drugs are increasingly first-line in neonatal and pediatric ICUs. Many carry limited pediatric dosing data or have never been tested in children, the authors said.
In ICUs, resistance to watch antibiotics rose from 15% to 33% over the study period. Resistance to reserve antibiotics rose from 9% to 32%. The increases were most pronounced in children up to age 2 and in cases of sepsis and respiratory infection.
Not all the trends pointed the same direction. Resistance to access antibiotics held flat or declined, which the authors tied in part to U.S. gains in infection control. For example, methicillin-resistant Staphylococcus aureus, or MRSA, infections decreased more than 50% between 2016 and 2021.
The authors said children remain underrepresented in national antimicrobial stewardship surveillance and stewardship strategies, despite distinct resistance patterns. They called for age-stratified surveillance tied directly to stewardship targeting sepsis and respiratory infections.
The study drew on the Antimicrobial Testing Leadership and Surveillance, or ATLAS, database, which the authors noted is not population-based; findings reflect a multi-national surveillance network rather than fully representative global rates.
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