Resistance to reserve antibiotics, the drugs held back for infections that nothing else will treat, rose from 9 percent to 32 percent in pediatric intensive care units over roughly two decades, according to an analysis of more than 100,000 bacterial samples from children in 82 countries.
The study, published in JAMA Pediatrics and covered by CIDRAP, examined 106,581 isolates collected from patients aged 0 to 18 between 2004 and 2022. Resistance to watch antibiotics in ICUs rose over the same period from 15 percent to 33 percent.
"There's really no area of the world that isn't seeing an increase," said Penelope Bryant, PhD, MBBCh, the corresponding author and a research clinician at Murdoch Children's Research Institute in Australia.
The Part of the Finding That Coverage Keeps Dropping
There is a second result in the same paper that complicates the headline, and readers deserve it.
Resistance to access antibiotics, the narrow-spectrum first-line drugs recommended for most common infections, declined in most inpatient settings across the study period. The increases were concentrated in the watch and reserve categories, the broader-spectrum drugs meant to be held in reserve.
Overall across the full dataset, 36 percent of isolates were resistant to access drugs, 22 percent to watch drugs, and 13 percent to reserve drugs. Those categories come from the World Health Organization's classification system, which sorts antibiotics by how freely they should be used.
So the accurate description is not that resistance rose everywhere. It is that first-line resistance has been improving in hospitals while resistance to the fallback options has been climbing sharply. That is arguably a more troubling pattern than uniform decline, because it erodes the drugs available when first-line therapy fails, but it is a different claim, and it should be reported as one.
The isolates came mostly from hospital wards (47 percent) and ICUs (27 percent). The most common organisms were Staphylococcus aureus at 19 percent, Klebsiella species at 11 percent, and Escherichia coli at 10 percent.
Resistance to watch and reserve drugs was highest in children aged 0 to 2, in children with sepsis, and in those with respiratory infections. It was highest overall in Southeast Asia, Africa, and Central America. Reserve-drug resistance in Klebsiella species reached 33 percent in Africa and 43 percent in Southeast Asia.
The Projection Is an Extrapolation, Not a Forecast
The study models out to 2035, indicating that pathogens in the hardest-hit regions will see larger increases in resistance to watch and reserve antibiotics.
That figure should be read for what it is. It projects forward from observed trajectories in a surveillance dataset. It is not a validated forecast; it does not account for interventions that may be adopted between now and then, and it inherits every gap in the underlying data. Surveillance databases capture the isolates that were collected and tested, which skews toward larger hospitals and toward patients sick enough to be cultured.
Bryant framed the intent as visibility rather than alarm, arguing that childhood resistance goes largely unnoticed because people assume children past the newborn period have strong immune systems.
The authors point to concrete drivers in low- and middle-income countries, including over-the-counter and market sales of antibiotics without prescription, and weaknesses in sanitation and infection control. They also argue that high-income countries will not be insulated, given global travel.
Joseph Harwell, MD, senior clinical director at the Clinton Health Access Initiative and a study coauthor, said in a statement accompanying the research that "better data is essential, but children can't wait for perfect data."
The Contrary Evidence from US Hospitals
Two weeks before this analysis appeared, the CDC published data pointing in the opposite direction in one specific setting.
A point-prevalence survey of 13,653 patients across 218 hospitals in 10 states, published in the New England Journal of Medicine, found that about 1 in 38 hospitalized patients had at least one healthcare-associated infection on a given day in 2023, compared with 1 in 31 in 2015. Among hospitals participating in both surveys, patients in 2023 were 27 percent less likely to have such an infection, even though they were older and stayed longer. MedicalDaily reported those findings earlier this month.
These two results are not a contradiction, and presenting them as a debate would misrepresent both. They measure different things. The CDC survey counts how often US hospital patients acquire infections. The JAMA Pediatrics analysis measures how resistant the bacteria are when infections do occur in children across 82 countries, with most of the burden concentrated in resource-limited regions.
A country can have fewer hospital infections while the organisms causing the remaining ones grow harder to treat. Reading them together suggests infection prevention can work even as resistance advances, which is the case for doing both.
CDC epidemiologist Nora Chea, who led the survey, cautioned that "there were still more than half a million HAIs in 2023."
What Parents and Clinicians Should Take From This
For a parent in the United States, this study is not a reason to worry about a routine ear infection or to question a prescription your child's clinician has recommended. It is also not a reason to request a broader-spectrum antibiotic, which is closer to the opposite of what the findings support.
The useful behaviors are unglamorous. Finish courses as prescribed rather than stopping when symptoms improve or saving leftovers. Do not use antibiotics prescribed for someone else. Ask whether an antibiotic is needed at all when an illness is likely viral, and accept the answer if it is no. Keep routine vaccinations current, since preventing infection removes the need for treatment entirely.
The authors' policy recommendations focus on stewardship programs targeting the most severe pediatric infections, restricting unregulated antibiotic sales, improving sanitation and infection control, and developing more child-friendly formulations so children receive correct doses.
The team also built a public dashboard, AMR in Kids, allowing resistance to be explored by country, organism, and drug class.
The confirmed finding is that resistance to fallback antibiotics has risen sharply in pediatric ICUs globally while first-line resistance has declined in most inpatient settings. The children most affected are the youngest, the sickest, and those in resource-limited regions. The most reasonable action for households is appropriate antibiotic use and current vaccinations. The central uncertainty is whether the projected 2035 trajectory holds, which depends on decisions not yet made.
Frequently Asked Questions
What did the study actually find? Across 106,581 pediatric bacterial isolates from 82 countries between 2004 and 2022, resistance to watch and reserve antibiotics rose sharply, particularly in ICUs, while resistance to first-line access antibiotics declined in most inpatient settings.
What are access, watch, and reserve antibiotics? A World Health Organization classification. Access drugs are narrow-spectrum first-line options, while watch and reserve drugs are broader-spectrum and meant to be limited to more serious infections.
Which children were most affected? Those aged 0 to 2, children with sepsis, and children with respiratory infections. Resistance was highest overall in Southeast Asia, Africa, and Central America.
Is the 2035 projection a forecast? No. It is an extrapolation from observed trends in a surveillance database. It does not account for future interventions and inherits the limitations of the underlying data.
Does this contradict the CDC finding that US hospital infections fell? No. They measure different things. One counts how often patients acquire infections in US hospitals; the other measures how resistant bacteria are when children are infected, globally.
Should I ask for a stronger antibiotic for my child? No. Broader-spectrum use is part of what drives resistance. Ask instead whether an antibiotic is needed at all, and follow the prescribed course.
Where can I look at the data myself? The research team published a public dashboard called AMR in Kids that allows resistance to be explored by country, bacterium, and antibiotic class.
