Antibiotic resistance has usually been told as an adult story: children, the argument went, have robust immune systems and shorter exposure histories, so the crisis could wait. A new study in JAMA Pediatrics, built on more than 106,000 bacterial isolates from children in 82 countries collected over 19 years, says that comfort is misplaced: resistance is rising in pediatric infections on every continent, and in the sickest children it is rising fastest.
The analysis, led by researchers at the University of Sydney, Murdoch Children’s Research Institute, and the Chinese University of Hong Kong, examined isolates from children aged 0 to 18 collected between 2004 and 2022. More than a third of all isolates were resistant to at least one first-line, or Access, antibiotic; roughly one in five to second-line Watch drugs; and one in eight to Reserve drugs, the last-resort antibiotics that medicine keeps for infections that resist everything else.
The trend lines
Resistance increased in every global region over the study period. The gap between rich and poor countries, nearly invisible in 2004, has become a chasm. In high-income countries, resistance to first-line drugs actually fell from 48 to 29 percent while last-resort resistance rose from 9 to 25 percent; in low-income countries, first-line resistance held at 47 percent while Watch resistance climbed from 16 to 48 percent and Reserve resistance from 4 to 37 percent.
The most alarming numbers come from intensive care. Among children in ICUs, resistance to Watch antibiotics more than doubled, from 15 to 33 percent, and resistance to Reserve antibiotics more than tripled, from 9 to 32 percent. In 2022, ICU Watch resistance in low-income countries reached 56 percent for the youngest children, against 26 percent in high-income countries. Last-resort resistance also climbed in emergency departments, from 2 to about 20 percent, evidence, the authors argue, that highly resistant infections are no longer confined to intensive care and may be spreading through communities.
The pathogens of greatest concern are Gram-negative. Acinetobacter baumannii showed the highest overall resistance, with more than 55 percent of specimens resistant to every antibiotic category by 2022. Klebsiella species had the fastest-rising resistance, particularly to third- and fourth-generation cephalosporins and carbapenems, the drugs that are supposed to be the last line. One encouraging exception: Staphylococcus aureus resistance to first-line drugs declined in every region except Southeast Asia, which the authors attribute to decades of MRSA infection-control programs.
Forecasts to 2035
The study projects the trajectories forward. Carbapenem resistance in Klebsiella is expected to rise to 35 percent by 2035, and in A. baumannii to 82 percent, from 15 and 51 percent today. Southeast Asia is projected to be the worst-hit region, with 84 percent Watch resistance by 2035. The authors are careful to frame these as warning scenarios, not inevitable outcomes, extrapolations that assume current trends continue without major policy changes.
The causes are structural. In many low-income countries, antibiotics are available over the counter, sometimes in markets, with no prescription; sanitation gaps amplify spread. Children have fewer antibiotic options to begin with, and pediatric formulations of new drugs are chronically delayed. The problem is also invisible: because children beyond the neonatal period often fight off infections, the damage accumulates quietly, in sepsis cases, pneumonia, and longer hospital stays.
Why this matters
The stakes are measured in lives. The Global Burden of Disease 2021 analysis estimated about 840,000 deaths among children under five were associated with antimicrobial resistance in that year, down from 2.29 million in 1990, thanks to vaccines and better care, but still enormous. The same team’s earlier work estimated more than 3 million children died from AMR-related infections in 2022. The tension is the story: child mortality from resistant infections has been falling, yet the resistance rates in the sickest children are climbing, a fuse being lit for the next generation of pediatric medicine.
The authors recommend treating stewardship as part of a system, prevention through vaccination, infection control, timely diagnosis, and access to care, rather than a standalone last line of defense, and they call for child-friendly formulations and revised first-line treatment guidelines given how often first-line drugs now fail. They have built a free public dashboard, AMR in Kids, to explore the data by country, pathogen, and drug class. The data are imperfect, a hospital-based surveillance network, not a population census, but one author said children cannot wait for perfect data.
Sources
- Hu, Y.J., Qiu, H., Harwell, J.I., Bryant, P.A. “Childhood Antimicrobial Resistance With Global Forecasts.” JAMA Pediatrics, published online July 20, 2026. DOI: 10.1001/jamapediatrics.2026.2808
- Global Burden of Disease 2021 AMR analysis, The Lancet (2024)
- CIDRAP, July 2026; Healio, July 31, 2026; MCRI press release, July 20, 2026
- Live Science, August 5, 2026