Antimicrobial resistance in children rises globally, threatening life-saving antibiotics, finds study
A global study analysing 106,581 pediatric bacterial isolates from 82 countries (2004-2022) found antimicrobial resistance (AMR) in children is rising worldwide, threatening the effectiveness of first-line and last-resort antibiotics.
The study was conducted by the University of Sydney with the Murdoch Children's Research Institute, the Clinton Health Access Initiative, and the Chinese University of Hong Kong.
Resistance was found in 36% of isolates to WHO "Access" (first-line) antibiotics, 22% to "Watch" antibiotics, and 13% to "Reserve" (last-resort) antibiotics; in intensive care units, resistance to Watch antibiotics rose from 15% to 33% and to Reserve antibiotics from 9% to 32% over the study period.
Resource-limited regions were hit hardest — resistance to Reserve antibiotics in Klebsiella species reached 33% in Africa and 43% in Southeast Asia — with newborns in intensive care, children on cancer treatment, and children aged 0-2 years identified as most vulnerable.
Approximately 840,000 deaths in children under five were associated with AMR in 2021; researchers launched an "AMR in Kids" platform to help clinicians and policymakers track resistance patterns by country, bacteria, and antibiotic class, with forecasts through 2035.
WHO AWaRe Classification of Antibiotics
The WHO AWaRe (Access, Watch, Reserve) classification, developed in 2017 by the WHO Expert Committee on Selection and Use of Essential Medicines, categorises antibiotics by their risk of driving antimicrobial resistance, guiding rational prescribing and antibiotic stewardship programmes globally, including in India.
Key Details
- Access group: narrow-spectrum, first-line antibiotics for common infections, lowest resistance-potential (e.g., amoxicillin)
- Watch group: broader-spectrum antibiotics with higher resistance potential, to be used cautiously (e.g., ciprofloxacin, third-generation cephalosporins)
- Reserve group: "last-resort" antibiotics reserved for multi-drug-resistant infections, to be used only when other options fail (e.g., colistin, carbapenems in some contexts)
- WHO recommends at least 60% of a country's antibiotic consumption should come from the Access category to curb resistance
The study frames rising resistance specifically in AWaRe terms (36% Access, 22% Watch, 13% Reserve resistance), showing that even "last-resort" Reserve antibiotics — meant to be the final line of defence — are losing effectiveness in children, a globally standardised way of measuring stewardship failure.
Antimicrobial Resistance (AMR) as a Global Health Threat
AMR occurs when bacteria, viruses, fungi, and parasites evolve to resist the drugs designed to kill them, driven substantially by antibiotic overuse and misuse in humans, animals, and agriculture. The WHO has classified AMR among the top global public health threats, given its potential to make routine infections and surgical procedures dangerous once again.
Key Details
- WHO estimates AMR was associated with approximately 1.27 million direct deaths globally in 2019, with several million more deaths where AMR played a contributory role
- India is one of the largest consumers of antibiotics globally and faces high rates of AMR, particularly in hospital-acquired infections
- The "One Health" approach — linking human health, animal health, and environmental/agricultural antibiotic use — is the globally endorsed strategy (WHO, FAO, WOAH) to tackle AMR
- Child mortality is disproportionately affected because pediatric drug options are more limited and infections in neonates/ICU patients progress rapidly
The study's finding that roughly 840,000 under-five deaths in 2021 were associated with AMR situates children as a uniquely vulnerable population within the broader global AMR burden, reinforcing why pediatric-specific surveillance (like the new "AMR in Kids" platform) is considered a policy priority.
India's National Action Plan on Antimicrobial Resistance (NAP-AMR)
India's Ministry of Health and Family Welfare released the National Action Plan on Antimicrobial Resistance (NAP-AMR) in April 2017, a five-year (2017-2021) multi-sectoral strategy submitted to the World Health Assembly, aligned with the WHO Global Action Plan on AMR (2015).
Key Details
- NAP-AMR's priority areas: improving awareness and understanding of AMR, strengthening surveillance, enhancing infection prevention and control, optimising antimicrobial use, promoting research and innovation, and strengthening India's leadership on AMR (including international collaboration)
- Implemented through the Indian Council of Medical Research's Antimicrobial Resistance Surveillance Network (ICMR-AMRSN)
- Complemented by the "Red Line" campaign, which mandates prescription-only labelling (a red line) on strip packaging of certain antibiotics to discourage over-the-counter use
- Reflects the "One Health" framework, coordinating the Ministry of Health, Ministry of Agriculture, and Ministry of Environment given antibiotic use spans human medicine, livestock, and agriculture
The global study's findings on rising pediatric AMR, especially the disproportionate burden on resource-limited regions such as parts of South Asia, are directly relevant to evaluating the effectiveness and next phase of India's NAP-AMR, particularly its surveillance and pediatric-specific stewardship components.
- Study scope: 106,581 pediatric bacterial isolates, 82 countries, 2004-2022 (University of Sydney, Murdoch Children's Research Institute, Clinton Health Access Initiative, Chinese University of Hong Kong)
- Resistance rates found: 36% (Access antibiotics), 22% (Watch antibiotics), 13% (Reserve antibiotics)
- ICU resistance trend: Watch antibiotic resistance rose from 15% to 33%; Reserve antibiotic resistance rose from 9% to 32%
- Regional peak: Reserve-antibiotic resistance in Klebsiella species reached 33% (Africa) and 43% (Southeast Asia)
- Estimated AMR-associated deaths in children under five (2021): approximately 840,000
- WHO AWaRe classification introduced: 2017; India's NAP-AMR launched: April 2017 (five-year plan, 2017-2021)
- WHO global estimate: AMR directly associated with about 1.27 million deaths worldwide in 2019