This multiregional surveillance study analyzed AMR trends in 106,581 pediatric bacterial isolates (ages 0–18) from 82 countries using the ATLAS database (2004–2022), categorized by WHO AWaRe antibiotic groups, region, age, care setting, and infection type.
Pediatric AMR rose in all regions from 2004–2022; ICU Watch-group resistance doubled (15% → 33%, P<.001). By 2035, carbapenem resistance is projected at 35% (95% UI 29%–40%) for *Klebsiella* spp. and 82% (95% UI 77%–85%) for *A. baumannii*. Resistance was highest in resource-limited settings, and infants aged 0–2 saw the steepest ICU Watch-group increases (12% → 32%, P<.001).
- ATLAS is a commercial surveillance database and may not fully represent resource-limited settings where AMR is rising fastest. - Only isolates submitted to the database are analyzed — susceptibility testing and submission practices vary by country, risking selection bias. - Projections to 2035 carry wide uncertainty intervals and assume continuation of current trends.
Empiric regimens for pediatric sepsis and pneumonia — especially in ICUs and low-resource settings — are under increasing threat; clinicians should audit local resistance patterns for *Klebsiella* spp. and *A. baumannii* and anticipate shrinking carbapenem efficacy over the next decade. Stewardship efforts targeting Watch- and Reserve-group antibiotics in neonates and young infants are urgently needed.
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