Global burden of bacterial antimicrobial resistance among children under 5 years 1990-2021: A systematic analysis...

Antimicrobial resistance (AMR) poses a critical threat to child health, particularly in resource-limited settings. A comprehensive assessment of the AMR-related mortality burden in children under five is needed to inform global strategies.

We conducted a secondary analysis of the Global Burden of Disease (GBD) 2021 estimates, extracting AMR-associated and AMR-attributable mortality data for children under five from 1990 to 2021, with projections to 2050. Analyses included historical trends, pathogen- and syndrome-specific burdens, and future projections under a reference scenario and two alternative scenarios. The alternative scenarios included a scenario assuming future drug development that targets Gram-negative pathogens (Gram-negative drug scenario) and a scenario assuming future improvements in health-care quality and access to appropriate antimicrobials (better care scenario).

In 2021, AMR was associated with 0.84 million (95% UI 0.64-1.04) and attributable to 0.19 million (0.14-0.24) deaths globally in children under five, reflecting a substantial decline since 1990. Substantial regional disparities persisted, with Sub-Saharan Africa bearing the highest burden. Streptococcus pneumoniae accounted for largest number of AMR-associated deaths, while Klebsiella pneumoniae accounted for largest number of AMR-attributable deaths. Bloodstream infections and lower respiratory infections accounted for the majority of AMR-related mortality. For AMR-attributable deaths, key pathogen-drug combinations included beta-lactam-resistant S. pneumoniae, methicillin-resistant Staphylococcus aureus, and carbapenem-resistant Acinetobacter baumannii. Projections to 2050 indicate a continued decline. From 2025 to 2050, the better care scenario was projected to avert an estimated 10.65 million deaths, substantially exceeding the 1.09 million deaths averted under the Gram-negative drug scenario.

Despite a declining global trend, AMR remains a pressing cause of mortality in children under five, marked by severe inequity. The persistent burden from multidrug-resistant Gram-negative pathogens underscores the need for comprehensive strategies that extend beyond antibiotic development, prioritizing improved healthcare access, infection prevention, and vaccination, especially in high-burden regions.