Research presented at this year’s ESCMID Global Congress 2025 highlights a steep and deadly rise in pediatric AMR cases, particularly in Southeast Asia and Africa, which together accounted for more than 1.4 million of the total deaths. Most of these fatalities were linked to the use of Watch and Reserve antibiotics, which are typically intended for limited use due to their high potential to drive resistance.
Between 2019 and 2021, antibiotic usage data showed significant increases in these high-risk categories. In Southeast Asia, Watch antibiotic use rose by 160 percent and Reserve antibiotic use by 45 percent. In Africa, Watch use increased by 126 percent while Reserve antibiotics rose by 125 percent. Globally, over 2 million of the AMR-related deaths in children were associated with Watch and Reserve antibiotic use.
Experts caution that this growing dependence on high-risk antibiotics may severely limit future treatment options. Professor Joseph Harwell, co-author of the study and senior clinical director at the Clinton Health Access Initiative, warned, “If bacteria develop resistance to these antibiotics, there will be few, if any, alternatives for treating multidrug-resistant infections.”
The study identifies several key drivers of AMR in low- and middle-income countries, including overcrowded hospitals, poor sanitation, weak infection control, limited access to diagnostic tools, and the lack of effective antimicrobial stewardship programs. Misuse and overuse of antibiotics remain widespread, often due to concerns about misdiagnosis and the absence of national surveillance systems.
To address this escalating crisis, the authors recommend implementing hospital-based antimicrobial stewardship programs in all pediatric care facilities. They also call for improved age classifications in AMR surveillance data and the development of national treatment guidelines that reflect real-time resistance patterns.
Harwell emphasized the urgent need for a coordinated response. “Addressing this issue requires urgent and coordinated action at both the regional and global levels,” he said. He called for a One Health approach to surveillance, treatment guidance, and interventions. “Mortality from resistant infections in children will continue to rise without stronger action.”
In response to the global AMR challenge, countries like the United Kingdom are adapting the World Health Organization’s AWaRe antibiotic classification to support national stewardship efforts. A new UK-specific version of the AWaRe framework was developed through expert consensus and reclassifies certain antibiotics, such as first-generation cephalosporins, to expand safe treatment options. The goal is to increase the proportion of antibiotic use from the safer Access category.
In an email interview, a spokesperson from the UK Health Security Agency stated, “The proposed 2024 UK-AWaRe classification is aligned with 81 percent of the WHO’s 2023 AWaRe classification, with 17 antibiotics differing in categorization. The most notable difference is that Amoxicillin/clavulanic acid (co-amoxiclav) remains in the Watch classification from our 2019 England-AWaRe classification, compared to Access for the WHO AWaRe classification.”
The spokesperson elaborated on the national action plan’s commitment, “By 2029, the UK is aiming to achieve 70% of total use of antibiotics from the UK-Adapted Access category across the human healthcare system to preserve efficacy.”
Together, these findings underscore the critical need for stronger antibiotic stewardship, improved surveillance, and policy adaptation across the globe to prevent further AMR-related deaths, particularly among vulnerable pediatric populations.
