Global Forecasts Reveal Rising Antimicrobial Resistance Threats in Children
Global pediatric antimicrobial resistance increased from 2004 to 2022 across all regions. Resistance was highest among Gram-negative pathogens, children in intensive care, those with sepsis, and resource-limited settings. By 2035, carbapenem resistance is projected to reach 35% in Klebsiella species and 82% in Acinetobacter baumannii.
KEY FINDINGS: This global pediatric surveillance study demonstrates a sustained increase in antimicrobial resistance among children, with the greatest concern involving Gram-negative pathogens, intensive care settings, sepsis cases, and resource-limited regions. Increasing resistance to Watch and Reserve antibiotics may compromise treatment options for severe childhood infections. Forecasted growth in carbapenem resistance among Klebsiella species and Acinetobacter baumannii highlights the need for strengthened antimicrobial stewardship, surveillance systems, and development of effective pediatric treatment strategies.
BACKGROUND: Antimicrobial resistance (AMR) threatens the effectiveness of antibiotic therapy for severe childhood infections, yet comprehensive pediatric AMR surveillance data across multiple regions remain limited. This study evaluated global and temporal patterns of antimicrobial resistance among children using the World Health Organization (WHO) Access, Watch, and Reserve (AWaRe) antibiotic classification framework and projected future resistance trends
DETAILS: This cross-sectional surveillance study analyzed pediatric bacterial isolates from the Antimicrobial Testing Leadership and Surveillance (ATLAS) database collected between January 2004 and December 2022. The study included 106 581 isolates from 106 581 children aged 0 to 18 years across 82 countries. Data were analyzed from February 2024 to April 2026. Resistance trends were assessed by geographic region, age group, clinical setting, infection syndrome, and pathogen type, with spatiotemporal models used to forecast resistance patterns through 2035.
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The analysis categorized antibiotics according to the WHO AWaRe framework: Access antibiotics used for first-line treatment, Watch antibiotics with higher resistance potential, and Reserve antibiotics intended for difficult-to-treat infections. The study evaluated WHO priority pathogens and examined resistance patterns among different pediatric populations, including children with sepsis and respiratory infections.
From 2004 to 2022, pediatric AMR increased across all regions, with higher resistance levels and faster increases observed in resource-limited settings. Resistance to Access-group antibiotics was highest overall, with a mean resistance of 36% (range, 2%-66%), compared with Watch-group antibiotics at a mean of 22% (range, 1%-47%) and Reserve-group antibiotics at a mean of 13% (range, 0%-30%).
Resistance to higher-tier antibiotics increased substantially in vulnerable clinical groups. In intensive care units, Watch-group resistance increased from 15% (517/3564) to 33% (2910/8748) (P < .001), particularly among children aged 0 to 2 years, where resistance increased from 12% (325/2649) to 32% (1257/3959) (P < .001). Among children with sepsis, Watch-group resistance increased from 15% (298/2030) to 30% (1409/4705) (P < .001), while Reserve-group resistance increased from 3% (16/474) to 26% (746/2824) (P < .001).
Among critical pathogens, Acinetobacter baumannii demonstrated the highest overall resistance, exceeding 55% in every AWaRe antibiotic category in 2022. Klebsiella species showed the fastest increases in resistance, particularly to third- or fourth-generation cephalosporins and carbapenems. Forecasts estimated that by 2035, carbapenem resistance would reach 35% (95% uncertainty interval [UI], 29%-40%) in Klebsiella species and 82% (95% UI, 77%-85%) in A baumannii.
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Source: Hu, Y. J., Qiu, H., Harwell, J. I., et al. Childhood Antimicrobial Resistance With Global Forecasts. JAMA Pediatrics. 2026; Published: July 20, 2026. DOI: 10.1001/jamapediatrics.2026.2808.
US Measles Cases Rise in 2026 as Outbreaks Continue Amid Declining MMR Coverage
US measles activity has increased substantially in 2026, with 2,465 confirmed cases and 38 new outbreaks reported as of August 6. Declining MMR coverage may increase community vulnerability to transmission. Maintaining high vaccination coverage remains central to preventing measles outbreaks and sustaining elimination.
KEY FINDINGS: As of August 6, 2026, the US had reported 2,465 confirmed measles cases and 38 new outbreaks, with 94% of cases outbreak-associated. The increase occurs alongside a decline in kindergarten MMR coverage to 92.5% in 2024-2025 from 95.2% in 2019-2020. CDC emphasizes that measles can spread rapidly in communities with lower vaccination coverage, while 2 doses of MMR vaccine provide 97% protection against measles.
BACKGROUND: Measles was officially eliminated in the United States in 2000 following widespread use of the measles, mumps, and rubella (MMR) vaccine. However, declining vaccination coverage and increasing global measles activity have increased opportunities for measles transmission following importation into the United States.
DETAILS: As of August 6, 2026, the Centers for Disease Control and Prevention (CDC) reported 2,465 confirmed measles cases in the United States in 2026. Of these, 2,449 cases were reported by 47 jurisdictions, while 16 cases occurred among international visitors to the United States. Thirty-eight new outbreaks had been reported during 2026.
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Overall, 94% of confirmed cases in 2026 (2,309 of 2,465) were associated with outbreaks, including 936 cases from outbreaks beginning in 2026 and 1,373 from outbreaks that began in 2025. For comparison, 2,289 confirmed cases and 48 outbreaks were reported during the full year of 2025; 90% of cases (2,066 of 2,289) were outbreak-associated.
CDC reports confirmed measles cases notified by jurisdictions as of noon on Thursdays. An outbreak is defined as 3 or more related cases. State and CDC counts may differ because jurisdictions update and publicly report their data on different schedules.
MMR vaccination coverage among US kindergartners declined from 95.2% during the 2019-2020 school year to 92.5% during the 2024-2025 school year, leaving approximately 286,000 kindergartners at risk during the 2024-2025 school year. CDC notes that communities with vaccination coverage below the 95% level are more vulnerable to measles outbreaks. The 2026 measles case count reported by CDC as of August 6, 2026, had already exceeded the total number of confirmed cases reported during all of 2025 (2,465 vs 2,289). The high proportion of outbreak-associated cases indicates sustained transmission within affected communities.
The burden of measles remains closely associated with vaccination status. CDC reports that 2 doses of MMR vaccine are 97% effective at preventing measles, while 1 dose is 93% effective. Breakthrough infections can occur, particularly during outbreaks with high levels of circulating measles virus, and account for approximately 10% of all measles infections.
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Source: CDC: Measles Cases and Outbreaks. Centers for Disease Control and Prevention (CDC). 2026; Published: August 7, 2026.
High-Quality Donor Kidneys Frequently Allocated to Adults Despite Pediatric Priority
Among deceased-donor kidneys with KDPI-10 below 35%, 23.4% were allocated to higher-priority adults. For ideal pediatric-quality kidneys, this proportion was 34.3%, with 77.5% received by multiorgan transplant recipients. KDPI-8 is unlikely to materially change pediatric access to ideal donor kidneys.
KEY FINDINGS: Despite pediatric allocation priority, a substantial proportion of high-quality donor kidneys continues to be allocated to adults with greater priority, predominantly multiorgan transplant recipients. The revised KDPI-8 calculation is not expected to materially alter the proportion of ideal pediatric-quality kidneys prioritized for children, although it changes the clinical composition of the donor pool by increasing the proportion of HCV-seropositive donors and reducing the proportion of donors after circulatory death. These findings highlight persistent limitations of KDPI-based allocation for pediatric candidates and support continued evaluation of policies that balance equity, donor-recipient matching, and long-term transplant outcomes.
BACKGROUND: Children receive allocation priority for deceased-donor kidneys with a kidney donor profile index (KDPI) <35%, although certain adult candidates retain higher priority. The recent transition from the 10-variable KDPI (KDPI-10) to the revised 8-variable KDPI (KDPI-8), which excludes donor race and hepatitis C virus (HCV) status, raised questions regarding its potential effect on pediatric access to high-quality donor kidneys.
DETAILS: This retrospective cohort study analyzed 60,587 deceased donors and their kidney recipients recorded in the Organ Procurement and Transplantation Network registry from January 1, 2018, through December 31, 2023. The investigators compared donor characteristics and kidney allocation patterns using KDPI-10 and KDPI-8. Ideal pediatric-quality donors were defined as donors with a KDPI <35%, donation after brain death, age <35 years, creatinine <=1.5 mg/dL, and no infectious risk, diabetes, or hypertension. Among kidneys from donors with KDPI-10 <35%, 23.4% were allocated to adults in categories with greater priority than pediatric candidates. Among ideal pediatric-quality kidneys, 34.3% were allocated to these higher-priority adult recipients, and 77.5% of these transplants were received by multiorgan transplant recipients. The proportion of donors meeting ideal pediatric-quality criteria was similar with KDPI-10 and KDPI-8 calculations (32.7% vs 33.5%). However, the KDPI-8 group included more Black donors (15.3% vs 9.9%) and HCV-seropositive donors (11.1% vs 3.6%) and fewer donors after circulatory death (12.7% vs 20.3%).
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Source: Sonnenberg, E. M., Amaral, S., Zhang, S., et al. Allocation of Kidney Allografts From Donors With Kidney Donor Profile Index <35% and the Impact of Kidney Donor Profile Index Revisions on Access to Transplantation for Children. American Journal of Kidney Diseases. 2026; Published: August 22, 2026. DOI: 10.1053/j.ajkd.2026.02.643.
Nationwide Recall of Cetirizine Hydrochloride Tablets USP 5 mg Due to Potential Ranitidine Cross-Contamination
Four nationwide-distributed lots of Cetirizine Hydrochloride Tablets USP 5 mg are being voluntarily recalled because of potential ranitidine cross-contamination. Patients with ranitidine hypersensitivity may be at risk for severe allergic reactions or anaphylaxis. No recall-related adverse events had been reported.
KEY FINDINGS: Unique Pharmaceutical Laboratories has initiated a voluntary nationwide recall of four lots of Cetirizine Hydrochloride Tablets USP 5 mg because of potential cross-contamination with ranitidine. The affected product was distributed nationwide in 100-count HDPE bottles under the Rising Pharma Holdings Inc. brand. Patients with hypersensitivity to ranitidine ingredients may be at risk for serious reactions, including severe hypersensitivity and life-threatening anaphylaxis. No adverse events related to the recalled product had been reported at the time of the announcement.
The recall was initiated after a pharmacy technician identified a discrepancy while counting tablets during dispensing. A product complaint described red dots and discoloration on some cetirizine tablets. The recalled lots are GY825029, GY825030, GY825031, and GY825032, each with an expiration date of 10/2028 and NDC 16571-401-10.
The manufacturer and distributor are arranging the return of the affected products. Clinicians should consider the recall when evaluating patients who may have received the affected medication and should assess and manage any suspected adverse reactions appropriately.
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Source: Unique Pharmaceutical Laboratories (A Div. of J. B. Chemicals & Pharmaceuticals Ltd.) Issues Voluntary Nationwide Recall of Cetirizine Hydrochloride Tablets USP 5 mg Due to Potential Cross Contamination with Ranitidine. FDA. Published: July 20, 2026.
Obesity, Rather Than High Body Surface Area Alone, Predicts Clinically Significant Asparaginase Toxicity During Induction Therapy for Acute Lymphoblastic Leukemia
Among 4,925 children and young adults with ALL, obesity—not high BSA alone—was the strongest predictor of clinically significant asparaginase toxicity. Patients with obesity and high BSA had the highest risk of hepatic toxicity and thromboembolism, whereas induction toxicities were not associated with increased end-of-induction MRD positivity.
KEY FINDINGS: This large multicenter analysis demonstrates that obesity-not elevated BSA alone-is the principal patient-related risk factor for clinically significant asparaginase toxicity during induction therapy for ALL. The greatest excess risk occurred in patients with both obesity and high BSA, particularly for hepatic toxicity and thromboembolic events, while pancreatitis risk was unaffected. Older age independently increased toxicity risk, especially hyperbilirubinemia. Notably, induction-phase AAT did not compromise early treatment response, as measured by EOI MRD. These findings suggest that obesity should be prioritized when identifying patients for enhanced toxicity surveillance and future preventive strategies, whereas high BSA in the absence of obesity does not appear to justify dose modification based solely on body size.
BACKGROUND: Asparaginase remains a cornerstone of induction therapy for acute lymphoblastic leukemia (ALL), but treatment-limiting toxicities frequently interrupt therapy and may compromise long-term outcomes. Previous studies have produced conflicting evidence regarding whether older age, obesity, or high body surface area (BSA) independently increase the risk of asparaginase-associated toxicities (AAT). This large Children’s Oncology Group analysis evaluated the relative contributions of these risk factors and examined whether induction-phase AAT affected early treatment response measured by end-of-induction (EOI) minimal residual disease (MRD).
DETAILS: This retrospective analysis included 4,925 patients aged 1-30 years enrolled in the Children’s Oncology Group trials AALL0232 and AALL0434. All patients received a single induction dose of pegaspargase 2500 IU/m² without dose capping. Investigators assessed grade >=3 hyperbilirubinemia, grade >=4 alanine aminotransferase (ALT) elevation, grade >=2 thromboembolism, and grade >=3 acute pancreatitis. Multivariable analyses evaluated the independent effects of age, obesity, and BSA, while EOI MRD positivity (>=0.01%) was analyzed to determine whether AAT adversely influenced early leukemia response. Among 4,925 patients, 290 (6%) experienced at least one clinically significant AAT during induction. Toxicity rates increased with advancing age and obesity. After adjustment for confounding variables, obesity independently increased the likelihood of AAT (OR 2.5; 95% CI 1.88-3.24), whereas high BSA alone was not an independent predictor. Patients with both obesity and high BSA had the greatest risk of overall AAT (OR 3.3; 95% CI 2.22-4.77), while high BSA without obesity was not associated with increased risk (OR 1.4; 95% CI 0.94-2.04). Older patients (>=10 years) demonstrated more than a twofold increase in AAT risk compared with younger children.
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Obesity combined with high BSA significantly increased the risk of hyperbilirubinemia (OR 3.5; 95% CI 2.2-5.7), severe ALT elevation (OR 3.3; 95% CI 1.7-6.6), and thromboembolism (OR 3.1; 95% CI 1.5-6.5). Acute pancreatitis showed no significant association with obesity or BSA. Importantly, development of AAT did not increase the likelihood of EOI MRD positivity (36.6% vs 33.5%; Ps= .318), suggesting that induction toxicities did not adversely affect early disease response.
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Source: Orgel, E., Maese, L. D., Devidas, M., et al. Toxicity From Asparaginase During Acute Lymphoblastic Leukemia Induction: A Report From the Children's Oncology Group. Blood Advances. 2026; 10(14):4923-4930. Published: July 28, 2026. DOI: 10.1182/bloodadvances.2026019870
Accuracy of Fetal Echocardiography for Detecting Associated Lesions and Predicting Surgical Management in Dextro-Transposition of the Great Arteries and Double Outlet Right Ventricle with Subpulmonary Ventricular Septal Defect
In a cohort of 99 fetuses with D-TGA or DORV-SPV, fetal echocardiography showed high diagnostic accuracy for simple D-TGA but lower accuracy for complex lesions. Serial assessment frequently altered VSD characterization, while fetal aortic measurements and aortic-to-pulmonary artery ratios (AUC above 0.9) accurately predicted postnatal CoA repair.
KEY FINDINGS: Fetal echocardiography demonstrated excellent diagnostic performance for simple D-TGA but substantially lower accuracy in complex D-TGA and DORV-SPV with associated lesions. Serial fetal assessment frequently altered qualitative VSD size estimation, while many small postnatally confirmed VSDs did not require surgical repair. Quantitative fetal aortic measurements and aortic-to-pulmonary artery ratios showed strong discriminatory ability (AUC >0.9) for identifying fetuses requiring postnatal CoA repair, supporting their role in improving prenatal risk stratification and surgical planning.
BACKGROUND: Associated cardiac lesions, including ventricular septal defect (VSD), coarctation of the aorta (CoA), and pulmonary stenosis (PS), substantially influence prenatal counseling and postnatal surgical management in fetuses with dextro-transposition of the great arteries (D-TGA) and double outlet right ventricle with subpulmonary ventricular septal defect (DORV-SPV). This study assessed the diagnostic accuracy of fetal echocardiography (FE) for identifying associated lesions and predicting the postnatal surgical approach.
DETAILS: This single-center retrospective cohort study included 99 fetuses with D-TGA or DORV-SPV managed at Lucile Packard Children's Hospital (Palo Alto, California, USA) between January 2013 and January 2024. Eligible fetuses were liveborn, had a documented prenatal surgical plan, and underwent postnatal management at the study center. In 65% of cases, serial fetal echocardiograms were available. Prenatal diagnoses and predicted surgical plans were compared with postnatal echocardiographic findings and the surgical procedures ultimately performed. Receiver-operating characteristic (ROC) analysis evaluated the predictive performance of fetal aortic and pulmonary artery measurements for postnatal CoA repair. Among the 99 fetuses, postnatal diagnoses included 45 with simple D-TGA, 38 with complex D-TGA, 15 with DORV, and 1 case reclassified from prenatal DORV-SPV to truncus arteriosus. Diagnostic concordance between fetal and postnatal echocardiography was highest for simple D-TGA (95% (42/44)) and D-TGA with VSD and PS (100% (3/3)), followed by D-TGA with VSD (93% (25/27)). Lower concordance was observed for DORV-SPV (60% (3/5)), DORV-SPV with CoA (40% (4/10)), D-TGA with VSD and CoA (29% (2/7)), D-TGA with isolated CoA (0% (0/2)), and DORV-SPV with PS (0% (0/1)). Surgical-plan prediction showed a similar pattern, with the greatest accuracy in simple D-TGA and D-TGA with VSD and PS. Qualitative assessment of VSD size frequently changed across serial fetal examinations, with defects generally appearing larger prenatally but often smaller on postnatal echocardiography. Only 50% of small VSDs identified postnatally required repair. All infants undergoing postnatal CoA repair had an associated VSD. ROC analysis demonstrated that fetal aortic measurements and aortic-to-pulmonary artery dimension ratios achieved area under the curve values greater than 0.9 for predicting the need for postnatal CoA repair.
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Source: Chandrasekar, H., Kaplinski, M., Maskatia, S. A., et al. Accuracy of Fetal Echocardiography in Detecting Lesions Associated With, and Predicting Surgical Plan for, Dextro-Transposition of the Great Arteries and Double Outlet Right Ventricle With Subpulmonary Ventricular Septal Defect and Predicted Transposition Physiology. Ultrasound in Obstetrics & Gynecology. 2026; 68(1):v79-87. Published: January 30, 2026. DOI: 10.1002/uog.70169
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