WHO Bacterial Priority Pathogens List: a 32-year global trend and inequality analysis of antimicrobial resistance burden by age and region

Introduction The WHO Bacterial Priority Pathogens List identifies antibiotic-resistant bacteria posing a serious health threat. We aimed to analyse age-specific and region-specific burden trajectories and inequalities across countries with different socio-development levels for these pathogens.Methods We conducted a systematic analysis (1990–2021) using the Global Burden of Disease Study’s Measuring Infectious Causes and Resistance Outcomes for Burden Estimation database, assessing trends and inequalities in mortality burden attributable to priority pathogens by age and region. Analyses included age-period-cohort modelling, average annual percentage change (AAPC) and health inequality metrics across countries stratified by sociodemographic index (SDI).Results Global mortality attributable to priority antibiotic-resistant pathogens rose from 5.47 to 6.12 per 100 000 in 1990–2021 (annual net drift: 0.086%). By age, mortality declined in under 5 but increased in the middle-aged and elderly (peaking at 40–44 and ≥95), primarily driven by carbapenem-resistant Klebsiella (AAPC 2.1%−2.4%) and Escherichia coli (AAPC 1.6%−2.2%). Mortality from multidrug-resistant tuberculosis rose across all ages, particularly in neonates (AAPC 7.4%, 95% CI 6.6% to 8.1%). Regionally, high-income Asia Pacific saw the steepest mortality decline (AAPC –2.5%, 95% CI –2.7% to –2.3%), while Eastern Europe exhibited the sharpest increase (AAPC 1.2%, 95% CI 0.2% to 2.2%), fueled by multidrug-resistant tuberculosis (AAPC 7.7%, 95% CI 6.0% to 9.5%), carbapenem-resistant Klebsiella (AAPC 3.5%, 95% CI 2.2% to 4.9%) and vancomycin-resistant Enterococcus (AAPC 3.1%, 95% CI 1.5% to 4.7%). Southern sub-Saharan Africa experienced a rise in fluoroquinolone-resistant Salmonella Typhi (AAPC 4.6%, 95% CI 2.5% to 6.8%). Over the 32-year period, the slope index of inequality in mortality burden of priority pathogens narrowed from –333.65 to –282.20, while the concentration index widened from –0.28 to –0.31.Conclusions The global mortality burden of priority antibiotic-resistant pathogens increased between 1990 and 2021, with age and regional disparities demanding targeted containment. Higher burden in low-SDI regions requires equitable healthcare resource allocation to combat antimicrobial resistance.