Carbapenemase-Producing Carbapenem-Resistant Enterobacterales Among Children in the United States, 2019-2024

BACKGROUND: The current epidemiology of carbapenem-resistant Enterobacterales (CRE) among pediatric patients in the United States is poorly described. We assessed trends in pediatric CRE and carbapenemase-producing-CRE (CP-CRE) incidence in the U.S. and characterized recent pediatric CP-CRE cases. METHODS: We analyzed CRE clinical isolates from patients <18 years submitted to CDC's Antimicrobial Resistance Laboratory Network from January 2019 through December 2024. Annual unadjusted incidence rates for CRE and CP-CRE were estimated overall and by age group for a national convenience sample and an open cohort of 29 states with required CRE isolate submission. Trends were assessed using Poisson regression. For pediatric patients with incident CP-CRE identified from January 2023 through March 2024, medical chart reviews were performed. RESULTS: From 2019-2024, the estimated national pediatric CRE and CP-CRE incidence increased 51% (IRR:1.51; 95% CI:1.22, 1.88) and 92% (IRR:1.92; 95% CI:1.25, 2.99), respectively; increases were similar in the open cohort. Infants had the highest incidence rates. Overall, NDM-CRE incidence increased (IRR: 4.24; 95% CI: 2.07, 9.16), surpassing KPC-CRE as the most prominent carbapenemase. Chart reviews were completed for 109 of 129 pediatric patients with CP-CRE; 14% were in patients without healthcare risk factors. Among patients with healthcare risk factors, 75% had an underlying medical condition; the most common underlying condition among infants and toddlers was cardiovascular disease (64%) and among older children was neurocognitive conditions (49%) and malignancies (41%). Common exposures across all age groups included intensive care unit hospitalization (40%) and healthcare outside the United States (37%). CONCLUSIONS: Pediatric CP-CRE incidence is increasing, driven by NDM-CRE for which there are few treatment options. Most cases occurred among children with serious underlying conditions receiving high-acuity care. Prevention opportunities may include admission screening for patients with prior healthcare exposure outside the United States and strengthening infection prevention practices.