Antibiotic Resistance Has Left Children Behind to Invade Nursing Homes

Mortality linked to antibiotic-resistant bacteria declined by 50% in children under five between 1990 and 2021. In the same period, it increased by more than 80% in people over seventy years old. These two figures come from a study published in The Lancet on September 16, 2024 by the GBD 2021 AMR Collaborators (Naghavi, Vollset, Ikuta et al.), covering 204 countries and territories, and tell the same story: that of a burden which has not disappeared, but which has changed face.

Antibiotic resistance is often presented as an undifferentiated threat, a growing evil that progresses everywhere and affects everyone. This vision is both correct and misleading. It is correct because the problem remains considerable. It is misleading because it masks a profound demographic shift, now documented on an unprecedented scale, which forces us to rethink where to concentrate resources and how to calibrate public policies.

The Essential Points

  • Between 1990 and 2021, mortality attributable to antibiotic resistance fell by 50% in children under five, according to a study published in The Lancet in September 2024 by the GBD 2021 AMR Collaborators, covering 204 countries and territories
  • Over the same period, this mortality increased by more than 80% in people over seventy years old
  • The burden has shifted toward acute care hospitals and long-term care facilities for dependent elderly persons
  • Adoption of a national plan to combat antibiotic resistance takes an average of five years to produce a measurable effect on the prevalence of resistance

Children Won a Battle That Adults Are Losing

Thirty years ago, pneumococcal pneumonia killed millions of infants in low and middle-income countries. Haemophilus influenzae meningitis struck day care centers and maternity wards. Diarrhea caused by resistant E. coli decimated malnourished children. These pathologies have not disappeared, but their mortality has been massively reduced.

How? Through three levers that reinforced each other. Vaccination against pneumococcus, deployed on a large scale since the 2000s with support from Gavi, the Vaccine Alliance, reduced the prevalence of strains responsible for the most severe infections. Access to safe drinking water and sanitation cut the transmission routes of resistant enterobacteria. And the expansion of basic pediatric care in countries like India, Bangladesh, and several sub-Saharan states made it possible to treat infections earlier, with the right medications, infections that otherwise became uncontrollable.

It is no coincidence that childhood mortality from AMR (antimicrobial resistance) has declined the most in countries that simultaneously invested in these three dimensions. The mechanism of progress is legible here: antibiotic resistance declines when you reduce the need for antibiotics, not just when you seek new molecules.

The result is real. It deserves to be named as such, without preventive reservations.

Over Seventy: The Terrain Where Resistance Thrives

At the other end of the age pyramid, the trajectory is reversed. In people over seventy, the 2024 Lancet study (Naghavi, Ikuta et al.) records an increase of more than 80% in mortality attributable to antibiotic-resistant bacteria between 1990 and 2021. This figure is not merely a statistical effect linked to aging of the world population.

It reflects a biological and institutional reality. Elderly people accumulate risk factors: immunosenescence, comorbidities, frequent recourse to medical care, repeated hospitalization, repeated antibiotherapy that selects resistant strains. In nursing homes, the density of frail residents creates conditions close to those of a hospital ward, without always having the infection control protocols.

The germs involved are well identified. Klebsiella pneumoniae resistant to carbapenems, Acinetobacter baumannii, methicillin-resistant Staphylococcus aureus (MRSA) in its most virulent variants: these bacteria thrive in acute care units, intensive care services, catheters, and urinary catheters. They are difficult to eradicate from the clinical environment and nearly impossible to treat when therapeutic options are exhausted.

The demographic aging of Europe, Japan, South Korea and, within twenty years, China, means that this terrain will expand. Without adaptation of strategies, the upward curve observed between 1990 and 2021 has no reason to bend downward.

Five Years Between Political Decision and Measurable Effect

One of the most operational conclusions of this work is often overlooked in commentary on antibiotic resistance: adoption of a national plan to combat AMR takes an average of five years to produce a measurable effect on the prevalence of resistance.

This delay is not an anomaly. It is the logic inherent to all public health policy that seeks to modify deeply entrenched behaviors, prescriptions, and hospital practices. A national plan that provides for reducing unnecessary prescriptions in primary care, strengthening microbiology laboratories to quickly identify resistant strains, and establishing antibiotic stewardship committees in health facilities takes time to traverse the layers of the system.

What this implies is important: countries that adopted their first national action plans in the 2015-2018 period, in response to the O’Neill report and the first WHO resolutions, are only now beginning to see effects. And countries that do not yet have a structured plan are accumulating a lag that, by 2030, will be counted in preventable deaths.

Data from the 2024 Lancet study and work on AMR governance identify countries that have adopted a national plan meeting WHO criteria. Results suggest the tool works. But the five-year delay also means that policies calibrated on 2010 data partly target a problem that has shifted in demographic geography. Plans designed to protect children and rural populations in low-income countries are not superimposable with those required to protect elderly people in care facilities of advanced economies.

Hospitals and Nursing Homes at the Center of the Problem

The shift of the burden toward those over seventy is also a geographic shift of risk: from rural communities to hospital and healthcare facilities. It is there that antibiotic-resistant bacteria circulate, are selected, and kill.

This reality has been known to infectious disease specialists since the 1990s. Yet it struggles to impose itself in public policies, which continue to view antibiotic resistance primarily as a problem of prescriptions in primary care and agricultural use of antibiotics. These two fronts matter. But they are not sufficient.

What is at stake in health facilities requires different answers: teams dedicated to infection control, nurse ratios that allow respect for hygiene protocols, laboratories capable of producing antibiograms in less than twenty-four hours, and real-time surveillance systems capable of detecting an emergence before it becomes epidemic. In several European countries, including France, programs such as PRIMO (Prevention of Infections and Resistance in Community Pharmacy) or the REA-Raisin surveillance network in intensive care are already charting this course. But their coverage of facilities for elderly people remains insufficient.

The United Kingdom, through NHS England and its national sterilization and infection control program, has produced measurable results in hospital services since 2014. The number of MRSA infections in hospital settings fell by more than 80% between 2007 and 2022, according to UK Health Security Agency data. The method: mandatory surveillance, feedback to teams, obligation of results for facility directors. What works in acute hospital settings must now be adapted to the healthcare and social care sector, where governance and resources are structurally different.

Missing Data in Low-Income Countries Hamper the Global Response

The strength of the 2024 Lancet study, which covers 204 countries and territories, is also to make visible its own limitations. For about thirty low-income countries, mainly in sub-Saharan Africa and South Asia, estimates of AMR mortality are based on models due to lack of sufficient surveillance systems. Data is missing where resistance could progress fastest.

This problem is not merely methodological. It is political. A country that does not know how many people die from antibiotic-resistant bacteria, nor which strains are involved, nor in which facilities they circulate, cannot calibrate its investments. It cannot know if its national plan is working. It cannot trigger an alert in time.

The WHO, in partnership with the Fleming Fund, a British financing program, has since 2017 launched efforts to strengthen laboratory capacity in about forty priority countries. The objective is to produce reliable local data on resistance, where global estimates remain the only reference points. These programs are progressing slowly, but they are progressing. Several African countries, including Ghana, Ethiopia, and Tanzania, have strengthened their microbiological surveillance networks as part of this program. The results are beginning to feed global databases.

The challenge is not to find the molecule that will solve everything. It is to build the information systems that will enable action in the right place, at the right time, on the right populations.

What the Demographic Shift Forces Us to Reconsider

Antibiotic resistance is not a threat that progresses homogeneously. It declines where primary prevention has worked, it advances where the population is most vulnerable and most medicalized. This heterogeneity is strategic information.

For high-income countries, it means that the bulk of effort must now focus on elderly care facilities: enhanced surveillance, demanding hygiene protocols, rapid diagnosis, antibiotherapy guided by antibiogram rather than probabilistic. This is not a battle lost in advance. Results obtained in British or Danish acute hospitals show that resistant infections can be contained, even in fragile populations, when protocols are applied consistently.

For middle-income countries aging rapidly, the window is still open. China, Brazil, Indonesia, and several North African countries combine a growing elderly population, rapidly expanding health systems, and already high resistance rates. Building surveillance capacity and prevention protocols in healthcare and social care settings now is less costly than reconstructing them after a decade of preventable infections.

The real question is not whether antibiotic resistance can be controlled. Data on children under five prove it can be. It is whether public policies are capable of recalibrating quickly enough to follow the shift in risk. Five years of delay between decision and effect: the time to act is now.

Sources

  1. Naghavi M., Vollset SE., Ikuta KS. et al. (GBD 2021 AMR Collaborators), “Global burden of bacterial antimicrobial resistance 1990–2021: a systematic analysis with forecasts to 2050”, The Lancet, September 16, 2024. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)01867-1/fulltext
  2. Nature Medicine study, March 2026 (193 countries, AMR governance — national action plans 2017-2022). https://www.nature.com/articles/s41591-026-04257-1
  3. UK Health Security Agency, MRSA infection surveillance data in hospital settings, 2007-2022. https://www.gov.uk/government/statistics/mrsa-mssa-and-e-coli-bacteraemia-and-c-difficile-infection-annual-epidemiological-commentary/annual-epidemiological-commentary-gram-negative-mrsa-mssa-bacteraemia-and-c-difficile-infections-up-to-and-including-financial-year-2023-to-2024
  4. Gavi, the Vaccine Alliance, impact reports on pneumococcal vaccination in low-income countries. https://www.gavi.org/vaccineswork/gavi-vaccine-alliance-25-years-25-moments
  5. PRIMO Mission – Santé Publique France. https://antibioresistance.fr/nos-missions
  6. REA-Raisin Network – Santé Publique France. https://www.santepubliquefrance.fr/maladies-et-traumatismes/infections-associees-aux-soins-et-resistance-aux-antibiotiques/infections-associees-aux-soins/surveillance-des-infections-nosocomiales-en-reanimation-adulte.-reseau-rea-raisin-france-resultats-2015
  7. Fleming Fund, program to strengthen AMR surveillance capacity in priority countries. https://www.flemingfund.org
  8. World Health Organization, Global Action Plan on Antimicrobial Resistance. https://www.who.int/publications/i/item/9789241509763