Pediatric CP-CRE incidence nearly doubled, driven by NDM, CDC finds

Carbapenemase-producing carbapenem-resistant Enterobacterales (CP-CRE) infections in US children nearly doubled from 2019 through 2024, and most cases occurred in children with serious underlying conditions receiving high-acuity care, according to a CDC-led surveillance analysis published November 4, 2026, in the Journal of the Pediatric Infectious Diseases Society.¹ The increase was driven by New Delhi metallo-β-lactamase (NDM)–producing CRE, which surpassed Klebsiella pneumoniae carbapenemase (KPC) as the most common carbapenemase among pediatric isolates.¹

"Recent increases in the incidence of NDM-producing CRE pose new challenges for managing CRE infections," wrote lead author Danielle A. Rankin, PhD, MPH, of the CDC's Division of Healthcare Quality Promotion, and colleagues. "These challenges are accentuated in pediatric populations, where approval and age-specific safety data are limited or unavailable for newer therapies that have expanded CP-CRE treatment options in adults."¹

CDC surveillance of pediatric CRE and CP-CRE, 2019-2024

Investigators analyzed CRE clinical isolates from patients younger than 18 years submitted to the CDC's Antimicrobial Resistance Laboratory Network from January 2019 through December 2024.¹ They estimated annual unadjusted incidence rates for CRE and CP-CRE overall and by age group, using both a national convenience sample and an open cohort of 29 states that require CRE isolate submission, and assessed trends with Poisson regression.¹ Medical chart reviews were performed for children with incident CP-CRE identified from January 2023 through March 2024.¹

NDM-CRE incidence in children rose more than 4-fold

The analysis included 1,845 CRE cases among 1,753 children (median age, 5 years; 58% female), about one-quarter of which were CP-CRE.¹ From 2019 to 2024, estimated national pediatric CRE incidence increased 51% (incidence rate ratio [IRR], 1.51; 95% CI, 1.22-1.88), and CP-CRE incidence increased 92% (IRR, 1.92; 95% CI, 1.25-2.99), with similar increases in the 29-state cohort.¹ Infants had the highest incidence rates.¹

NDM-CRE incidence rose more than 4-fold over the study period (IRR, 4.24; 95% CI, 2.07-9.16).¹ The pediatric trend mirrors an earlier CDC analysis across all ages, which found that age-adjusted NDM-CRE incidence increased 461% from 2019 through 2023.²

Underlying conditions and healthcare exposures in pediatric CP-CRE

Chart reviews were completed for 109 of 129 children with CP-CRE, and only 14% of cases occurred in children without healthcare risk factors.¹ Among those with healthcare risk factors, 75% had an underlying medical condition.¹ Cardiovascular disease was the most common condition among infants and toddlers (64%), whereas neurocognitive conditions (49%) and malignancies (41%) predominated among older children.¹ Common exposures across all age groups included intensive care unit hospitalization (40%) and healthcare received outside the United States (37%).¹

Limited pediatric treatment options for NDM-CRE infections

CRE infections were already a substantial burden before the recent rise, with an estimated 12,700 infections and 1,100 deaths in the United States in 2020.³ NDM-producing organisms complicate management further, and many clinical laboratories lack the capacity to detect NDM promptly, which can delay appropriate therapy.³

Aztreonam-avibactam, approved by the FDA in February 2025, offers an option against some NDM-producing organisms, but its labeled indication is limited to patients 18 years and older with complicated intra-abdominal infections.⁴ That gap underscores the authors' concern about the lack of pediatric approval and safety data for newer agents.¹

"These findings indicate that CP-CRE—and particularly NDM-CRE, with its more limited treatment options—is a growing issue in U.S. pediatric healthcare settings," the authors wrote.¹

Pediatric CP-CRE prevention, limitations, and next steps

The authors suggested that prevention opportunities may include admission screening for patients with prior healthcare exposure outside the United States and strengthening infection prevention practices.¹

Several limitations temper interpretation. National estimates were derived from a convenience sample, incidence rates were unadjusted, and chart review was restricted to CP-CRE cases identified during a 15-month window.¹ The publication is an accepted manuscript, and figures may be refined in the final typeset version.¹ Whether the pattern reflects increased transmission, expanded testing, or both remains an open question for continued surveillance.

References

1. Rankin DA, Stahl AL, Ali M, et al; Pediatric CRE Investigation Group. Carbapenemase-producing carbapenem-resistant Enterobacterales among children in the United States, 2019-2024. J Pediatric Infect Dis Soc. Published online November 4, 2026. doi:10.1093/jpids/piag115

2. Rankin DA, et al. Changes in carbapenemase-producing carbapenem-resistant Enterobacterales, 2019 to 2023. Ann Intern Med. Published online September 23, 2025. doi:10.7326/ANNALS-25-02404

3. Centers for Disease Control and Prevention. CDC report finds sharp rise in dangerous drug-resistant bacteria. News release. September 23, 2025. Accessed November 10, 2026. https://www.cdc.gov/media/releases/2025/2025-cdc-report-finds-sharp-rise-in-dangerous-drug-resistant-bacteria.html

4. Emblaveo (aztreonam and avibactam) for injection. Prescribing information. AbbVie Inc; 2025. Accessed November 10, 2026. https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/217906s000lbl.pdf