2024 • Volume 48

Communicable Diseases Intelligence
Australian Group on Antimicrobial Research
surveillance outcome programs – bloodstream
infections and antimicrobial resistance patterns
from patients less than 18 years of age,
January 2020 – December 2021
Anita Williams, Geoffrey W Coombs, Jan Bell, Denise A Daley, Shakeel Mowlaboccus,
Penelope A Bryant, Anita J Campbell, Louise Cooley, Jon Iredell, Adam D Irwin, Alison Kesson,
Brendan McMullan, Morgyn S Warner, Phoebe Williams, Christopher C Blyth

https://doi.org/10.33321/cdi.2024.48.32
Electronic publication date: 21/08/2024
http://health.gov.au/cdi

Communicable Diseases Intelligence
Communicable Diseases Intelligence (CDI) is a peer-reviewed scientific journal publishedby the Health Security & Emergency Management Division, Department of Health and Aged Care.
The journal aims to disseminate information on the epidemiology, surveillance, prevention and control
of communicable diseases of relevance to Australia.
© 2024 Commonwealth of Australia as represented by the
Department of Health and Aged CareISSN: 2209-6051 Online

EditorChristina Bareja

This journal is indexed by Index Medicus and Medline.

Deputy Editor

Creative Commons Licence – Attribution-NonCommercialNoDerivatives CC BY-NC-ND

Simon PetrieThis publication is licensed undera Creative Commons AttributionNon-Commercial NoDerivatives
4.0 International Licence fromhttps://creativecommons.org/
licenses/by-nc-nd/4.0/legalcode (Licence). You must read andunderstand the Licence before using any material from thispublication.

Lisa Thompson

Restrictions
The Licence does not cover, and there is no permission
given for, use of any of the following material found in thispublication (if any):• the Commonwealth Coat of Arms (by way of
information, the terms under which the Coat of Arms
may be used can be found at www.pmc.gov.au/resources/
commonwealth-coat-arms-information-and-guidelines);• any logos (including the Department of Health and Aged
Care’s logo) and trademarks;• any photographs and images;• any signatures; and• any material belonging to third parties.
Disclaimer
Opinions expressed in Communicable Diseases Intelligence arethose of the authors and not necessarily those of the AustralianGovernment Department of Health and Aged Care or theCommunicable Diseases Network Australia. Data may besubject to revision.

Design and Production
Editorial Advisory Board
David Durrheim, Mark Ferson, Clare Huppatz,
John Kaldor, Martyn Kirk, Meru Sheel andStephanie Williams
Contacts
CDI is produced by:Health Security & Emergency Management Division
Australian Government Department of Health andAged CareGPO Box 9848, (MDP 6)
CANBERRA ACT 2601
www.health.gov.au/cdi
cdi.editor@health.gov.au
Submit an Article
You are invited to submit your next communicabledisease related article to Communicable Diseases
Intelligence (CDI) for consideration. Moreinformation regarding CDI can be found at:
www.health.gov.au/cdi.
Further enquiries should be directed to:
cdi.editor@health.gov.au.

Enquiries
Enquiries regarding any other use of this publication should be
addressed to the CDI Editor at: cdi.editor@health.gov.au
Communicable Diseases Network Australia
Communicable Diseases Intelligence contributes to the work of
the Communicable Diseases Network Australia.
www.health.gov.au/cdna

www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/2024

2

Original article

Australian Group on Antimicrobial Research
surveillance outcome programs – bloodstream
infections and antimicrobial resistance patterns
from patients less than 18 years of age,
January 2020 – December 2021
Anita Williams, Geoffrey W Coombs, Jan Bell, Denise A Daley, Shakeel Mowlaboccus,
Penelope A Bryant, Anita J Campbell, Louise Cooley, Jon Iredell, Adam D Irwin, Alison Kesson,
Brendan McMullan, Morgyn S Warner, Phoebe Williams, Christopher C Blyth

Abstract
From 1 January 2020 to 31 December 2021, thirty-eight institutions across Australia submitted data
to the Australian Group on Antimicrobial Resistance (AGAR) from patients aged < 18 years (AGARKids). Over the two years, 1,679 isolates were reported from 1,611 patients. This AGAR-Kids report aims
to describe the population of children and adolescents with bacteraemia reported to AGAR and the
proportion of resistant isolates.
Overall, there were 902 gram-negative isolates reported: 800 Enterobacterales, 61 Pseudomonas
aeruginosa and 41 Acinetobacter spp. Among the Enterobacterales, 12.9% were resistant to third
generation cephalosporins; 11.6% to gentamicin/tobramycin; and 11.2% to piperacillin-tazobactam.
In total, 14.5% of Enterobacterales were multi-drug resistant (MDR). Only 3.3% of P. aeruginosa wereresistant to carbapenems and 4.9% were MDR. Resistance in Acinetobacter spp was uncommon.
Of 607 Staphylococcus aureus isolates, 12.9% were methicillin-resistant (MRSA). Almost half of S. aureus
isolates from the Northern Territory were MRSA. In S. aureus, resistance to erythromycin was 13.2%;
12.4% to clindamycin; and 5.3% to ciprofloxacin. Resistance to all antibiotics tested was higher in
MRSA. Overall, 6.5% of S. aureus were MDR, of which 65% were MRSA.
Almost three-quarters of the 170 Enterococcus spp. reported were E. faecalis, and half were from patients< 1 year old. Ampicillin resistance in enterococci was 19.6%. Eight isolates were vancomycin resistantand three isolates were teicoplanin resistant. Five E. faecium isolates were classified as MDR.
This AGAR-Kids report highlights clear differences in the geographic distribution of pathogens andresistance profiles across Australia.
Keywords: Australian Group on Antimicrobial Resistance (AGAR); antimicrobial resistance surveillance;
paediatrics; bacteraemia; Enterobacterales; Staphylococcus aureus; Enterococcus

www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/2024

3

Introduction

Methods

The Australian Group on Antimicrobial Resistance(AGAR) produces annual reports from the whole of
the Australian population. However, previous analysis of the AGAR data, comparing adult (> 18 years)
and paediatric (≤ 18 years) bacteraemia, suggests
there are lower rates of antimicrobial-resistantorganisms isolated in children, with different phenotypes and lower mortality rates.

Participants

In 2018, the World Society for Paediatric Infectious
Diseases (WSPID) declared that antimicrobial resistance (AMR) surveillance programs should present
neonatal- and paediatric-specific data to assist withstrengthening knowledge.1 Currently, age-specificdata are not routinely reported in the majority of
AMR surveillance programs, making paediatricspecific interventions difficult.2 By monitoring paediatric bacteraemia, we are able to provide insightnot only into the dynamic aetiology of bloodstream
infections, but also into the impact of vaccine programs, and to inform strategies aimed at targetinginvasive infections.3
The key influences on bacteraemia incidence areage, vaccination coverage and exposure to invasive
procedures.3 In previous studies, neonates were
often over-represented, reflecting the immaturity of
the immune system and the use of invasive devices(e.g., intravenous catheters). Various reports from
Australia and Europe suggest there are differencesin the AMR burden of various organisms, not only
between adults and children, but within different age
groups among children. For example, gram-negative
multidrug resistant (MDR; resistant to three or more
antimicrobial classes) organisms were previously
found to disproportionately impact children, as demonstrated by a higher odds of death in children withbacteraemia secondary to an extended spectrum
beta-lactamase (ESBL) containing organism vs nonESBL bacteraemia when compared to the same ratio
in adults.4 In a European study, isolates from children< 1 year of age had less AMR than those isolated fromchildren ≥ 1 year old.2 In a Scottish study, instancesof bacteraemia in children < 1 year old were more
likely to be healthcare associated, whilst bacteraemia
in children aged 1–15 years were more often community associated.5 These findings impact the empiric
treatment guidelines and stewardship initiatives,
thereby highlighting the value of paediatric-specificreporting of bacteraemia.

Thirty-eight laboratories participating in AGAR
who reported data from patients < 18 years old (0–17years of age inclusive); 35 laboratories in each year
respectively. AGAR collects data from 24 of the 29
principal referral centres and from all tertiary paediatric centres (8 hospitals) in Australia, as well asfrom seven public acute group A hospitals, three private group A hospitals, two private group B hospitals
and all public group C hospitals in the north-west ofWestern Australia.6

Collection period
From 1 January 2020 to 31 December 2021, participating laboratories submitted all isolates from uniquepatient episodes of bacteraemia for S. aureus andEnterococcus spp., and up to 200 isolates per year forEnterobacterales, P. aeruginosa, and Acinetobacter
spp.
An episode was defined as a clinical event associated with a positive blood culture, irrespective of thenumber of bacterial species identified. A new episodeof bacteraemia in the same patient was recorded
if the blood culture was collected more than two
weeks after the initial positive culture. An episodewas defined as community-onset if the first positive
blood culture of the episode was collected 48 hours
or less after hospital admission, and as hospital-onset
if collected more than 48 hours after admission.

Laboratory methods
Isolates were identified to the species level by theparticipating laboratories using matrix-assisted laser
desorption ionization (MALDI) [MALDI Biotyper(Bruker Daltonics, United States of America [USA])or Vitek-MS (bioMérieux, France) or using Vitek2®
(bioMérieux). Antimicrobial susceptibility testing
was performed using the Vitek2® (bioMérieux) or
BD Phoenix™ (Becton Dickinson, USA) automatedmicrobiology systems according to the manufacturer’s instructions.

www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/2024

4

Data collection and analysis

Results

Data were collected on age, sex, dates of admission
and discharge , and mortality at seven and 30 days
from date of blood culture collection. To avoid interpretive bias, no attempt was made to assign attributable mortality.

Patient characteristics

The AMR for R package (v2.0) was used to transform minimum inhibitory concentration data as
per EUCAST 2022 (v12) breakpoints.7,8 Multi-drugresistance (MDR) was defined as resistance to one
or more agents in three or more antimicrobial categories.9 Descriptive statistics for the populationand isolates for the overall population and per year
were stratified by age, sex, and state/territory whereappropriate. Categorical data was assessed using thechi-square or Fisher’s exact test. Continuous data wasassessed using the Student t-test or Mann-Whitney
U test. Proportions were not calculated where fewer
than ten isolates in a category were tested.

EthicsApproval to conduct the prospective data collection
was given by the research ethics committee associated with each participating healthcare facility.

Overall, there were 1,679 isolates from 1,611 bacteraemic episodes in 1,611 patients: 826 episodes with
856 isolates in 2020, and 785 episodes with 823 isolates in 2021. The most frequently reported species
were S. aureus (n: 607/1,679; 36.2%) and Escherichia
coli (n: 378/1,679; 22.5%). In all states and mainland
territories, S. aureus was the most frequently reported
species, followed by E. coli, except in Queensland
where non-typhoidal Salmonella was more frequent.
For patients aged < 1 year, the most common species was E. coli, whereas in patients aged ≥ 1 year, themost common species was S. aureus (Table 1).
There was an over-representation of episodes inpatients aged < 1 year (n: 623/1,611; 38.7%), and15.1% of all episodes were in neonates (n: 244). Morebacteraemia episodes affected males (n: 976/1,611;
60.6%). The median age of patients with S. aureus
bacteraemia was older than for enterococcal orgram-negative bacteraemia.
Most bacteraemic episodes were community-onset(69.0%); however, enterococcal episodes were more
often hospital-onset. The proportion of hospitalonset episodes was highest in the neonatal age groupand decreased with age; the median age for community-onset bacteraemia was 3 years (interquartile
range, IQR: 0–10 years), whereas the median age forhospital-onset bacteraemia was < 12 months (IQR:
0–5 years). Tasmania had the highest proportionof community-onset episodes (85% of all episodes)
with Victoria having the lowest proportion (58% of
episodes).
Overall, the mean length of stay following blood
culture collection was 17.0 days (standard deviation,
SD: 21.5) and the median was 10 days (IQR: 6–21
days). At 30 days, 21.7% of all children with bacteraemia (n = 350/1,611) were still admitted to hospital.
Over the two-year period, bone and joint infections were the most frequently reported clinicalmanifestations (n: 255/1,679; 15.2%), followed bydevice-related infections without metastatic focus(n: 210/1,679; 12.5%). Community-onset bacteraemic episodes were more frequently associated withan osteoarticular focus, whereas hospital-onset
episodes were more frequently device-related or inpatients with febrile neutropenia.

www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/20245www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/2024

6

b
c

a

Median60

5

Yes

Unknown72

Hospital
90

97

Community

No

11
70

Unknown

150

Survived

6

11
12.5

WA

Died

56

Vic.

7.8–34.3

4

Tas.

IQRb

13

SA

NSW
2

68

ACT

10

3

Male

Qld

107

FemaleNT4160

5–17 years

38

26

29–90 days

1–4 years38≤ 28 days
24

0–4

IQRb

91–364 daysn
<1

Characteristic

Median

%

35.9

3.0

53.9

43.1

58.1

41.9

6.6

89.8

3.6

—

—

6.6

33.5

2.4

7.8

6.0

1.2

40.7

1.8

64.1

35.9

24.6

22.8

14.4

15.6

22.8

—

—

43

25

473

108

129

477

85

515

6

7–18

11

73

152

15

57

88

29

172

20

398

208

326

133

45

51

51

1–11.86nS. aureus(N = 606)
%

7.1

4.1

78.1

17.8

21.3

78.7

14.0

85.0

1.0

—

—

12.0

25.1

2.5

9.4

14.5

4.8

28.4

3.3

65.7

34.3

53.8

21.9

7.4

8.4

8.4

—

—

100

55

600

212

284

583

123

702

42

5–21

10

76

239

20

63

116

41

290

22

490

377

266

198

139

104

160

0–7

1

n

11.5

6.3

69.2

24.5

32.8

67.2

14.2

81.0

4.8

—

—

8.8

27.6

2.3

7.3

13.4

4.7

33.4

2.5

56.5

43.5

30.7

22.8

16.0

12.0

18.5

—

—

%

Gram-negative bacteria(N = 867)

174

85

1,147

379

499

1,112

218

1,340

53

6–21

10

158

438

39

130

213

72

516

45

976

635

629

359

206

173

244

0–10

2

n

10.8

5.3

71.2

23.5

31.0

69.0

13.5

83.2

3.3

—

—

9.8

27.2

2.4

8.1

13.2

4.5

32.0

2.8

60.6

39.4

39.0

22.3

12.8

10.7

15.1

—

—

%

Total patients(N = 1,611)a

The numbers in each organism group may not add up to the total column, as some patients have polymicrobial bacteraemic episodes and are reported in each respective column to their episode,but only counted once in the total number of patients.
IQR: interquartile range.
ACT: Australian Capital Territory; NSW: New South Wales; NT: Northern Territory; Qld: Queensland; SA: South Australia; Tas.: Tasmania; Vic.: Victoria; WA: Western Australia.

Polymicrobial

Device-related infection

Onset

30-day outcome

Length of stay (days)

Jurisdictionc

Sex

Age group

Age (years)

Category

Enterococcus spp.
(N = 167)

Table 1: Characteristics of patients aged < 18 years with a bacteraemic event reported to AGAR, per survey, January 2020 – December 2021

Overall, 23.5% of patients had a device-related bacteraemic episode (n: 379/1,611). The proportion was
higher in 2021 (n: 213; 27.4%) than in 2020 (n: 166;
22.2%). The median length of stay was longer forpatients with a device-related episode than for thosepatients without a device-related episode. Moredevice-related episodes were reported with gramnegative isolates. Overall, 13% of episodes that were
MDR were associated with a device-related infection.
Ten percent of patients had more than one isolate
reported in a bacteraemia episode (174/1,611; 10.8%).
The largest proportion of polymicrobial episodes
were reported in children < 12 months (72/174;
41.4%).
At seven days after blood culture collection, 2.6% of
patients had died (n: 42); the proportion of patients
who died increased to 3.3% at 30 days (n: 53). The
median age of patients who died was younger that forsurvivors (X 2: 12.5; p: < 0.001). More than half of thedeaths occurred in patients ≤ 28 days of age (27/53;51%), including ten neonates with community-onset
bacteraemia.

Gram-negative isolates
Overall, there were 902 gram-negative isolates
reported from 867 bacteraemia episodes in patients
aged < 18 years in 2020–2021; 800 Enterobacterales(88.7%), 61 Pseudomonas aeruginosa (6.8%) and41 (4.5%) Acinetobacter spp. The most frequently
reported Enterobacterales were E. coli and Klebsiellapneumoniae complex.
The largest proportion of Enterobacterales werefrom New South Wales, followed by Victoria. The
highest proportion of isolates were from patients< 12 months old, and from males. Enterobacterales
episodes were more frequently community-onset,
and 14% of episodes were polymicrobial (Table 1).
Overall, 18% of the Enterobacterales were MDR.
The proportion of Enterobacterales resistant to theaminoglycosides (gentamicin/tobramycin) was
11.6% (n: 92/793; 95% CI: 9.5–14.0%). Victoria
reported the highest proportion of aminoglycosideresistant isolates, followed by South Australia and
New South Wales. No aminoglycoside-resistant isolates were reported in Tasmania. Resistant isolates
were more frequently reported in children aged
1–4 years of age. Isolates from patients with a hospital-onset episode were more frequently reported as
resistant than those with a community-onset episode(Table 2).

The proportion of Enterobacterales resistant topiperacillin-tazobactam was 11.2% (88/784; 95% CI:
9.1–13.6%). Victoria reported the highest proportionof resistant isolates, followed by New South Wales.
No piperacillin-tazobactam resistant isolates werereported in Tasmania and the Australian Capital
Territory (Table 2).
Overall, 13.2% of Enterobacterales (101/766; 95%
CI: 10.9–15.8) were reported as ciprofloxacin resistant. Isolates from patients with a hospital-onset episode were more frequently reported as ciprofloxacin
resistant than those with a community-onset bacteraemia. Isolates from children aged over 1 year
were more frequently resistant. Victoria reported thehighest proportion of resistant isolates (Table 2).
Of the 792 Enterobacterales that had meropenem susceptibility testing performed, only two
Enterobacter cloacae complex isolates were resistant (0.3%; 95% CI: 0.0–0.9%). The isolates reported
were from a community-onset bacteraemic episodein Queensland and a hospital-onset bacteraemic episode in Victoria, both in patients aged 5–17 years.
Fourteen percent of Enterobacterales isolates wereidentified as MDR. MDR Enterobacterales isolates
were more likely to be hospital-onset (p: < 0.01) andassociated with a device-related infection (p: < 0.01).
MDR Enterobacterales isolates were more frequentin patients with febrile neutropenia. Of the 41
patients who died with an Enterobacterales episode,19.5% of the isolates were MDR (n: 8). The highest
proportion of MDR Enterobacterales isolates werefrom Victoria (n: 59, 39.6%) and New South Wales(n: 53, 35.6%). Victoria had the highest proportionof Enterobacterales isolates that were MDR (24.8%),
followed by New South Wales (20.1%) [Table 3].
There were 61 Pseudomonas aeruginosa reported to
AGAR: 31 isolates in 2020 and 30 isolates in 2021. No
isolates were reported from the Australian Capital
Territory, and only one isolate was reported from
Tasmania. Overall, 4.9% of P. aeruginosa isolates
were MDR, and two isolates were carbapenem resistant (3.3%), classified as a World Health Organization(WHO) priority pathogen.
No P. aeruginosa isolates were reported tobramycin resistant. Overall, 19.7% of P. aeruginosa were
piperacillin-tazobactam resistant (n: 12; 95% CI:
10.6–31.8%). All ciprofloxacin-resistant P. aeruginosa isolates were reported from patients aged 5-17
years. Only two P. aeruginosa were reported meropenem resistant (3.3%; 95%CI: 0.4–11.3%): one isolate from Queensland and one isolate from Victoria.

www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/20247www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/2024

8

16.1–26.5

5.2–9.7

6.0–13.9

12.1–24.0

3.2–12.6

4.9–17.5

8.5–19.8

1.0–12.9

12.3–22.2—

6.5–26.7

2.3–12.7

1.8–22.5

8.2–16.5

0.1–21.9

9.5–14.0

95% CI

253

540

236

173

132

102

157

66

238

17

56

99

37

264

23

793

N

58

44

31

35

12

11

13

5

46

1

4

6

2

37

1

102

n

22.9

8.1

13.3

20.3

9.2

10.9

8.3

7.7

19.3

5.9

7.3

6.1

5.6

14.2

4.3

12.9

R%

17.9–28.6

6.0–10.8

9.2–18.4

14.6–27.1

4.8–15.5

5.6–18.7

4.5–13.8

2.5–17.0

14.5–24.9

0.1–28.7

2.0–17.6

2.3–12.7

0.7–18.7

10.2–19.1

0.1–21.9

10.6–15.4

95% CI

250

534

230

170

132

97

155

61

235

17

55

97

36

260

23

784

N

50

38

38

27

9

12

2

6

36

0

1

8

3

34

0

88

n

20

7.1

16.5

15.9

7

12

1.3

9.8

15.3

0

1.8

8.2

8.3

13.1

0

11.2

R%

15.2–25.5

5.1–9.6

12.0–22.0

10.7–22.3

3.2–12.8

6.4–20.0

0.2–4.6

3.7–20.2

11.0–20.6—

0.0–9.7

3.6–15.6

1.8–22.5

9.2–17.8—

9.1–13.6

95% CI

253

513

226

160

126

98

156

65

236

17

55

85

35

250

23

766

N

58

44

31

35

12

11

13

5

46

1

4

6

2

37

1

101

n

22.9

8.1

13.3

20.3

9.2

10.9

8.3

7.7

19.3

5.9

7.3

6.1

5.6

14.2

4.3

13.2

R%

ACT: Australian Capital Territory; NSW: New South Wales; NT: Northern Territory; Qld: Queensland; SA: South Australia; Tas.: Tasmania; Vic.: Victoria; WA: Western Australia.

20.9

7.2

9.4

17.4

6.9

9.9

13.5

4.6

16.8

0

14.5

6.1

8.3

11.9

4.3

11.6

R%

Ciprofloxacina

N: number of isolates tested; n: number of resistant isolates; R%: proportion of resistant isolates; 95% CI: 95% confidence interval.

53

39

22

30

9

10

21

3

40

0

8

6

3

31

1

92

n

Piperacillin–tazobactama

b

253

102

29–90 days

Hospital157≤ 28 days

540

66

WA

Community

238

Vic.

236

17

Tas.

5–17 years

56

SA

173

99

Qld

1–4 years

37

NT

132

264

NSW

91–364 days

23

793

N

ACT

Characteristic

Ceftriaxone/ceftazidimea

a

Onset

Age group

Jurisdictionb

OverallCategory

Gentamycin/tobramycina

Table 2: Number of Enterobacterales isolates tested and proportion of isolates resistant to gentamicin/tobramycin, ceftriaxone/ceftazidime,
piperacillin-tazobactam, and ciprofloxacin from children aged < 18 years as reported to AGAR, January 2020 – December 2021

14.7–24.8

7.7–13.1

10.6–20.4

13.6–26.4

4.0–14.4

4.9–17.5

6.0–16.1

1.7–15.0

15.4–26.0

1.5–36.4

6.5–26.7

5.8–20.6—

7.2–15.3

1.1–28.0

10.9–15.8

95% CIwww.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/2024

9

c
d

a
b

Characteristic
Median
IQRc≤ 28 days
29–90 days
91–364 days
1–4 years
5–17 years
Female
Male
ACT
NSW
NT
Qld
SA
Tas.
Vic.
WA
MedianIQRc
Died
Survived
Unknown
Community
Hospital
Yes
No
Unknown

n
<1
0–3.8
5
7
6
12
4
15
19
2
15
4
1
3
0
5
4
14.5
10.0–19.8
1
28
5
18
16
7
23
4
4

%
—
—
9.8
13.7
13.3
9.0
1.2
7.2
4.8
10.0
8.7
13.8
1.1
5.3
0
3.3
5.5
—
—
16.7
5.4
5.9
3.8
12.4
6.5
4.9
16.0
9.3

S. aureus(n = 34/572)a

Gram-negative bacteria(n = 118/749)a
n
%
2
—
0–8
—
18
11.3
12
11.5
9
6.5
39
19.7
40
15.0
48
12.7
70
14.3
1
4.5
40
13.8
2
4.9
9
7.8
8
12.7
2
10.0
50
20.9
6
7.9
13
—
8.3–23.5
—
8
19.0
98
14.0
12
9.8
58
9.9
60
21.1
44
20.8
65
10.8
9
16.4
11
11.0

Total patients(n = 156/1,484)a,b
n
%
1
—
0–8
—
24
9.6
20
11.0
16
7.7
52
14.1
44
7.0
63
9.8
93
9.3
3
6.7
55
10.4
6
8.3
10
4.7
12
9.0
2
5.1
58
13.0
10
6.3
14
—
9.0–24.5
—
9
16.7
130
9.5
17
7.8
76
6.7
80
15.7
53
13.5
90
7.7
13
15.3
18
8.9

n: number of MDR isolates; %: proportion of MDR isolates compared to all tested isolates of the indicated organism.
The numbers in each organism group may not add up to the total column, as some patients have polymicrobial bacteraemic episodes and are reported in each respective column to their episode,but only counted once in the total number of patients.
IQR: interquartile range.
ACT: Australian Capital Territory; NSW: New South Wales; NT: Northern Territory; Qld: Queensland; SA: South Australia; Tas.: Tasmania; Vic.: Victoria; WA: Western Australia.

Polymicrobial

Device-related infection

Onset

30-day outcome

Length of stay (days)

Jurisdictiond

Sex

Age group

Age (years)

Category

Enterococcus spp.
(n = 4/163)a
n
%
<1
—
0–0.3
—
1
2.6
1
3.8
1
4.2
1
2.6
0
0
0
0
4
3.7
0
0
0
0
0
0
0
0
1
7.7
0
0
3
5.4
0
0
38.5
—
21.0–56.5
—
0
0
4
2.7
0
0
0
0
4
4.1
2
2.8
2
2.2
0
0
3
5.0

Table 3: Characteristics of patients aged < 18 years with a bacteraemic event reported to AGAR for which one or more isolate was multidrug resistant (MDR),
per survey, January 2020 – December 2021

Only three P. aeruginosa were identified as MDR(3/61; 4.9%) – one from New South Wales and two
from South Australia.
Forty-one Acinetobacter spp. isolates were reported
to AGAR: most were A. baumanii complex (18/41;
43.9%). All Acinetobacter isolates were meropenem
susceptible. One Acinetobacter isolate was reported as
ciprofloxacin resistant and one isolate was resistantto amikacin. Three isolates were resistant to co-trimoxazole (8.6%; 95%CI: 1.8–23.1%), and all resistantisolates were reported from patients aged 1–4 years.

Staphylococcus aureus
There were 607 S. aureus isolates reported to AGAR:
303 in 2020 and 304 in 2021. Overall, 12.9% of S.
aureus were methicillin resistant (n: 78) and 5.6%
of isolates were MDR (n: 34). The median age was
6 years, and the number of episodes reported acrossdifferent age groups was similar. The majority of
isolates were reported from New South Wales andVictoria. Most episodes were community-onset andwere monomicrobial events (Table 1).
The Northern Territory reported the highest proportion of S. aureus isolates that were MRSA (45%).
MRSA was not reported in the Australian Capital
Territory or Tasmania. MRSA isolates were most frequently reported in patients aged 1–4 years and in
hospital-onset infections (Table 4).
Overall, 12.4% of S. aureus were clindamycin resistant (n: 75; 95% CI: 9.8–15.2). The Northern Territory
had the highest proportion of clindamycin-resistantisolates. No clindamycin-resistant isolates werereported in Tasmania. All age groups < 5 years of age
reported approximately 15% of isolates resistant toclindamycin (Table 4).
Five percent of S. aureus were ciprofloxacin resistant(n: 32; 5.3%; 95% CI: 3.6–7.4%); 3.6% of S. aureus
isolates were reported as resistant in 2020 (n: 11),
and 6.9% in 2021 (n: 21). The highest proportionof isolates reported as ciprofloxacin resistance wasin New South Wales (9.8%, n: 17). No isolates were
ciprofloxacin resistant in Tasmania. Resistant isolates were most frequently reported in patients aged
91–364 days (Table 4).
Overall, 13.2% of S. aureus were erythromycin resistant (n: 80; 95% CI: 10.6–16.1%): The proportion ofresistant isolates was 11.2% (n: 34) in 2020 and 15.1%(n: 46) in 2021. The highest proportion of erythromycin resistant isolates was reported in the Northern
Territory, and from neonatal patients (Table 4).

No S. aureus isolates were reported trimethoprimsulfamethoxazole or vancomycin resistant.
Overall, 5.6% of all S. aureus were MDR (n: 34), 64.7%
of which were MRSA (n: 22). A statistically significant difference in age was identified in patients witha MDR S. aureus episode compared to patients witha non-MDR S. aureus (p < 0.001). MDR S. aureus episodes are more likely to be hospital-onset (p < 0.001);
however, MDR infections were not more devicerelated (p = 0.06). The largest number of all MDR S.
aureus isolates were from New South Wales, whilst
the Northern Territory and the Australian Capital
Territory had the highest proportion of S. aureus thatwere MDR (Table 3).

Enterococcus spp.
Overall, 170 enterococci were reported to AGAR, 95
isolates in 2020 and 75 isolates in 2021. Of the 170
isolates, 122 were E. faecalis and 41 were E. faecium.
Five E. faecium isolates were MDR. Enterococci isolates were most frequently reported from patients< 1 year old. The largest proportions of episodes werefrom New South Wales and Victoria. The proportionof patients still in hospital at 30 days was higher inpatients who had an enterococcal infection (Table 1).
Overall, 19.6% of isolates were ampicillin resistant(n: 33; 95% CI: 13.9–26.5%); one isolate was E. faecalis, whilst the rest were E. faecium (n: 32). Over 70%
of ampicillin-resistant isolates were hospital-onset.
Most isolates were reported in patients aged 5–17
years, and from patients living in New South Wales.
Enterococci from hospital-onset episodes were more
frequently ampicillin resistant compared to community-onset enterococcal episodes (Table 5).
Fewer than five percent of Enterococci isolates werevancomycin resistant (4.7%; 95% CI: 2.1–9.1%). Eightvancomycin-resistant E. faecium (VREfm) were identified (19.5%; 95% CI: 8.8–34.9%), all from hospitalonset episodes. VREfm isolates were identified in
Queensland, Victoria, and New South Wales. Three
E. faecium were identified as teicoplanin resistant(7.3%; 95% CI: 1.5–19.9%); all were from hospitalonset episodes. Teicoplanin resistant isolates wereidentified in New South Wales and Victoria (Table 5).
Five Enterococci were MDR (2.9%), all E. faecium.
Four of the five MDR Enterococcus were identified
in Victoria; the remaining isolate was identified inSouth Australia (Table 3).

www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/202410www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/2024

11

3.6

2.2–5.6

9.2–26.8

62

18

21

59

32

24

5

9

10

6

17

0

7

14

6

28

2

80

n

11.7

23.1

16.3

12.3

9.8

18

10.9

17.6

19.6

8.2

11.2

0.0

12.3

15.9

20.7

16.2

10

13.2

R%

MRSA: methicillin-resistant S. aureus; MSSA: methicillin-susceptible S. aureus.

19

16.7

3.8–13.8

2.9–6.9

1.9–6.3

2.6–11.5

4.9–26.3

0.5–13.5

2.2–18.9

0.3–9.5

0.7–6.6—

1.1–14.6

1.3–11.2

0.1–17.8

5.8–15.3

0.1–24.9

3.6–7.4

95% CI

ACT: Australian Capital Territory; NSW: New South Wales; NT: Northern Territory; Qld: Queensland; SA: South Australia; Tas.: Tasmania; Vic.: Victoria; WA: Western Australia.

8.8–14.4

13

7.8

4.6

3.7

6.0

13

3.9

7.8

2.7

2.6

0.0

5.3

4.5

3.4

9.8

5.0

5.3

R%

d

11.3

11.2–29.7

10

22

12

8

6

2

4

2

4

0

3

4

1

17

1

32

n

n: number of resistant isolates; R%: proportion of resistant isolates; 95% CI: 95% confidence interval.

60

19.2

9.7–22.9

8.8–4.7

6.3–12.9

1.0–23.1

6.3–28.9

7.0–28.6

8.4–30.9

3.1–17.0

5.6–15.8—

1.1–14.6

8.1–23.9

8.0–39.7

11.5–23.2

3.2–37.9

9.8–15.2

95% CI

c

529

MSSA

15

15.5

11.5

9.2

15.8

15.2

15.7

17.6

8.2

9.9

0.0

5.3

14.8

20.7

16.8

15

12.4

R%

N: number of isolates tested.

78

MRSA

20

55

30

21

7

8

9

6

15

0

3

13

6

29

3

75

n

Erythromycinb

b

129

51

29–90 days

Hospital

51≤ 28 days

478

73

WA

Community

152

Vic.

326

15

Tas.

5–17 years

57

SA

133

88

Qld

1–4 years

29

NT

46

173

NSW

91–364 days

20

607

Na

ACT

Characteristic

CiprofloxacinbaMethicillin resistanced

Onset

Age group

Jurisdictionc

OverallCategory

Clindamycinb

95% CI

9.1–14.8

14.3–34.0

10.4–23.8

9.5–15.6

6.8–13.6

11.9–25.6

3.6–23.6

8.4–30.9

9.8–33.1

3.4–16.3

6.9–17.0—

5.5–22.8

9.4–24.7

8.8–38.2

11.3–22.2

1.7–29.3

10.6–16.1

Table 4: Number of Staphylococcus aureus isolates tested and proportion of isolates resistant to clindamycin, ciprofloxacin, and erythromycin fromchildren aged < 18 years as reported to AGAR, January 2020 – December 2021

www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/2024

12

16.5–34.5

6.0–22.7

30.7–62.6

7.2–32.1

2.8–33.6

0.9–25.1

0.7–18.2—

6.1–25.4—

23.0–77.0——

13.3–34.7—

13.9–26.5

95% CI

98

71

41

41

24

26

38

11

58

4

14

10

2

68

3

170

N

8

0

2

3

1

1

1

0

4

0

2

0

0

2

0

8

n

8.2

0

4.9

7.3

4.2

3.8

2.6

0

6.9

0

14.3

0

0

2.9

0

4.7

R%

3.6–15.5—

0.6–16.5

1.5–19.9

0.1–21.1

0.1–19.6

0.1–13.8—

1.9–16.7—

1.8–42.8——

0.4–10.2—

2.1–9.1

95% CI

98

72

41

41

24

26

38

11

58

4

14

10

2

68

3

170

N

3

0

1

2

0

0

0

0

1

0

0

0

0

2

0

3

n

3.1

0

2.4

4.9

0

0

0

0

1.7

0

0

0

0

2.9

0

1.8

R%

ACT: Australian Capital Territory; NSW: New South Wales; NT: Northern Territory; Qld: Queensland; SA: South Australia; Tas.: Tasmania; Vic.: Victoria; WA: Western Australia.

24.7

12.7

46.3

17.1

13

7.7

5.4

0

13.8

25

50

0

50

22.7

33.3

19.6

R%

N: number of isolates tested; n: number of resistant isolates; R%: proportion of resistant isolates; 95% CI: 95% confidence interval.

24

9

19

7

3

2

2

0

8

1

7

0

1

15

1

33

n

Teicoplanina

b

97

26

29–90 days

Hospital37≤ 28 days

71

11

WA

Community

58

Vic.

41

4

Tas.

5–17 years

14

SA

41

10

Qld

1–4 years

2

NT

23

68

NSW

91–364 days

3

168

N

ACT

Characteristic

Vancomycina

a

Onset

Age group

Jurisdictionb

OverallCategory

Ampicillina

Table 5: Number of Enterococcus spp. isolates tested and proportion of isolates resistant to ampicillin, vancomycin, and teicoplanin fromchildren aged < 18 years as reported to AGAR, January 2020 – December 2021

0.6–8.7—

0.1–12.9

0.6–16.5

—

—

—

—

0.0–9.2

—

—

—

—

0.4–10.2—

0.4–5.1

95% CI

Discussion
This AGAR Kids report is the first comprehensive
AGAR report describing the epidemiology of AMR
in the Australian paediatric population. The AGAR
surveillance programs provide the opportunity to
specifically analyse and report on bacteraemia from
Australian children. The programs also provide an
opportunity to compare paediatric data with theAustralian adult population. Although there aresome similarities, numerous differences warrant
ongoing paediatric specific reporting.
AMR surveillance of paediatric bacteraemia is a powerful public health tool, providing an understandingof the aetiology of disease, susceptibility patterns,
and the impact of infection prevention and control
strategies.3,10 AMR surveillance can also point topotential targets for therapeutics specifically for paediatrics: the development of medicines for children
lags unacceptably behind that for adults, and industry and funders remain unguided by robust healthcosting data to prioritise paediatric AMR strategies.11
It is estimated that every year, globally, AMR infection result in 700,000 deaths, including 200,000
newborns.12
There are few reports on paediatric populations fromsimilar AMR national surveillance systems. Whilst
the European system (EARS-Net) requests age to thenearest year, the data point is not mandatory andthus EARS-Net data are not routinely stratified byage.2 In the UK, the English Surveillance Programme
for Antimicrobial Utilisation and Resistance(ESPAUR) does stratify patient age, but paediatricspecific reports are not available.13 The Canadian
AMR surveillance program presents key highlights
of age-stratified data.14 One-off epidemiologicalreports have been produced from different regions
and countries, yet interpretation and comparison
to AGAR Kids is difficult because of differences in
the organisms selected for surveillance.2,4,10,15–23

This report is one of the most detailed paediatricspecific reports to date and facilitates the national
public health benchmarking of AMR in children
and neonates to ensure the effectiveness of AMR
programs. In Australian children (excluding neonates), the most frequently reported organism was
S. aureus (36% of isolates) and E. coli (23%); in neonates and the adult population this is reversed, with
E. coli being the most frequently reported organism(43.1% and 39% respectively) followed by S. aureus(20.2% and 20.9% respectively). A similar observation has been identified in Japan by Kusama et al.,22
and likely reflects the commonality of urinary tract
infections as the predominant source of bacteraemia
in the neonatal and adult population and bone andjoint infection the predominant source in children.24
Several papers globally have demonstrated that E.
coli bacteraemia is more frequent in children < 1 yearof age and S. aureus is more frequent in children withincreasing age.10,16,19,25–28
In enterococcal bacteraemia, differences in the predominant species in adults and children were identified. In paediatrics, whilst approximately 25% ofenterococci were identified as E. faecium, in adults
almost 40% of episodes were due to E. faecium.
Similarly, in several studies assessing paediatric bacteraemia, E. faecalis was more frequently identified
than E. faecium.15,29 Interestingly, on a populationlevel, the UK has reported a shift in enterococcal
bacteraemia, with more E. faecium and less E. faecalis reported during the coronavirus disease 2019
(COVID-19) pandemic; future AGAR Kids reports
will be needed to investigate if a similar trend
occurs in the Australian paediatric population.13
Additionally, whilst when compared to the EARSNet data, Australia ranks in the top third of countries for vancomycin-resistant E. faecium (VREfm),
the proportion of resistance in children is significantly lower: in 2021, AGAR reported 37.9% VREfm,
whilst in children there were only eight VREfm isolates (19.5%). This vast difference is important in theway infection prevention and stewardship programs
need to be targeted for specific populations.

www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/2024

13

Regional differences were noted in the pathogens
causing paediatric bacteraemia. The increased proportion of Salmonella bacteraemia in Queensland
is consistent with previous Australian reports,17,26
and is consistent with the literature of bacteraemia
in tropical environments.30–32 Significant differencesin the antimicrobial susceptibility patterns were also
observed between jurisdictions. The proportions ofEnterobacterales in Victoria resistant to gentamicin/
tobramycin and to third-generation cephalosporins were both significantly higher than the national
average: 16.8% compared to 11.6% for gentamicin/
tobramycin (p: 0.04) and 19.3% compared to 12.9%
for third-generation cephalosporins (p: 0.01). Similar
to gram-negative bacteraemia, regional differences
in S. aureus were noted; there was a clear disproportion in the geographic distribution of MRSA episodes reported across Australia, and the over representation from the NT is found in both adults andchildren. The higher proportions of resistance in
MRSA compared to MSSA and an older age group isaligned with the literature.13 A more detailed investigation in the geographic distribution of pathogens
in paediatrics is proposed and it is hypothesised that
there will be a higher proportion of MRSA across thenorth of Australia which has been reported in theliterature.33–36 These geographical differences haveimportant implications for jurisdictional infection
prevention and stewardship programs.

The AGAR surveillance system only captures
S. aureus, Enterococcus spp., Enterobacterales,
P. aeruginosa and Acinetobacter spp. This limits theunderstanding of the true burden of bacteraemia,
as key pathogens such as Streptococcus spp. are notrecorded. Additionally, vaccine-preventable bacteraemic pathogens are not reported, and thus any
changes in incidence or proportion of aetiology ofbacteraemia is not captured.
Additional data analysis will be undertaken on aregular basis to track the emergence of AMR in
Australian children, to investigate the differencesin AMR between adults and paediatric bacteraemia
isolates, and to assess the trends in paediatric AMR
across Australia.
Overall, this report highlights key differences in antimicrobial resistance and geographic distributions ofbacteraemic pathogens in Australian children. These
differences emphasise the importance of paediatricspecific infection prevention and stewardship programs, and the need to continue AMR surveillancein the paediatric population.

As per the WHO-defined priority list of pathogens,37 only four critical priority isolates were identified: two P. aeruginosa and two E. cloacae complex
carbapenem-resistant (CRE). However, 21 WHOdefined high priority pathogens were identified
other than MRSA: eight vancomycin-resistant E.
faecium and 13 fluroquinolone-resistant Salmonella.
These findings suggest that despite the increasinglevels of AMR in the general Australian population,
WHO priority pathogens are rarely detected in theAustralian paediatric population. This also demonstrates the benefit of using local paediatric data tostrengthen antimicrobial stewardship programs andinform antibiotic guidelines.

www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/2024

14

Acknowledgments
This report is from the AGAR-Kids group andfunded by the Australian Government Department
of Health and Aged Care.

South Australia

Members of AGAR in 2020/2021 were:Morgyn Warner and Kija Smith, SA Pathology(Royal Adelaide Hospital and Women’s andChildren’s Hospital)

Australian Capital Territory
Peter Collignon and Susan Bradbury, The Canberra
Hospital
New South Wales
Thomas Gottlieb and John Huynh, Concord Hospital

Kelly Papanaoum and Xiao Ming Chen, SA
Pathology (Flinders Medical Centre)

Tasmania
Louise Cooley and David Jones, Royal Hobart
HospitalJames Branley and Linda Douglass, Nepean Hospital

Pankaja Kalukottege, Kathy Wilcox and
Brooke Wooley, Launceston General Hospital

Angela Wong, Royal North Shore Hospital

Victoria

Jon Iredell and Andrew Ginn, Westmead Hospital
Rod Givney and Bree Harris, John Hunter HospitalPeter Newton and Melissa Hoddle, Wollongong
HospitalDavid Lorenz, St Vincent’s Hospital
Monica Lahra and Peter Huntington, Sydney
Children’s Hospital
Alison Kesson and Andrew Jarrett, Children’s
Hospital Westmead
Michael Maley and Helen Ziochos, Liverpool HospitalNorthern Territory
Sebastiaan van Hal and Alicia Beukers, RoyalPrince Alfred Hospital Northern Territory
Rob Baird and Jann Hennessy, Royal Darwin HospitalJames McLeod, Alice Springs Hospital
Queensland
Graeme Nimmo and Narelle George, Pathology
Queensland Central Laboratory, Royal Brisbane
and Women’s Hospital
Petra Derrington and Cheryl Curtis, Pathology
Queensland Gold Coast Hospital
Robert Horvath and Laura Martin, Pathology
Queensland Prince Charles Hospital
Naomi Runnegar and Joel Douglas, Pathology
Queensland Princess Alexandra Hospital
Jennifer Robson and Marianne Allen, Sullivan
Nicolaides Pathology, Greenslopes Hospital

Denis Spelman, Adam Jenney and
Jacqueline Williams, The Alfred Hospital
Marcel Leroi and Elizabeth Grabsch, Austin Health
Tony Korman, Despina Kotsanas andKathryn Cisera, Monash Medical Centre, Monash
Children’s Hospital and Dandenong Hospital
Andrew Daley and Gena Gonis, Royal Women’s andChildren’s Hospital
Mary Jo Waters, Amy Crowe and Lisa Brenton,
St Vincent’s Hospital
Katherine Bond and Rose Cotronei,
Royal Melbourne HospitalWestern Australia
David McGechie and Denise Daley, PathWest
Laboratory Medicine – WA Fiona Stanley Hospital
Ronan Murray and Jacinta Bowman, PathWest
Laboratory Medicine – WA Sir Charles Gairdner
Hospital
Michael Leung, PathWest Laboratory Medicine –Northwest WA
Owen Robinson and Geoffrey Coombs, PathWest
Laboratory Medicine – WA Royal Perth Hospital
Sudha Pottumarthy-Boddu and Jacqueline Foster,Australian Clinical Laboratories, St John of God
Hospital, Murdoch
Shalinie Perera and Ian Meyer, Western Diagnostic
Pathology, Joondalup Hospital
Christopher Blyth, Perth Children’s Hospital

Clare Nourse, Queensland Children’s Hospital

www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/2024

15

Author details
Anita Williams,1
Geoffrey W Coombs,

2,3,4

Jan Bell,5Denise A Daley,3,4
Shakeel Mowlaboccus,2,3,4
Penelope A Bryant,6,7
Anita J Campbell,1,9,10
Louise Cooley,11
Jon Iredell,12,13,14,15
Adam D Irwin,16,17
Alison Kesson,13,18
Brendan McMullan,19, 20
Morgyn S Warner,21,22
Phoebe Williams,13,20,23
Christopher C Blyth.1,9,10,24

12. Centre for Infectious Diseases andMicrobiology, The Westmead Institute for
Medical Research, Westmead, NSW
13. Faculty of Medicine and Health, University ofSydney, Sydney, NSW
14. Westmead Hospital, Western Sydney Local
Health District, Westmead, NSW
15. Sydney Institute for Infectious Disease, The
University of Sydney, Sydney, NSW
16. Centre for Clinical Research, University of
Queensland, Brisbane, Queensland
17. Infection Management Prevention Service,
Queensland Children’s Hospital, Brisbane,
Queensland
18. Department of Infectious Disease &Microbiology, The Children’s Hospital atWestmead, Westmead, NSW

1.

Wesfarmers Centre of Vaccines and Infectious
Diseases, Telethon Kids Institute, Nedlands, WA

19. School of Clinical Medicine, Faculty of
Medicine and Health, University of New South
Wales, Kensington, NSW

2.

Antimicrobial Resistance and Infectious
Diseases (AMRID) Research Laboratory,
Murdoch University, Murdoch, WA

20. Department of Immunology and Infectious
Diseases, Sydney Children’s Hospital, Sydney
Children’s Hospitals Network, Randwick, NSW

3.

Department of Microbiology, PathWest
Laboratory Medicine WA, Fiona Stanley
Hospital, Murdoch, WA

21. Infectious Diseases Unit, Central Adelaide
Local Health Network, Adelaide, SA

4.

Australian Group on Antimicrobial Resistance,
Fiona Stanley Hospital, Murdoch, WA

5.

Australian Group on Antimicrobial Resistance,
Adelaide, SA

6.

Infectious Diseases, The Royal Children’s
Hospital Melbourne, Parkville, VIC

7.

Department of Paediatrics, University of
Melbourne, Parkville, Victoria

8.

Murdoch Children’s Research Institute,
Parkville, Victoria

9.

Department of Infectious Diseases, PerthChildren’s Hospital, Nedlands, WA

10. Division of Paediatrics, School of Medicine,
University of Western Australia, Nedlands, WA
11. Department of Infectious Diseases, Royal
Hobart Hospital, Tasmania

22. Faculty of Health and Medical Sciences,
University of Adelaide, Adelaide, SA
23. School of Women and Children’s Health,
University of New South Wales, Kensington,
NSW
24. Department of Microbiology, PathWest
Laboratory Medicine WA, QEII Medical
Centre, Nedlands, WA

Corresponding author
Ms Anita Williams
Address: Telethon Kids Institute, 15 Hospital
Ave, Nedlands 6009 WA
Phone: +61 8 6319 1000
Email: anita.williams@telethonkids.org.au

www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/2024

16

References
1.

Buttery J, Yang Y, Sharland M, World Society for Pediatric Infectious Diseases. World Society
for Pediatric Infectious Diseases declaration on combating antimicrobial resistance in children.
World J Pediatr. 2018;14(6):523–4. doi: https://doi.org/10.1007/s12519-018-0195-x.

2.

Bielicki JA, Lundin R, Sharland M, ARPEC Project. Antibiotic resistance prevalence in routine
bloodstream isolates from children’s hospitals varies substantially from adult surveillance data in
Europe. Pediatr Infect Dis J. 2015;34(7):734–41. doi: https://doi.org/10.1097/INF.0000000000000652.

3.

Pai S, Enoch DA, Aliyu SH. Bacteremia in children: epidemiology, clinicaldiagnosis and antibiotic treatment. Expert Rev Anti Infect Ther. 2015;13(9):1073–88.
doi: https://doi.org/:10.1586/14787210.2015.1063418.

4.

Campbell AJ, Daley DA, Bell JM, Pang S, Coombs GW, Carapetis JR et al. Progress towards acoordinated, national paediatric antimicrobial resistance surveillance programme: Staphylococcus
aureus, enterococcal and gram-negative bacteraemia in Australia. J Antimicrob Chemother.
2020;75(6):1639–44. doi: https://doi.org/10.1093/jac/dkaa065.

5.

Murdoch F, Danial J, Morris AK, Czarniak E, Bishop JL, Glass E et al. The Scottish enhanced
Staphylococcus aureus bacteraemia surveillance programme: the first 18 months of data in children.
J Hosp Infect. 2017;97(2):127–32. doi: https://doi.org/10.1016/j.jhin.2017.06.017.

6.

Australian Institute of Health and Welfare (AIHW). Australian Hospital Peer Groups. Health Services
Series No. 66. Canberra: AIHW; 2015. Available from: https://www.aihw.gov.au/getmedia/79e7d756-7cfe49bf-b8c0-0bbb0daa2430/14825.pdf.

7.

The European Committee on Antimicrobial Susceptibility Testing (EUCAST). Breakpoint tables forinterpretation of MICs and zone diameters. Version 12.0. Basel: EUCAST; 1 January 2022. Available from:https://www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/Breakpoint_tables/v_12.0_
Breakpoint_Tables.xlsx.

8.

Berends MS, Friedrich AW, Albers CJ, Luz CF, Sinha BNM, Glasner C. AMR – an R package for working
with antimicrobial resistance data. J Stat Softw. 2022;104(3):1–31. doi: https://doi.org/10.18637/jss.v104.i03.

9.

Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG et al. Multidrugresistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal
for interim standard definitions for acquired resistance. Clin Microbiol Infect. 2012;18(3):268–81.
doi: https://doi.org/10.1111/j.1469-0691.2011.03570.x.

10. Henderson KL, Johnson AP, Muller-Pebody B, Charlett A, Gilbert R, Sharland M. The changing
aetiology of paediatric bacteraemia in England and Wales, 1998–2007. J Med Microbiol. 2010;59(2):213–
19. doi: https://doi.org/10.1099/jmm.0.015271-0.
11. Pana ZD, El-Shabrawi M, Sultan MA, Murray T, Alam A, Yewale V et al. Fighting the hidden pandemicof antimicrobial resistance in paediatrics: recommendations from the International Pediatric
Association. BMJ Paediatr Open. 2023;7(1):e002084. doi: https://doi.org/10.1136/bmjpo-2023-002084.
12. Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: asystematic analysis. Lancet. 2022;399(10325):629–55. doi: https://doi.org/10.1016/S0140-6736(21)02724-0.
13. United Kingdom Health Security Agency. English surveillance programme for antimicrobial
utilisation and resistance (ESPAUR) report 2021 to 2022. London: United Kingdom Health
Security Agency; 21 November 2022. Available from: https://webarchive.nationalarchives.
gov.uk/ukgwa/20231002172235/https://www.gov.uk/government/publications/english-surveillance-programme-antimicrobial-utilisation-and-resistance-espaur-report.

www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/202417

14. Antimicrobial Resistance Taskforce (AMRTF). Système canadien de surveillance de la résistance
aux antimicrobiens : Rapport de 2022. Ottawa, Canada: Public Health Agency of Canada (PHAC);
28 November 2022. doi: https://doi.org/10.58333/f241022.
15. Bizot E, Truong J, Mariani-Kurkdjian P, Bonacorsi S, Faye A, Caseris M. Pediatric enterococcal
bacteremia: a 12-year retrospective study in a French pediatric center. Pediatr Infect Dis J.
2022;41(9):e346–50. doi: https://doi.org/10.1097/INF.0000000000003631.
16. Buetti N, Atkinson A, Kottanattu L, Bielicki J, Marschall J, Kronenberg A. Patterns and trendsof pediatric bloodstream infections: a 7-year surveillance study. Eur J Clin Microbiol Infect Dis.
2017;36(3):537–44. doi: https://doi.org/10.1007/s10096-016-2830-6.
17. Douglas MW, Lum G, Roy J, Fisher DA, Anstey NM, Currie BJ. Epidemiology of community-acquired
and nosocomial bloodstream infections in tropical Australia: a 12-month prospective study. Trop Med
Int Health. 2004;9(7):795–804. doi: https://doi.org/10.1111/j.1365-3156.2004.01269.x.
18. Droz N, Hsia Y, Ellis S, Dramowski A, Sharland M, Basmaci R. Bacterial pathogens and resistancecausing community acquired paediatric bloodstream infections in low- and middle-income
countries: a systematic review and meta-analysis. Antimicrob Resist Infect Control. 2019;8(1):207.
doi: https://doi.org/10.1186/s13756-019-0673-5.
19. Ferreira M, Santos M, Rodrigues J, Diogo C, Resende C, Baptista C et al. Epidemiology of bacteremia
in a pediatric population – a 10-year study. Enferm Infecc Microbiol Clin (Engl Ed). 2021:S0213005X(21)00207-X. doi: https://doi.org/10.1016/j.eimc.2021.06.011.
20. Graff KE, Windsor WJ, Calvimontes DM, Melgar MA, Galvez N, Rivera JG et al. Antimicrobial
resistance trends at a pediatric hospital in Guatemala City, 2005–2019. J Pediatric Infect Dis Soc.
2021:piab048. doi: https://doi.org/10.1093/jpids/piab048.
21. Iroh Tam P-Y, Musicha P, Kawaza K, Cornick J, Denis B, Freyne B et al. Emerging resistance to empiric
antimicrobial regimens for pediatric bloodstream infections in Malawi (1998–2017). Clin Infect Dis.
2019;69(1):61–8. doi: https://doi.org/10.1093/cid/ciy834.
22. Kusama Y, Ito K, Fukuda H, Matsunaga N, Ohmagari N. National database study of trends inbacteraemia aetiology among children and adults in Japan: a longitudinal observational study.
BMJ Open. 2021;11(3):e043774. doi: https://doi.org/10.1136/bmjopen-2020-043774.
23. Agyeman PKA, Schlapbach LJ, Giannoni E, Stocker M, Posfay-Barbe KM, Heininger U
et al. Epidemiology of blood culture-proven bacterial sepsis in children in Switzerland:
a population-based cohort study. Lancet Child Adolesc Health. 2017;1(2):124–33.
doi: https://doi.org/10.1016/S2352-4642(17)30010-X.
24. Coombs G, Bell JM, Daley D, Collignon P, Cooley L, Gottlieb T et al. Australian Group on Antimicrobial
Resistance (AGAR) Surveillance Outcomes Programs: Bloodstream infections 2021 Report. Sydney:
Australian Commission on Safety and Quality in Health Care; November 2022. Available from:https://www.safetyandquality.gov.au/sites/default/files/2022-12/2021_agar_amalgam_report.pdf.
25. Laupland KB, Gregson DB, Vanderkooi OG, Ross T, Kellner JD. The changing burden of pediatricbloodstream infections in Calgary, Canada, 2000–2006. Pediatr Infect Dis J. 2009;28(2):114–7.
doi: https://doi.org/10.1097/INF.0b013e318187ad5a.
26. Er J, Wallis P, Maloney S, Norton R. Paediatric bacteraemias in tropical Australia. J Paediatr Child
Health. 2015;51(4):437–42. doi: https://doi.org/10.1111/jpc.12750.
27. Shakur SM, Whitehall J, Mudgil P. Pediatric bloodstream infections in metropolitan Australia. World J
Pediatr. 2019;15(2):161–7. doi: https://doi.org/10.1007/s12519-018-00221-3.

www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/202418

28. Qiu Y, Yang J, Chen Y, Yang J, Zhu Q, Zhu C et al. Microbiological profiles and antimicrobial resistancepatterns of pediatric bloodstream pathogens in China, 2016–2018. Eur J Clin Microbiol Infect Dis.
2021;40(4):739–49. doi: https://doi.org/10.1007/s10096-020-04069-2.
29. Stover KR, Morrison A, Collier T, Schneider E, Wagner JL, Capino AC et al. Epidemiology andrisk factors for bacteremia in pediatric and adolescent patients. J Pharm Pract. 2021;34(3):360–4.
doi: https://doi.org/10.1177/0897190019868056.
30. Chang YJ, Chen YC, Chen NW, Hsu YJ, Chu HH, Chen CL et al. Changing antimicrobial resistanceand epidemiology of non-typhoidal Salmonella infection in Taiwanese children. Front Microbiol.
2021;12:648008. doi: https://doi.org/10.3389/fmicb.2021.648008.
31. Moore N, Ashley EA, Dickson B, Douangnouvong A, Panyaviseth P, Turner P et al. A systematic review
of antimicrobial resistance among children in low- and middle-income countries in the Western
Pacific Region (WPRO). Amsterdam: Elsevier, Social Sciences Research Network (SSRN); 4 May 2023.
[Accessed on 23 June 2023.] doi: https://doi.org/10.2139/ssrn.4430748.
32. Parisi A, Crump JA, Stafford R, Glass K, Howden BP, Kirk MD. Increasing incidence of invasive
nontyphoidal Salmonella infections in Queensland, Australia, 2007–2016. PLoS Negl Trop Dis.
2019;13(3):e0007187. doi: https://doi.org/10.1371/journal.pntd.0007187.
33. McMullan BJ, Bowen A, Blyth CC, Van Hal S, Korman TM, Buttery J et al. Epidemiology andmortality of Staphylococcus aureus bacteremia in Australian and New Zealand children. JAMA Pediatr.
2016;170(10):979–86. doi: https://doi.org/10.1001/jamapediatrics.2016.1477.
34. Harch SAJ, MacMorran E, Tong SYC, Holt DC, Wilson J, Athan E et al. High burden of complicatedskin and soft tissue infections in the Indigenous population of Central Australia due to dominant
Panton Valentine leucocidin clones ST93-MRSA and CC121-MSSA. BMC Infect Dis. 2017;17(1):405.
doi: https://doi.org/10.1186/s12879-017-2460-3.
35. Engelman D, Hofer A, Davis JS, Carapetis JR, Baird RW, Giffard PM et al. Invasive Staphylococcus
aureus infections in children in tropical northern Australia. J Pediatr Infect Dis Soc. 2014;3(4):304–11.
doi: https://doi.org/10.1093/jpids/piu013.
36. Hewagama S, Spelman T, Woolley M, McLeod J, Gordon D, Einsiedel L. The epidemiology ofStaphylococcus aureus and Panton-Valentine leucocidin (pvl) in Central Australia, 2006–2010.
BMC Infect Dis. 2016;16:382. doi: https://doi.org/10.1186/s12879-016-1698-5.
37. World Health Organization (WHO). WHO Bacterial Priority Pathogens List, 2024: Bacterial
pathogens of public health importance to guide research, development and strategies to prevent andcontrol antimicrobial resistance. Geneva: WHO; 17 May 2024. Available from: https://www.who.int/
publications/i/item/9789240093461.

www.health.gov.au/cdi • Commun Dis Intell (2018) 2024;48 (https://doi.org/10.33321/cdi.2024.48.32) • Epub 21/08/202419