Antimicrobial Resistance and Paediatric Endocarditis: A One Health Crisis

Abstract

Infective endocarditis (IE) in children, though relatively rare, carries significant morbidity and mortality. The emergence of antimicrobial resistance (AMR) among causative pathogens is transforming the landscape of paediatric IE, complicating treatment and worsening outcomes. This narrative review examines the growing crisis of AMR in paediatric endocarditis through a One Health lens, recognising that resistance genes do not respect the boundaries between human medicine, animal agriculture, and the environment. We synthesise current evidence on the microbiology of paediatric IE, with emphasis on methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and multidrug-resistant Gram-negative bacilli. The contribution of agricultural antibiotic use to the resistance burden in human infections is explored, drawing on epidemiological and genomic studies. We examine transmission pathways; foodborne, environmental, and direct contact, through which resistant organisms and their resistance genes travel from animals and ecosystems to children. The unique vulnerabilities of children with congenital heart disease, prosthetic materials, and central venous catheters are discussed. Current therapeutic challenges include limited paediatric data for newer antibiotics, the complexities of managing biofilm-associated infections, and the near-absence of cardiac surgical services in many low-resource settings. We propose a framework for action grounded in antimicrobial stewardship across human and veterinary medicine, enhanced surveillance integrating human, animal, and environmental data, infection prevention and control, and targeted research priorities. Addressing the crisis of AMR in paediatric endocarditis demands a coordinated, multisectoral One Health approach.