Longitudinal Trends in Pediatric Non- Salmonella Gram-Negative Enterobacterales Infections at a Tertiary Care Center in West Africa, 2005–2023

BACKGROUND: Despite data demonstrating the high prevalence of third-generation cephalosporin resistant Gram-negative Enterobacterales (GNE) among children in sub-Saharan Africa, longitudinal descriptions of resistance among these pathogens from Francophone West Africa remain rare. METHODS: We conducted a retrospective analysis of pathogen-positive children 0-15 years old included in an invasive bacterial infection study at l'Hôpital Gabriel Touré (in Bamako, Mali) from 2005 to 2023. We aimed to describe changes in pathogen burden and non-Salmonella GNE resistance over time and compare in-hospital mortality between patients with and without non-Salmonella GNE pathogens. Isolates from 2021 to 2023 underwent whole-genome sequencing to identify genes conferring antimicrobial resistance. RESULTS: Of 3803 pathogen-positive patients, 392 grew at least 1 non-Salmonella GNE pathogen. The proportion of pathogen-positive patients with non-Salmonella GNE increased (6% vs 38%) from 2005-2023. Third-generation cephalosporin and multidrug resistance among non-Salmonella GNE increased from 30% and 55%, respectively, in 2005-2009, to 93% (both) by 2021-2023. Children 0-2 months old from outside Bamako and 3 months-15 years old from and from outside Bamako with non-Salmonella GNE had higher mortality odds (3.17, 95% CI 1.69-5.95; 2.13, 95% CI 1.44-3.14; and 2.25, 95% CI 1.38-3.66, respectively) than similar patients with other pathogens. Sequencing confirmed the presence of the emerging pathogen Pantoea dispersa and revealed genes conferring multidrug resistance. CONCLUSIONS: Data from this large pediatric referral center in Mali show a high and rising burden of multidrug-resistant Gram-negative Enterobacterales. These patterns reflect concerns increasingly reported across sub-Saharan Africa, highlighting the urgency of strengthening antimicrobial access, diagnostics, and stewardship strategies in similar settings.