Background: Antimicrobial resistance (AMR) is a growing global health threat, with children in low- and middle-income countries bearing a disproportionate burden. Data on resistance patterns and diagnostic practices in pediatric populations remain limited. This study evaluated diagnostic utilization and AMR among children hospitalized with bacterial infections at a national referral hospital in Kenya. Methods: We conducted a retrospective cohort study of pediatric inpatients (0–12 years) admitted with bacterial infections between 2017 and 2021. Patient records were identified using ICD-10 codes and reviewed for diagnostic testing and antimicrobial susceptibility. Descriptive statistics were conducted to show infection counts, diagnostic testing, and resistance outcomes. Results: Among 1608 patients, 1009/1608 (63%) were infants under one year. Culture was conducted in 640/1608 (40%) and antimicrobial sensitivity testing in 111/640 (17%) patients. Gastroenteritis (46%) was the most common infection and blood the most frequently collected specimen (31%). Of 1039 cultured specimens, 896/1039 (86%) showed no growth. The most commonly isolated organisms were Klebsiella pneumoniae 19/128 (15%), Staphylococcus epidermidis (13%, 17/128), and Enterococcus faecium (13%, 16/128). Notably, K. pneumoniae showed 100% resistance to third-generation cephalosporins, suggestive of ESBL production. Among the tested samples, 92/128 (72%) had MDROs, and 26/92 (28%) were extensively drug-resistant (XDR). Among the patients tested, 84/111 (76%) had MDROs, of which 25/84 (30%) were XDR. Children under 5 years had higher odds (OR = 5.84, 95% CI: 1.17-38.21) of having MDRO infections, as well as those with multiple admissions (OR = 3.77, 95% CI: 1.06–20.34). Further, increasing age was inversely associated with MDRO presence. The odds of MDRO infection decreased by 24% for every year increase in age (aOR = 0.76; 95% CI: 0.60–0.93; p = 0.006). Conclusions: The findings highlight the limited diagnostic use and a high burden of MDROs and XDR infections in hospitalized children. Strengthening diagnostic capacity and pediatric antimicrobial stewardship is urgently needed in such settings.

: Antimicrobial resistance poses a growing threat to pediatric care, yet data on its clinical and economic burden in low-resource settings remain limited. The impact of antibiotic-resistant infections on mortality, hospital stay, and treatment costs was assessed among children admitted to a national referral hospital in Kenya in the present study. A retrospective review of medical records for pediatric patients (0–12 years) hospitalized with bacterial infections between January 2017 and December 2021 was conducted. Diagnoses included gastroenteritis, pneumonia, sepsis, urinary tract infections, meningitis, and others. Data on treatment, laboratory testing, outcomes, hospital stays, and costs were abstracted. Statistical analyses included Kaplan–Meier survival curves, Cox regression, and mixed-effects negative binomial and generalized linear models. Among 1,608 patients, 63% were infants, and 38% were referrals. Gastroenteritis (46%) and pneumonia (28%) were the most common diagnoses. Antibiotic-resistant infections occurred in 27% of participants and were associated with higher mortality (26% versus 9% in susceptible participants) and an attributable risk of 17%; the population attributable fraction was 65%. After adjustment, resistance was associated with increased mortality (HR 1.44), longer hospital stays (60% increase), and higher treatment costs (33% increase). Antimicrobial resistance significantly increases mortality, hospital stays, and healthcare costs in pediatric patients. Strengthening diagnostics, antimicrobial stewardship, and policy interventions is critical to address this threat.