Purpose of Review
We aim to systematically review the literature on the effectiveness of pediatric antimicrobial stewardship programs (ASPs) and antimicrobial stewardship (AS) strategies in the United States (US) inpatient setting. Furthermore, we review current gaps and challenges for unique pediatric populations and those in ambulatory settings.
Misuse and overuse of antimicrobials have been identified as key factors for antimicrobial resistance (AR). Multiple professional organizations support the implementation of hospital-based ASPs to decrease antimicrobial consumption, improve patient outcomes, and reduce healthcare costs. There is limited data on the effectiveness of inpatient pediatric ASPs and AS strategies in unique populations. Furthermore, there is a paucity of evidence on ASPs in ambulatory settings.
This review contributes to the growing body of evidence that supports the use of pediatric ASPs to optimize antimicrobial therapy in the inpatient setting as well as in unique patient populations and ambulatory settings. Active stewardship is critical and antimicrobial consumption is a key outcome metric for programs.
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Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
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• Hersh AL, De Lurgio SA, Thurm C, Lee BR, Weissman SJ, Courter JD, et al. Antimicrobial stewardship programs in freestanding children's hospitals. Pediatrics. 2015;135(1):33–9. This is a multicenter study across freestanding children’s hospitals. Authors observed an overall decrease in antimicrobial use in DOT per 1000 PD across freestanding children’s hospitals with or without ASP. The rate of decline was highest in those with a formalized ASP. This study adds to the growing body of evidence that suggests inpatient pediatric ASPs can be effective at decreasing antimicrobial consumption
• Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep. 2016;65(6):1–12. These authors provide guidance for antimicrobial stewardship in the outpatient setting based on existing evidence-based guidelines and expert opinion from other clinical settings.
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• Turner RB, Valcarlos E, Loeffler AM, Gilbert M, Chan D. Impact of an Antimicrobial Stewardship Program on Antibiotic Use at a Nonfreestanding Children's Hospital. J Pediatric Infect Dis Soc. 2017;6(3):e36–40. This is a single-center study in a non-freestanding children’s hospital that reported on the impact of PAF on antimicrobial consumption. Authors found an overall reduction of antimicrobial use and vancomycin use in DOT per 1000 PD without a difference in hospital LOS or in-hospital mortality. This study adds to the growing body of evidence that suggests inpatient pediatric ASPs can be effective at decreasing antimicrobial consumption without affecting patient safety
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• Hurst AL, Child J, Pearce K, Palmer C, Todd JK, Parker SK. Handshake stewardship: a highly effective rounding-based antimicrobial optimization service. Pediatr Infect Dis J. 2016;35(10):1104–10. This is a single-center study in a freestanding children’s hospital. Authors implemented a “handshake stewardship” program defined by lack of restriction and preauthorization, review of all prescribed antimicrobials, and rounding-based feedback by a pharmacist-physician team. This approach reduced hospital-wide antimicrobial consumption and reduced meropenem and vancomycin use as well. This study adds to the growing body of evidence that suggests inpatient pediatric ASPs can be effective at decreasing antimicrobial consumption.
• Willis ZI, Gillon J, Xu M, Slaughter JC, Di Pentima MC. Reducing antimicrobial use in an academic pediatric institution: evaluation of the effectiveness of a prospective audit with real-time feedback. J Pediatric Infect Dis Soc. 2017;6(4):339–45. This is a single-center center that implemented an ASP primarily focused on PAF, but that also included elements of prior authorization and CPG development, which led to an overall reduction of antimicrobial DOT per 1000 PD. Using a comparator group, authors concluded that the ASPs impact was greater than would have been expected based on secular trends.
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• Molloy L, McGrath E, Thomas R, Kaye KS, Rybak MJ. Acceptance of pharmacist-driven antimicrobial stewardship recommendations with differing levels of physician involvement in a children’s hospital. Clin Pediatr (Phila). 2017;56(8):744–51. This is a single-center center that implemented a pharmacist-driven ASP and found no difference in hospital LOS, in-hospital mortality, or all-cause readmission after implementation. This study adds to the growing body of evidence that suggests inpatient pediatric ASPs can be effective at decreasing antimicrobial consumption.
• Ross RK, Beus JM, Metjian TA, Localio AR, Shelov ED, Desai BR, et al. Safety of automatic end dates for antimicrobial orders to facilitate stewardship. Infect Control Hosp Epidemiol. 2016;37(8):974–8. This is a single-center center that implemented an ASP focused on restriction with an automated EMR stop order and found no difference in hospital LOS, in-hospital mortality, or readmission rates during the study period. This study adds to the growing body of evidence that suggests inpatient pediatric ASPs can be implemented without affecting patient safety.
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• Lee KR, Bagga B, Arnold SR. Reduction of broad-spectrum antimicrobial use in a tertiary children’s hospital post antimicrobial stewardship program guideline implementation. Pediatr Crit Care Med. 2016;17(3):187–93. This is a single-center center that implemented multiple CPGS for patients in their institution’s pediatric, NICU, and cardiac ICU. Authors found a reduction in overall and targeted antimicrobial consumption across studied units.
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• Goldman JL, Richardson T, Newland JG, Lee B, Gerber JS, Hall M, et al. Outpatient parenteral antimicrobial therapy in pediatric Medicaid enrollees. J Pediatric Infect Dis Soc. 2017;6(1):65–71. Authors studied outpatient parenteral antibiotic therapy (OPAT) in a large population of US children enrolled in Medicaid and found a high rate of adverse events coupled with administration of systemic agents that are highly bioavailable that could be given orally. OPAT may be a suitable target for an outpatient-based ASP.
• Hersh AL, Olson J, Stockmann C, Thorell EA, Knackstedt ED, Esquibel L, et al. Impact of antimicrobial stewardship for pediatric outpatient parenteral antibiotic therapy. J Pediatric Infect Dis Soc 2017. This is a single-center study where authors incorporated outpatient parenteral antibiotic therapy into their established ASP. This study demonstrates that traditional ASPs can be extended and incorporated in the outpatient setting.
•• Moehring RW, Anderson DJ, Cochran RL, Hicks LA, Srinivasan A, Dodds Ashley ES, et al. Expert consensus on metrics to assess the impact of patient-level antimicrobial stewardship interventions in acute-care settings. Clin Infect Dis. 2017;64(3):377–83. This article provides expert consensus on appropriate metrics to assess ASP interventions in inpatient settings.
• Gerber JS, Hersh AL, Kronman MP, Newland JG, Ross RK, Metjian TA. Development and application of an antibiotic spectrum index for benchmarking antibiotic selection patterns across hospitals. Infect Control Hosp Epidemiol. 2017;38(8):993–7. Authors created an antibiotic spectrum index to measure and compare the broad spectrum of antimicrobial use across US children’s hospitals. This metric, based on spectrum of activity against clinically relevant pathogens, provides a new opportunity to assess ASPs along with the standard metric of DOT per 1000 PD. This metric may be helpful in evaluating the effectiveness of ASP at decreasing the utilization of broad-spectrum antimicrobials.
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•• Joint Commission on Hospital Accreditation. APPROVED: new antimicrobial stewardship standard. Jt Comm Perspect. 2016;36(7):1, 3–4, 8. This statement from the Joint Commission requires that all hospitals implement an ASP based on current scientific literature, which was effective on January 1, 2017.
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• Feldstein D, Sloane PD, Feltner C. Antibiotic stewardship programs in nursing homes: a systematic review. J Am Med Dir Assoc 2017. This is a systematic review of studies published on the effectiveness of ASPs in nursing homes. Authors concluded that ASPs in this unique patient population can reduce antimicrobial prescriptions and improve provider adherence to proposed AS guidelines. This study adds to the growing body of evidence that ASPs can be effectively used in unique patient populations.
Conflict of Interest
The authors declare that they have no conflicts of interest.
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This article does not contain any studies with human or animal subjects performed by any of the authors.
This article is part of the Topical Collection on Healthcare Associated Infections
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Godbout, E.J., Pakyz, A.L., Markley, J.D. et al. Pediatric Antimicrobial Stewardship: State of the Art. Curr Infect Dis Rep 20, 39 (2018). https://doi.org/10.1007/s11908-018-0644-7
- Pediatric antimicrobial stewardship
- Pediatric antimicrobial stewardship program
- Antimicrobial stewardship
- Antimicrobial resistance