Antibiotic Stewardship in Pediatrics

Utility of Antibiotic Use in Pediatric Facial Fractures: A Systematic Review

Background: In regard to antibiotic stewardship, it is important to understand the appropriate time to prescribe antibiotics in pediatric facial fracture management. Objective: To evaluate the utility of antibiotics in pediatric facial fractures and determine situational variables influencing appropriate antibiotic prescription. Methods: A comprehensive literature search was conducted in PubMed, Cochrane, and Web of Science databases for articles published from 2000 to 2022. Inclusion criteria consisted of all studies assessing pediatric facial fractures that mentioned antibiotic use. Results: A total of 13 studies were included in the full review. The reviewed studies comprised 31 pediatric patients ranging from 6 months to 18 years old. Most studies were case reports and case series (N = 9). Antibiotics were prescribed for the majority (96.7%) of patients. Antibiotic regimens varied by timing of administration, antibiotic used, and dosage. Fracture locations also varied widely, including orbital, zygomatic, nasal, mandibular, and maxillary fractures. Conclusions: Additional studies with more substantial evidence are needed to fully understand the situational appropriateness of antibiotic use in pediatric facial fractures.

Trend in antibiotic prescription at pediatric primary emergency medical centers in Japan: A multi-center, cross-sectional study

INTRODUCTION

Antimicrobial resistance is a global issue, and implementation of antimicrobial stewardship programs in outpatient settings is crucial. Japan has also focused on outpatient oral antimicrobial stewardship programs and difficulties in standardizing prescriptions have led to overprescription in primary emergency medical centers. There is a lack of research investigating the antibiotic prescription status of pediatric primary emergency medical centers and the benchmark prescription rates in pediatric outpatient settings.

METHODS

We conducted a multi-center, cross-sectional study of seven pediatric primary emergency medical centers located in five prefectures of Japan. We retrospectively extracted data from health claims or directly obtained them from charts at each institution and evaluated trends in the antibiotic prescription rate based on the AWaRe classification between April 2016 and December 2019.

RESULTS

Our study included 383,525 encounters, with the most common infectious disease diagnosis being acute upper respiratory tract infection in 93,449 cases (24.4 %). The antibiotic prescription rate during the study period was 7.4 %, representing a decrease of 46 %, from 10.2 % in 2016 to 5.5 % in 2019. The percentage of prescriptions in the Access group increased at all institutions; however, it exceeded 60 % in only three facilities in 2019. The percentage of third-generation cephalosporins varied among facilities, ranging from 1.7 % to 59.4 %, as of 2019.

CONCLUSIONS

For pediatric primary emergency medical centers where antimicrobial stewardship programs are implemented, we suggest 5 % as a reasonable benchmark level for the antibiotic prescription rate. Prescribing the antibiotics in the Access groups less frequently remains a domestic challenge in Japan.

Antibiotic Stewardship in the Neonatal Intensive Care Unit

Antibiotic stewardship is a multidisciplinary, evidence-based approach to optimize antibiotic use and mitigate development of antibiotic resistance. Neonates have high rates of antibiotic exposure, particularly those born preterm and admitted to the NICU, and mounting evidence describes the adverse consequences of such exposures in the absence of infection. Here, we review the general principles of antibiotic stewardship and how they can be applied in NICUs. The unique characteristics of NICUs and patients cared for in this setting, which warrant unique implementation strategies and special considerations are discussed. We summarize current antibiotic use metrics for assessment of responses to stewardship interventions and changes over time, and review evidence-based infection prevention practices in the NICU. Current recommendations for empiric antibiotic use in the NICU and the utility of infection biomarkers are summarized. Lastly, given the growing global threat of increasing antibiotic resistance, specific threats in the NICU are highlighted.

Five-Year Evaluation of the PROA-NEN Pediatric Antimicrobial Stewardship Program in a Spanish Tertiary Hospital

Introduction: Actions to reduce and optimize antimicrobial use are crucial in the management of infectious diseases to counteract the emergence of short- and long-term resistance. This is particularly important for pediatric patients due to the increasing incidence of serious infections caused by resistant bacteria in this population. The aim of this study was to evaluate the impact of a pediatric antimicrobial stewardship program (PROA-NEN) implemented in a Spanish tertiary hospital by assessing the use of systemic antimicrobials, clinical indicators, antimicrobial resistance, and costs. Methods: In this quasi-experimental, single-center study, we included pediatric patients (0-18 years) admitted to specialized pediatric medical and surgical units, as well as pediatric and neonatal intensive care units, from January 2015 to December 2019. The impact of the PROA-NEN program was assessed using process (consumption trends and prescription quality) and outcome indicators (clinical and microbiological). Antibiotic prescription quality was determined using quarterly point prevalence cross-sectional analyses. Results: Total antimicrobial consumption decreased during the initial three years of the PROA-NEN program, followed by a slight rebound in 2019. This decrease was particularly evident in intensive care and surgical units. Antibiotic use, according to the WHO Access, Watch and Reserve (AWaRe) classification, remained stable during the study period. The overall rate of appropriate prescription was 83.2%, with a significant increase over the study period. Clinical indicators did not substantially change over the study period. Direct antimicrobial expenses decreased by 27.3% from 2015 to 2019. Conclusions: The PROA-NEN program was associated with reduced antimicrobial consumption, improved appropriate use, and decreased costs without compromising clinical and/or microbiological outcomes in patients.

Antibiotic Overtreatment of Presumed Urinary Tract Infection Among Children with Spina Bifida

OBJECTIVE

To identify factors associated with overtreatment of presumed urinary tract infection (UTI) among children with spina bifida using such criteria.

STUDY DESIGN

A retrospective review of children with spina bifida (age <21 years) evaluated in the Emergency Department (ED) at a single institution was performed. Patients with a urinalysis (UA) performed who were reliant on assisted bladder emptying were included. The primary outcome was overtreatment, defined as receiving antibiotics for presumed UTI but ultimately not meeting spina bifida UTI criteria (≥2 urologic symptoms plus pyuria and urine culture growing >100k CFU/mL). The primary exposure was whether the components of the criteria available at the time of the ED visit (≥2 urologic symptoms plus pyuria) were met when antibiotics were initiated.

RESULTS

Among 236 ED encounters, overtreatment occurred in 80% of cases in which antibiotics were initiated (47% of the entire cohort). Pyuria with <2 urologic symptoms was the most important factor associated with overtreatment (OR 9.6). Non-Hispanic White race was associated with decreased odds of overtreatment (OR 0.3).

CONCLUSIONS

Overtreatment of presumed UTI among patients with spina bifida was common. Pyuria, which is not specific to UTI in this population, was the main driver of overtreatment. Symptoms are a cornerstone of UTI diagnosis among children with spina bifida, should be collected in a standardized manner, and considered in a decision to treat.

Increasing the Use of Enteral Antibiotics in Hospitalized Children With Uncomplicated Infections

BACKGROUND

Route of administration is an important component of antimicrobial stewardship. Early transition from intravenous to enteral antibiotics in hospitalized children is associated with fewer catheter-related adverse events, as well as decreased costs and length of stay. Our aim was to increase the percentage of enteral antibiotic doses for hospital medicine patients with uncomplicated common bacterial infections (community-acquired pneumonia, skin and soft tissue infection, urinary tract infection, neck infection) from 50% to 80% in 6 months.

METHODS

We formed a multidisciplinary team to evaluate key drivers and design plan-do-study-act cycles. Interventions included provider education, structured discussion at existing team huddles, and pocket-sized printed information. Our primary measure was the percentage of antibiotic doses given enterally to patients receiving other enteral medications. Secondary measures included antibiotic cost, number of peripheral intravenous catheters, length of stay, and 7-day readmission. We used statistical process control charts to track our measures.

RESULTS

Over a 6-month baseline period and 12 months of improvement work, we observed 3183 antibiotic doses (888 in the baseline period, 2295 doses during improvement work). We observed an increase in the percentage of antibiotic doses given enterally per week for eligible patients from 50% to 67%. We observed decreased antibiotic costs and fewer peripheral intravenous catheters per encounter after the interventions. There was no change in length of stay or readmissions.

CONCLUSIONS

We observed increased enteral antibiotic doses for children hospitalized with common bacterial infections. Interventions targeting culture change and communication were associated with sustained improvement.

Drug Prescription Indicators in Outpatient Services in Social Security Organization Facilities in Iran

OBJECTIVES

The aim of this study was to estimate drug prescription indicators in outpatient services provided at Iran Social Security Organization (SSO) healthcare facilities.

METHODS

Data on all prescribed drugs for outpatient visits from 2017 to 2018 were extracted from the SSO database. The data were categorized into 4 main subgroups: patient characteristics, provider characteristics, service characteristics, and type of healthcare facility. Logistic regression models were used to detect risk factors for inappropriate drug prescriptions. SPSS and IBM Modeler software were utilized for data analysis.

RESULTS

In 2017, approximately 150 981 752 drug items were issued to outpatients referred to SSO healthcare facilities in Iran. The average number of drug items per outpatient prescription was estimated at 3.33. The proportion of prescriptions that included an injection was 17.5%, and the rate of prescriptions that included an antibiotic was 37.5%. Factors such as patient sex and age, provider specialty, type of facility, and time of outpatient visit were associated with the risk of inappropriate prescriptions.

CONCLUSIONS

In this study, all drug prescription criteria exceeded the recommended limits set by the World Health Organization. To improve the current prescription patterns throughout the country, it would be beneficial to provide providers with monthly and annual reports and to consider implementing some prescription policies for physicians.

Effect of Antibiotic Prophylaxis on Infection Rates in Pediatric Supracondylar Humerus Fractures Treated with Closed Reduction and Percutaneous Pinning: A Prospective Double-Blinded Randomized Controlled Trial

BACKGROUND

Supracondylar humerus fractures (SCHFs) are the most common elbow fracture in the pediatric population. In the case of displaced fractures, closed reduction and percutaneous Kirschner wire pinning (CRPP) is commonly performed. Infection rates are between 0 and 7%; however, retrospective studies have shown no benefit of preoperative antibiotics. There continues to be notable variability in antibiotic usage based on surgeon preference and local institutional policy. We conducted a double-blinded, randomized controlled trial to evaluate whether antibiotic prophylaxis reduces the risk of infection in pediatric SCHF patients treated with CRPP.

METHODS

Pediatric patients with displaced SCHF who presented to a pediatric hospital were enrolled and randomized into two groups. Group I received one dose of prophylactic antibiotics (25 mg/kg cefazolin IV up to 1g or clindamycin 10 mg/kg up to 600 mg/kg IV in the case of cefazolin allergy). Group II received placebo (10-mL prefilled syringe of normal saline). All patients underwent CRPP and casting followed by pin removal 3 to 6 weeks after the initial procedure. The presence of pin-site infection, erythema, drainage, septic arthritis, and osteomyelitis was recorded.

RESULTS

One hundred sixty patients were enrolled in the study. Eighty-two patients were randomized to receive antibiotics, and 78 patients were randomized to placebo. No difference was seen in the rate of infection between the treatment groups (1.2% in the antibiotic group versus 1.3% in the placebo group; P = 1.00). Presence of purulent drainage (0.0% versus 1.3%; P = 0.49), septic arthritis (0.0% versus 0.0%; P = 1.00), and osteomyelitis (1.2% versus 0.0%; P = 1.00) was similar in both groups. No difference in the need for additional antibiotics (1.2% versus 1.3%; P = 1.00) or additional surgery (1.2% versus 0.0%; P = 1.00) was found between groups.

DISCUSSION

The use of antibiotic prophylaxis did not affect the risk of infection in pediatric patients who underwent CRPP for displaced SCHF.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT03261830.

LEVEL OF EVIDENCE

Therapeutic Level I.

Multidrug-Resistant Bacterial Infections in Pediatric Patients Hospitalized at King Abdulaziz University Hospital, Jeddah, Western Saudi Arabia

Multidrug-resistant bacterial infections (MDRIs) constitute a major global threat due to increased patient morbidity/mortality and hospital stay/healthcare costs. A few studies from KSA, including our locality, addressed antimicrobial resistance in pediatric patients. This study was performed to recognize the incidence and clinical/microbiologic features of MDRIs in hospitalized pediatric patients. A retrospective cross-sectional study included pediatric patients < 18 years, admitted to King Abdulaziz University Hospital, between October 2021 and November 2022, with confirmed positive cultures of bacteria isolated from blood/body fluids. Patients' medical files provided the required data. MDR organisms (MDROs) were identified in 12.8% of the total cultures. The incidence of MDRIs was relatively high, as it was detected in 42% of patients and in 54.3% of positive bacterial cultures especially among critically ill patients admitted to the NICU and PICU. Pneumonia/ventilator-associated pneumonia was the main type of infection in 37.8% of patients with MDROs. Klebsiella pneumoniae was the most common significantly isolated MDRO in 39.5% of MDR cultures. Interestingly, a low weight for (no need for their as terminology weight for age is standard and well-known) was the only significant risk factor associated with MDROs (p = 0.02). Mortality was significantly higher (p = 0.001) in patients with MDROs (32.4%) than in patients without MDROs (3.9%). Patients who died including 85.7% of patients with MDROs had significantly longer durations of admission, more cultures, and utilized a larger number of antibiotics than the surviving patients (p = 0.02, p = 0.01, p = 0.04, respectively). This study provided a comprehensive update on the seriously alarming problem of MDROs, and its impacts on pediatric patients. The detected findings are crucial and are a helpful guide to decid for implementing effective strategies to mitigate MDROs.

Decreasing Prescribing Errors in Antimicrobial Stewardship Program-Restricted Medications

OBJECTIVES

Antimicrobial stewardship programs (ASPs) restrict prescribing practices to regulate antimicrobial use, increasing the risk of prescribing errors. This quality improvement project aimed to decrease the proportion of prescribing errors in ASP-restricted medications by standardizing workflow.

METHODS

The study took place on all inpatient units at a tertiary care children's hospital between January 2020 and February 2022. Patients <22 years old with an order for an ASP-restricted medication course were included. An interprofessional team used the Model for Improvement to design interventions targeted at reducing ASP-restricted medication prescribing errors. Plan-Do-Study-Act cycles included standardizing communication and medication review, implementing protocols, and developing electronic health record safety nets. The primary outcome was the proportion of ASP-restricted medication orders with a prescribing error. The secondary outcome was time between prescribing errors. Outcomes were plotted on control charts and analyzed for special cause variation. Outcomes were monitored for a 3-month sustainability period.

RESULTS

Nine-hundred ASP-restricted medication orders were included in the baseline period (January 2020-December 2020) and 1035 orders were included in the intervention period (January 2021-February 2022). The proportion of prescribing errors decreased from 10.9% to 4.6%, and special cause variation was observed in Feb 2021. Mean time between prescribing errors increased from 2.9 days to 8.5 days. These outcomes were sustained.

CONCLUSIONS

Quality improvement methods can be used to achieve a sustained reduction in the proportion of ASP-restricted medication orders with a prescribing error throughout an entire children's hospital.

Antibiotic Stewardship and Treatment of Uncomplicated Urinary Tract Infection (UTI) in Children and Adolescents in the Emergency Department of a Community Hospital

A retrospective, cross-sectional study of children with suspected urinary tract infections (UTIs) 3 months to 18 years of age who had a urinalysis and urine culture (UC) during an emergency department (ED) visit between 2019 and 2020 was performed. Chi-square, Fisher exact, and independent samples T tests were used as appropriate. Median age was 6.6 years (interquartile range = 3.3-12.4). Urinalysis positivity was 92.8%, of which 81.9% of children were prescribed a first-line antibiotic. First-line antibiotic use was 82.7%. Positive UC rate was 84.7%, with 84% receiving a first-line antibiotic (P = .025). The correlation between a positive urinalysis and a positive UC was 80.8% (P < .001). Change of antibiotics based on the uropathogen of positive UCs was 6.3% (P < .001). The urinalysis and UC guided the diagnosis and treatment of UTIs. First-line antibiotics can be safely administered in the ED and prescribed for positive urinalyses. Studies are needed to evaluate the discontinuation of antibiotics with negative UCs as part of antibiotic stewardship initiatives.

Liquid antimicrobials: a national analysis of critical shortages

Medicine shortages, especially those involving antibiotics, pose a global public health dilemma that can lead to adverse health outcomes. The aim of this study was to assess the supply situation of various antimicrobials in liquid dosage forms, which represent the mainstay of therapy for paediatric infections. The availability was examined over a period of 27 weeks in Austria. During the time period investigated, 34 products (81.0%) were not available for over 50% of the time; eight of those (19.0%) experienced complete unavailability. Only four products (9.5%) demonstrated continuous availability. Regarding penicillin antibiotics, amoxicillin was not available for 77.8% of the time (21 weeks) and amoxicillin/clavulanic acid for 59.3% (16 weeks). Regular monitoring of availability status can help mitigate this issue; however, cross-national strategies are urgently needed to guarantee a constant supply in the future.

Long-term outcomes of an educational paediatric antimicrobial stewardship programme: a quality improvement study

BACKGROUND AND OBJECTIVES

Antimicrobial stewardship programmes (ASPs) have resulted in antimicrobial consumption (AMC) reduction and quality of prescription (QOP) improvement. However, evidence of ASP impact in paediatrics is still limited. This study aims to assess a paediatric ASP long-term outcomes.

METHODS

A quality improvement study assessed by a interrupted time series analysis was conducted in a paediatric tertiary hospital. QOP expressed as proportion of adequate prescriptions, AMC measured by defined daily dose incidence per 1000 occupied bed days, incidence density of bloodstream infections (BSIs) and its related all-cause crude death rate (CDR) were compared between pre (from January 2013 to December 2015) and post (from January 2016 to December 2019) ASP activities intensification, which included a dedicated paediatric infectious diseases physician to actively perform educational interviews with prescribers.

RESULTS

Inappropriate prescribing showed a significant downward shift associated to the intervention with a -51.4% (-61.2% to -41.8%) reduction with respect to the expected values. Overall AMC showed no trend change after the intervention. For neonatology a28.8% (-36.8% to -20.9%) reduction was observed. Overall anti-pseudomonal cephalosporin use showed a -51.2% (-57.0% to -45.4%) reduction. Decreasing trends were observed for carbapenem use, with a quarterly per cent change (QPC) of -2.4% (-4.3% to -0.4%) and BSI-related CDR (QPC=-3.6%; -5.4% to -1.7%) through the study period. Healthcare-associated multi-drug-resistant BSI remained stable (QPC=2.1; -0.6 to 4.9).

CONCLUSIONS

Intensification of counselling educational activities within an ASP suggests to improve QOP and to partially reduce AMC in paediatric patients. The decreasing trends in mortality remained unchanged.

Participation in and perceptions of antibiotic stewardship behaviors among nurses at a children's hospital in South Korea: a descriptive study

PURPOSE

This study investigated participation in and perceptions of antibiotic stewardship among nurses at a children's hospital.

METHODS

This descriptive study included 125 nurses working in the inpatient ward, intensive care unit and emergency room of a single tertiary children's hospital. The study measured 14 factors influencing antibiotic stewardship behaviors using the theoretical domains framework. Each factor was analyzed by categorizing it into components (capability, opportunity, and motivation) that have been proposed as influencing factors in the COM-B model of behavior. One-way analysis of variance and Pearson correlation coefficients were used to explore differences in antibiotic stewardship behaviors and influencing factors according to general characteristics and the correlation between antibiotic stewardship behaviors and COM-B components.

RESULTS

No statistically significant difference in antibiotic stewardship behaviors was found based on the experience of antibiotic stewardship education or the nursing department. However, significant differences were observed in the perception levels of factors related to antibiotic stewardship behaviors according to the experience of antibiotic stewardship education in skill (physical) (p=.042), knowledge (p=.027), intentions (p=.028), and social influences (p=.010). Additionally, significant differences were observed in perception levels according to the sub-components of the COM-B model, specifically physical capability (p=.042), psychological capability (p=.027), and social opportunity (p=.010).

CONCLUSION

To expand nurses' involvement and roles in antibiotic stewardship, nurses should acknowledge the significance of appropriate antibiotic use, aiming to enhance the quality of medical care and ensure patient safety. In pursuit of this objective, tailored education aligning with the specific needs and practices of nurses is essential.

Next Steps in Ambulatory Stewardship

Most antibiotics are prescribed in ambulatory setting and at least 30% to 50% of these prescriptions are unnecessary. The use of antibiotics when not needed promotes the development of antibiotic resistant organisms and harms patients by placing them at risk for adverse drug events and Clostridioides difficile infections. National guidelines recommend that health systems implement antibiotic stewardship programs in ambulatory settings. However, uptake of stewardship in ambulatory setting has remained low. This review discusses the current state of ambulatory stewardship in the United States, best practices for the successful implementation of effective ambulatory stewardship programs, and future directions to improve antibiotic use in ambulatory settings.

The Importance of a Healthy Microbiome in Pregnancy and Infancy and Microbiota Treatment to Reverse Dysbiosis for Improved Health

BACKGROUND

The microbiome of newborn infants during the first 1000 days, influenced early on by their mothers' microbiome health, mode of delivery and breast feeding, orchestrates the education and programming of the infant's immune system and determines in large part the general health of the infant for years.

METHODS

PubMed was reviewed for maternal infant microbiome health and microbiota therapy in this setting with prebiotics, probiotics, vaginal seeding and fecal microbiota transplantation (FMT).

RESULTS

A healthy nonobese mother, vaginal delivery and strict breast feeding contribute to microbiome health in a newborn and young infant. With reduced microbiome diversity (dysbiosis) during pregnancy, cesarean delivery, prematurity, and formula feeding contribute to dysbiosis in the newborn. Microbiota therapy is an important approach to repair dysbiosis in pregnant women and their infants. Currently available probiotics can have favorable metabolic effects on mothers and infants, but these effects are variable. In research settings, reversal of infant dysbiosis can be achieved via vaginal seeding or FMT. Next generation probiotics in development should replace current probiotics and FMT.

CONCLUSIONS

The most critical phase of human microbiome development is in the first 2-3 years of life. Preventing and treating dysbiosis during pregnancy and early life can have a profound effect on an infant's later health.

Pediatric antibiotic stewardship programs in Europe: a pilot survey among delegates of The European Academy of Pediatrics

Background

Antimicrobial resistance (AMR) is one of the leading causes of morbidity and mortality worldwide. Efforts to promote the judicious use of antibiotics and contain AMR are a priority of several medical organizations, including the WHO. One effective way to achieve this goal is the deployment of antibiotic stewardship programs (ASPs). This study aimed to survey the current situation of pediatric ASPs in European countries and establish a baseline for future attempts to harmonize pediatric ASPs and antibiotic use in Europe.

Methods

A web-based survey was conducted among national delegates of the European Academy of Paediatrics (EAP). The survey assessed the presence of pediatric ASPs in the representatives' countries in the inpatient and outpatient settings, the staff included in the programs, and their detailed activities regarding antibiotic use.

Results

Of the 41 EAP delegates surveyed, 27 (66%) responded. Inpatient pediatric ASPs were reported in 74% (20/27) countries, and outpatient programs in 48% (13/27), with considerable variability in their composition and activities. Guidelines for managing pediatric infectious diseases were available in nearly all countries (96%), with those for neonatal infections (96%), pneumonia (93%), urinary tract (89%), peri-operative (82%), and soft tissue (70%) infections being the most common. Pediatric ASPs were reported at the national (63%), institutional (41%), and regional/local (<15%) levels. Pediatricians with infectious disease training (62%) and microbiologists (58%) were the most common members of the program personnel, followed by physician leaders (46%), infectious disease/infection control physicians (39%), pharmacists (31%), and medical director representatives (15%). Activities of the pediatric ASPs included educational programs (85%), monitoring and reporting of antibiotic use (70%) and resistance (67%), periodic audits with feedback (44%), prior approval (44%), and post-prescription review of selected antibiotic agents (33%).

Conclusion

Although pediatric ASPs exist in most European countries, their composition and activities vary considerably across countries. Initiatives to harmonize comprehensive pediatric ASPs across Europe are needed.

Current State of Knowledge Regarding WHO High Priority Pathogens-Resistance Mechanisms and Proposed Solutions through Candidates Such as Essential Oils: A Systematic Review

Combating antimicrobial resistance (AMR) is among the 10 global health issues identified by the World Health Organization (WHO) in 2021. While AMR is a naturally occurring process, the inappropriate use of antibiotics in different settings and legislative gaps has led to its rapid progression. As a result, AMR has grown into a serious global menace that impacts not only humans but also animals and, ultimately, the entire environment. Thus, effective prophylactic measures, as well as more potent and non-toxic antimicrobial agents, are pressingly needed. The antimicrobial activity of essential oils (EOs) is supported by consistent research in the field. Although EOs have been used for centuries, they are newcomers when it comes to managing infections in clinical settings; it is mainly because methodological settings are largely non-overlapping and there are insufficient data regarding EOs' in vivo activity and toxicity. This review considers the concept of AMR and its main determinants, the modality by which the issue has been globally addressed and the potential of EOs as alternative or auxiliary therapy. The focus is shifted towards the pathogenesis, mechanism of resistance and activity of several EOs against the six high priority pathogens listed by WHO in 2017, for which new therapeutic solutions are pressingly required.

Improving Adherence to Evidence-based Practice for Uncomplicated UTI in a Pediatric Emergency Department

Introduction

Uncomplicated urinary tract infections (uUTIs) are among the more common pediatric bacterial infections. Despite their prevalence, significant variability exists in the treatment duration and antibiotic selection for uUTI. Our first aim was to improve adherence to a three-day course of antibiotic treatment for uUTI in children over 24 months old. Our second aim was to increase the selection of cephalexin in this population.

Methods

We conducted a single-center quality improvement study from March 2021 to March 2022. One thousand four hundred thirty-five patients were included across our baseline and intervention periods. We created an order set with embedded discharge prescriptions and followed this with education and provider feedback. The outcome measures for this study were percent of children receiving 3 days of antibiotic treatment and percent of children prescribed cephalexin. In addition, we tracked order set use as a process measure, and 7-day emergency department revisit as a balancing measure.

Results

Rates of 3-day prescriptions for uUTI demonstrated special cause variation with an increase from 3% to 44%. Prescription rates of cephalexin for uUTI demonstrated special cause variation with an increase from 49% to 74%. The process measure of order set use improved from 0% to 49% after implementation. No change occurred in 7-day emergency department revisits.

Conclusion

We demonstrated improved use of shorter course therapy for uUTI with a first-generation cephalosporin throughout this project without adverse events. We leveraged an order set with embedded discharge prescriptions to achieve our goals.

Antibiotic perceptions, adherence, and disposal practices among parents of pediatric patients

Antibiotics are frequently prescribed for children in the outpatient setting. Although sometimes necessary, antibiotic use is associated with important downstream effects including the development of antimicrobial resistance among human and environmental microorganisms. Current outpatient stewardship efforts focus on guiding appropriate antibiotic prescribing practices among providers, but little is known about parents' understanding of antibiotics and appropriate disposal of leftover antibiotics. To help bridge this gap, we conducted a qualitative study to assess parental understanding of their children's antibiotics, their adherence to antibiotic instructions, and their disposal practices. We conducted a semi-structured interview with parents of 13 children diagnosed with acute respiratory illnesses and prescribed antibiotics in an urban outpatient clinic. We found that parents had limited understanding of how antibiotics work. Although they received instructions about antibiotic use during the healthcare visit, adherence to the prescription and appropriate disposal of antibiotics was suboptimal. Limited baseline understanding of antibiotics, their prior experiences with antibiotics, perceptions about their social networks' antibiotic use, and information provided to them by healthcare providers may influence these behaviors. Our findings can inform educational efforts of outpatient stewardship programs to help optimize parental understanding of how to use and dispose of their children's antibiotics.

Antimicrobial Stewardship Programs (ASPS) in pediatric primary care

Antibiotic resistance is a major threat to global health. Optimizing the use of antibiotics is a key measure to prevent and control this problem. Antimicrobial Stewardship Programs (ASPs) are designed to improve clinical outcomes, minimize adverse effects and protect patients, and to ensure the administration of cost-effective treatments. Inappropriate use of antibiotics also occurs in pediatric clinical practice. For this reason, ASPs should include specific objectives and strategies aimed at pediatricians and families. Implementing these programs requires the involvement of institutions and policy makers, healthcare providers as well as individuals, adapting them to the characteristics of each healthcare setting. Pediatric primary care (PPC) faces specific issues such as high demand and immediacy, scarce specialized professional resources, difficulties to access regular training and to obtain feedback. This requires the design of specific policies and strategies to achieve the objectives, including structural and organizational measures, improvement of the information flow and accessibility to frequent trainings. These programs should reach all health professionals, promoting regular trainings, prescription support tools and supplying diagnostic tests, with adequate coordination between health care levels. Periodic evaluations and surveillance tools are useful to assess the impact of the actions taken and to provide feedback to health providers in order to adapt and improve their clinical practice to meet ASPs objectives.

Multinational consensus antimicrobial stewardship recommendations for children managed in hospital settings

Children are entitled to receive antibiotic therapy that is based on evidence and best practice, but might be overlooked in hospital programmes designed to achieve antimicrobial stewardship [AMS]. This failure to include children could be because children make up small proportion of patients in most hospitals, and are cared for by specialised paediatric staff. We reviewed the evidence and consulted experts in three global regions to develop ten recommendations for good-practice in hospital AMS programmes for children. We performed a review of scientific research, published between Jan 1, 2007, and Oct 17, 2019, concerning AMS, and formed a multinational expert group comprising members from the USA, Canada, the UK, Belgium, Switzerland, Australia, and Aotearoa New Zealand to develop the recommendations. These recommendations aim to help health-care workers who care for children in these regions to deliver best-practice care. We surveyed health-care workers with expertise in antibiotic therapy for children across these regions, and found that the recommendations were considered both very important and generally feasible. These recommendations should be implemented in hospitals to improve antibiotic therapy for children and to stimulate research into future improvements in care.

The Impact of a Multifaceted Tertiary Pediatric Hospital's Antimicrobial Stewardship Service

BACKGROUND

Antimicrobials are the most commonly prescribed drug class in children. Overuse through inappropriate prescribing is a key driver of antimicrobial resistance and is recognized as one of the top 10 threats to global health by the World Health Organization.

METHODS

A prospective observational cohort study was performed following implementation of a multifaceted Antimicrobial Stewardship (AMS) program (January 2014 to December 2020). Data were collected on AMS and "handshake" ward rounds from patient information sources and directly from clinicians responsible for patient care. Primary outcomes include appropriateness of therapy (drug, dose, antimicrobial spectrum, duration and route), compliance with prescribing guidelines, antimicrobial expenditure, use of high-priority antimicrobials and duration of hospitalization. We compared outcomes across 3 time periods; January 2014-December 2015, January 2016-December 2017 and January 2018-December 2020.

RESULTS

The appropriateness of individual antimicrobial orders improved across the study periods from 6111/7040 (79.4%) in the first 2 years following implementation of the AMS program to 17,819/19,229 (92.3%) in the latter period. Guideline compliance increased from 5426/7700 (70.5%) to 17,822/19,316 (92.3%). A reduction in overall antimicrobial expenditure (34% reduction, equivalent to $12.52 per bed day) and a decrease in antifungal expenditure (37% reduction, equivalent to $5.56 per bed day) was observed across the time periods.

CONCLUSIONS

This study quantifies a comprehensive pediatric AMS program's sustained impact on reducing inappropriate antimicrobial use and expenditure and improving compliance with guidelines. The effectiveness of these interventions has been demonstrated and should be considered by institutions seeking to improve rational antimicrobial use in children.

Position statement of the Spanish Society of Paediatric Infectious Diseases on the introduction, implementation and assessment of antimicrobial stewardship programmes in paediatric hospitals

In the past few years, antimicrobial resistance has increased, becoming a serious public health problem. The irrational use of antimicrobials is one of the main contributors to antimicrobial resistance. The paediatric population is not free from this problem, as antimicrobials are widely prescribed in this age group, often inappropriately. The introduction of antimicrobial stewardship programmes (ASPs) has proven crucial in curbing the emergence of antimicrobial resistance. At the international level, the need to develop specific paediatric ASPs has been recognised on account of the differences between adult and paediatric patients as concerns infection and approaches to diagnosis and treatment. For this reason, paediatric ASPs should be multidisciplinary programmes led by paediatric infectious disease specialists and use specific paediatric indicators (such as days of treatment, antimicrobial susceptibility patterns in the paediatric population, or clinical indicators) to help identify areas of improvement and develop effective targeted interventions. On the other hand, the support and leadership of the pertinent scientific societies are also essential. The purpose of this document is to present the position of the Sociedad Española de Infectología Pediátrica (SEIP, Spanish Society of Paediatric Infectious Diseases) concerning the implementation of paediatric ASPs in hospitals in Spain and to provide tools to facilitate their application in hospitals throughout the regional health care systems in the country.

Antibiotic Prescribing Patterns for Pediatric Urgent Care Clinicians

OBJECTIVE

Previous studies have reported high rates of inappropriate antibiotic prescriptions in urgent care (UC). Specific prescribing patterns for the most common diagnoses are not known. The aim of the study is to determine the diagnoses for which antibiotics are prescribed in pediatric UC settings.

METHODS

We recruited pediatric UC providers via email to participate in a national multisite quality improvement study. Participants completed a survey on 10 consecutive encounters in which an antibiotic was given between March and May 2018. Encounters in which only topical antibiotics were prescribed were excluded. We categorized the encounters into 3 previously established tiers to determine appropriateness of antibiotic use. The tiers represent a descending order for antibiotic need based on diagnoses, with the first tier representing diagnoses almost always requiring antibiotics and the third tier representing diagnoses when an antibiotic is almost never required. We reported the diagnoses and frequency of antibiotic prescription within each tier.

RESULTS

The 157 providers from 20 institutions submitted a total of 2809 encounters. We excluded 339 encounters in which only topical antibiotics were prescribed. Most diagnoses fell into the tier 2 category (85.81%), with only 9.12% in tier 1 and 5.06% in tier 3. The most common diagnoses reported were acute otitis media (48.96%), pharyngitis (25.09%), and skin and soft tissue infections (7.29%).

CONCLUSIONS

In this sample of pediatric UC encounters, only 5% of diagnoses receiving antibiotic prescriptions were made up of tier 3 diagnoses, determined to almost never require antibiotics. While viral respiratory infections have been reported to frequently be treated with antibiotics in general UC centers, our study of pediatric UC centers showed that this was infrequent. However, otitis media with effusion and otalgia should be further investigated. With most antibiotic prescriptions being tier 2 diagnoses, pediatric UC providers can use evidence-based prescribing practices, shared decision making, and contingency plans to reduce unnecessary antibiotic exposure.

Antimicrobial Stewardship Interventions in Pediatric Oncology: A Systematic Review

Antimicrobial stewardship programs represent efficacious measures for reducing antibiotic overuse and improving outcomes in different settings. Specific data on pediatric oncology are lacking. We conducted a systematic review on the PubMed and Trip databases according to the PRISMA guidelines, searching for reports regarding antimicrobial stewardship in pediatric oncology and hematology patients. The aim of the study was to summarize the present literature regarding the implementation of antimicrobial stewardship programs or initiatives in this particular population, and provide insights for future investigations. Nine papers were included in the qualitative analysis: three regarding antifungal interventions, five regarding antibacterial interventions, and one regarding both antifungal and antibacterial stewardship interventions. Variable strategies were reported among the included studies. Different parameters were used to evaluate the impact of these interventions, including days of therapy per 1000-patient-days, infections with resistant strains, safety analysis, and costs. We generally observed a reduction in the prescription of broad-spectrum antibiotics and an improved appropriateness, with reduced antibiotic-related side effects and no difference in infection-related mortality. Antibiotic stewardship programs or interventions are effective in reducing antibiotic consumption and improving outcomes in pediatric oncology hematology settings, although stewardship strategies differ substantially in different institutions. A standardized approach needs to be implemented in future studies in order to better elucidate the impact of stewardship programs in this category of patients.

Gist Representations and Decision-Making Processes Affecting Antibiotic Prescribing for Children with Acute Otitis Media

Objective. To test the predictions of fuzzy-trace theory regarding pediatric clinicians’ decision-making processes and risk perceptions about antibiotics for children with acute otitis media (AOM). Methods. We conducted an online survey experiment administered to a sample of 260 pediatric clinicians. We measured their risk perceptions and prescribing decisions across 3 hypothetical AOM treatment scenarios. Participants were asked to choose among the following options: prescribe antibiotics immediately, watchful waiting (“hedging”), or not prescribing antibiotics. Results. We identified 4 gists based on prior literature: 1) “why not take a risk?” 2) “antibiotics might not help but can hurt,” 3) “antibiotics do not have harmful side effects,” and 4) “antibiotics might have harmful side effects.” All 4 gists predicted risky choice (P < 0.001), and gist endorsements varied significantly between scenarios when antibiotics were indicated, F(2, 255) = 8.53, P < 0.001; F(2, 255) = 5.14, P < .01; and F(2, 255) = 3.56, P < 0.05 for the first 3 factors, respectively. In a logistic regression, more experienced clinicians were less likely to hedge (B = −0.05; P < 0.01). Conclusion. As predicted by fuzzy-trace theory, pediatric clinicians’ prescription decisions are associated with gist representations, which are distinct from verbatim risk estimates. Implications. Antibiotic stewardship programs can benefit by communicating the appropriate gists to clinicians who prescribe antibiotics for pediatric patients.

Early childhood antibiotic utilization for infants discharged from the neonatal intensive care unit

OBJECTIVE

To determine antibiotic utilization for NICU infants, as compared to non-NICU infants, in the first 3 years after birth hospital discharge.

STUDY DESIGN

Retrospective observational study using data from Medicaid Analytic Extract including 667 541 newborns discharged from 2007-2011. Associations between NICU admission and antibiotic prescription were assessed using regression models, adjusting for confounders, and stratified by gestational age and birth weight.

RESULTS

596 999 infants (89.4%) received ≥1 antibiotic, with a median of 4 prescriptions per 3 person-years (IQR 2-8). Prescribed antibiotics and associated indication were similar between groups. Compared to non-NICU infants (N = 586 227), NICU infants (N = 81 314) received more antibiotic prescriptions (adjusted incidence rate ratio 1.08, 95% confidence interval [CI] (1.08,1.08)). Similar results were observed in all NICU subgroups.

CONCLUSIONS

Antibiotic utilization in early childhood was higher among infants discharged from NICUs compared to non-NICU infants.

A Multisite Collaborative to Decrease Inappropriate Antibiotics in Urgent Care Centers

BACKGROUND

Urgent care (UC; a convenient site to receive care for ambulatory-sensitive) centers conditions; however, UC clinicians showed the highest rate of inappropriate antibiotic prescriptions among outpatient settings according to national billing data. Antibiotic prescribing practices in pediatric-specific UC centers were not known but assumed to require improvement. The aim of this multisite quality improvement project was to reduce inappropriate antibiotic prescribing practices for 3 target diagnoses in pediatric UC centers by a relative 20% by December 1, 2019.

METHODS

The Society of Pediatric Urgent Care invited pediatric UC clinicians to participate in a multisite quality improvement study from June 2019 to December 2019. The diagnoses included acute otitis media (AOM), otitis media with effusion, and pharyngitis. Algorithms based on published guidelines were used to identify inappropriate antibiotic prescriptions according to indication, agent, and duration. Sites completed multiple intervention cycles from a menu of publicly available antibiotic stewardship materials. Participants submitted data electronically. The outcome measure was the percentage of inappropriate antibiotic prescriptions for the target diagnoses. Process measures were use of delayed antibiotics for AOM and inappropriate testing in pharyngitis.

RESULTS

From 20 UC centers, 157 providers submitted data from 3833 encounters during the intervention cycles. Overall inappropriate antibiotic prescription rates decreased by a relative 53.9%. Inappropriate antibiotic prescribing decreased from 57.0% to 36.6% for AOM, 54.6% to 48.4% for otitis media with effusion, and 66.9% to 11.7% for pharyngitis.

CONCLUSIONS

Participating pediatric UC providers decreased inappropriate antibiotic prescriptions from 60.3% to 27.8% using publicly available interventions.

Effect of a virtual simulated participant experience on antibiotic stewardship knowledge among pre-licensure baccalaureate nursing students: A pilot study

BACKGROUND

Antibiotic resistant infections are a growing global public health threat poised to render antibiotics ineffective in treating even the most common infectious diseases. It is essential that future nurses have the knowledge and skills to keep patients safe from antibiotic harm in all health care settings, however, studies indicate that there is limited education provided in nursing schools regarding antibiotic use, antibiotic resistance, and antibiotic stewardship nursing practices.

OBJECTIVE

Evaluate the effect of a virtual, scenario-based simulation experience using simulated participants on pre-licensure baccalaureate nursing students' antibiotic, antibiotic resistance, and antibiotic stewardship nursing practice knowledge.

METHODS

A quasi-experiential repeated measure pre-posttest design was used with a convenience sample of 165 pre-licensure baccalaureate nursing students enrolled in a health promotion course at a private university in the northeast region of the United States. The NLN Jeffries Simulation Theory guided the virtual simulation experience and used simulated participants methodology.

RESULTS

All students participated in the simulation experience. Statistically significant increases were noted (p < 0.005) in antibiotic, antibiotic use, and antibiotic resistance knowledge between the pre and post surveys. The most significant changes were in knowledge of antibiotic stewardship nursing practices.

CONCLUSION

Integration of virtual, scenario-based simulations provided students an active learning opportunity to practice antibiotic stewardship assessment and practice skills through real life-like situational experiences with simulated participants, resulting in improved antibiotic, antibiotic resistance, and antibiotic stewardship knowledge.

Mastitis Control and Intramammary Antimicrobial Stewardship in Ireland: Challenges and Opportunities

The Veterinary Medicines Regulation (EU 2019/6) came into force in all EU member states on 28 January 2022. This regulation places particular emphasis on prudent and responsible antimicrobial use in food animal production. Key changes include restrictions on the prophylactic use of antimicrobials in animals, and the possibility to reserve certain antimicrobials for humans only. The Regulation presents challenges to the Irish dairy industry, particularly with respect to current approaches to dry cow therapy. In response, the CellCheck technical working group (TWG, a technical group working in support of CellCheck, the national mastitis control programme) have developed pragmatic national and farm-level recommendations in support of improved mastitis control and intramammary antimicrobial stewardship in the Irish dairy industry. This paper outlines these recommendations, and provides an overview of the evidence considered to inform the TWG during its work (including the Regulation, policy perspectives, international best-practice, international scientific reviews and specific Irish challenges). In many key areas of concern, the TWG recognises the challenges in seeking to shape recommendations in the absence of robust and practical scientific evidence. For this reason, some of the recommended actions are pragmatic in nature, informed by national and international experiences. Periodic programme review will be needed, informed by ongoing monitoring of key performance indicators, to identify those actions that are most effective in an Irish context.

Antibiotic Use in Children Before, During and After Hospitalization

Purpose

To investigate ambulatory antibiotic use in children during 1 year before and 1 year after in‐hospital antibiotic exposure compared to children from the general population that had not received antibiotics in‐hospital.

Methods

Explorative data‐linkage cohort study from Norway of children aged 3 months to 17 years. One group had received antibiotics in‐Hospital (H+), and one group had not received antibiotics in‐hospital (H‐). The H+ group was recruited during admission in 2017. Using the Norwegian Population Registry, 10 children from the H‐ group were matched with one child from the H+ group according to county of residence, age and sex. We used the Norwegian Prescription Database to register antibiotic use 1 year before and 1 year after the month of hospitalisation.

Results

Of 187 children in the H+ group, 83 (44%) received antibiotics before hospitalisation compared to 288/1870 (15%) in the H‐ group, relative risk (RR) 2.88 (95% confidence interval 2.38–3.49). After hospitalisation, 86 (46%) received antibiotics in the H+ group compared to 311 (17%) in the H‐ group, RR 2.77 (2.30–3.33). Comorbidity‐adjusted RR was 2.30 (1.84–2.86) before and 2.25 (1.81–2.79) after hospitalisation. RR after hospitalisation was 2.55 (1.99–3.26) in children 3 months‐2 years, 4.03 (2.84–5.71) in children 3–12 years and 2.07 (1.33–3.20) in children 13–17 years.

Conclusions

Children exposed to antibiotics in‐hospital had two to three times higher risk of receiving antibiotics in ambulatory care both before and after hospitalisation. The link between in‐hospital and ambulatory antibiotic exposure should be emphasised in future antibiotic stewardship programs.

Prolonged Perioperative Antibiotics: A Hidden Problem

OBJECTIVES

National guidelines generally recommend 24 hours or less of surgical antibiotic prophylaxis. In a freestanding, regional children's hospital, we evaluated the duration of antibiotic surgical prophylaxis to identify targets for standardization of practice.

METHODS

All procedures performed in 2017 were extracted from our local data warehouse; those involving an incision were considered a surgical procedure and correlated to antibiotic data. Antibiotic courses were reviewed if administered for >24 hours, or if the duration or indication for prophylaxis was uncertain. Total duration of prophylaxis (including discharge prescriptions) was calculated in hours for all procedures and categorized by department and by the quantity of prophylaxis received: none, single dose, multiple doses within 24 hours, and >24 hours. Percentage of procedures and total days of potential excess were calculated.

RESULTS

A total of 15 651 procedures were included; 5009 met criteria for chart review, and after further exclusions, 12 895 procedures were included in the analysis. In total, 55% of all 12 895 procedures received prophylaxis. A single dose was given in 30%. Over 24 hours was administered in 11%, and 14% received multiple doses <24 hours (both potential excess). Results were evaluated by surgical subspecialty and procedure type. There were 5733 cumulative days of surgical prophylaxis administered after 24 hours (potential excess).

CONCLUSION

In 2017, up to 25% of procedures received potentially unnecessary perioperative prophylaxis, indicating that national guidance specific to pediatrics would have high impact on antibiotic overuse in the pediatric surgical population.

Antimicrobial Therapy in Pediatric Sepsis: What Is the Best Strategy?

Pediatric sepsis is a relevant cause of morbidity and mortality in this age group. Children are affected differently in high and low-income countries. Antibiotics are crucial for the treatment of sepsis, but indiscriminate use can increase resistance worldwide. The choice of a correct empiric therapy takes into consideration the site of infection, local epidemiology, host comorbidities and recent antibiotic exposure. Antibiotics should be administered in the first hour for patients with septic shock, and always intravenously or via intraosseous access. Culture results and clinical improvement will guide de-escalation and length of treatment. New diagnostic methods can help improve the prescription of adequate treatment. Prevention of sepsis includes vaccination and prevention of healthcare-associated infections. More research and education for awareness of sepsis is needed to improve care.

A System-Wide Hospital Child Maltreatment Patient Safety Program

BACKGROUND AND OBJECTIVES

Hospital-wide patient safety programs have been used to ensure appropriate provision of care. Similar approaches have not been widely applied to child maltreatment. In this study, we describe a hospital-system child maltreatment safety program by characterizing the frequency of patients needing further intervention, associations between the age of patient and location of care and need for further intervention, and patients who require immediate intervention.

METHODS

For all staff concerns for child maltreatment, a social worker completed a patient at risk (PAR) form. All PAR forms were reviewed within 24 hours by the child abuse team and categorized on the basis of 6 types of interventions, most significantly an "immediate callback." Wilcoxon rank and χ² tests were used for group comparisons.

RESULTS

Over a 30-month period, program interventions occurred in 2061 of 7698 PARs (26.8%). The most common reason for a PAR form was physical abuse (32.5%). Subjects requiring an intervention were no different in age than those who did not (median age: 5.6 vs 5.2 years). PAR forms performed in the emergency departments or urgent care were more likely to require an intervention than inpatient (odds ratio: 4.4; 95% confidence interval 3.6-5.3) or clinic (odds ratio: 2.0; 95% confidence interval 1.7-2.3) PAR forms. Of the 53 immediate callbacks, potential diagnostic errors and safe discharge concerns occurred in nearly one-half, and >40% involved subjects with bruising. Immediate follow-up in the child abuse pediatrician clinic occurred in 87% (46 of 53) of cases, resulting in a new or changed diagnosis in 57% of such cases.

CONCLUSIONS

A child maltreatment safety program encompassing a health system can identify and address medical errors.

Pediatric antimicrobial stewardship practices at discharge: A national survey

We surveyed pediatric antimicrobial stewardship program (ASP) site leaders within the Sharing Antimicrobial Reports for Pediatric Stewardship collaborative regarding discharge stewardship practices. Among 67 sites, 13 (19%) reported ASP review of discharge antimicrobial prescriptions. These findings highlight discharge stewardship as a potential opportunity for improvement during the hospital-to-home transition.

The use of continuous electronic prescribing data to infer trends in antimicrobial consumption and estimate the impact of stewardship interventions in hospitalized children

Background

Understanding antimicrobial consumption is essential to mitigate the development of antimicrobial resistance, yet robust data in children are sparse and methodologically limited. Electronic prescribing systems provide an important opportunity to analyse and report antimicrobial consumption in detail.

Objectives

We investigated the value of electronic prescribing data from a tertiary children’s hospital to report temporal trends in antimicrobial consumption in hospitalized children and compare commonly used metrics of antimicrobial consumption.

Methods

Daily measures of antimicrobial consumption [days of therapy (DOT) and DDDs] were derived from the electronic prescribing system between 2010 and 2018. Autoregressive moving-average models were used to infer trends and the estimates were compared with simulated point prevalence surveys (PPSs).

Results

More than 1.3 million antimicrobial administrations were analysed. There was significant daily and seasonal variation in overall consumption, which reduced annually by 1.77% (95% CI 0.50% to 3.02%). Relative consumption of meropenem decreased by 6.6% annually (95% CI −3.5% to 15.8%) following the expansion of the hospital antimicrobial stewardship programme. DOT and DDDs exhibited similar trends for most antimicrobials, though inconsistencies were observed where changes to dosage guidelines altered consumption calculation by DDDs, but not DOT. PPS simulations resulted in estimates of change over time, which converged on the model estimates, but with much less precision.

Conclusions

Electronic prescribing systems offer significant opportunities to better understand and report antimicrobial consumption in children. This approach to modelling administration data overcomes the limitations of using interval data and dispensary data. It provides substantially more detailed inferences on prescribing patterns and the potential impact of stewardship interventions.