Advancing the Science of Pediatric Antimicrobial Stewardship Beyond Utilization and Direct Costs.

Formal antimicrobial stewardship programs (ASPs) have been recommended for all acute care hospitals by the Infectious Diseases Society of America since 2007 [1], but to date, there are limited data to support their effectiveness in pediatrics. A recent systematic review of pediatric stewardship studies identified only 9 studies from 4 centers that provided outcomes after ASP implementation [2].The results of these studies suggest that pediatric ASPs can decrease antimicrobial utilization, drug costs, and prescribing errors. The authors of a subsequent analysis of antimicrobial use at 31 freestanding children’s hospitals reached a similar conclusion [3]. Overall antimicrobial use decreased at all study hospitals after publication of the Infectious Diseases Society of America guidelines, but there was a significantly greater decrease in use at the 9 hospitals with a formal ASP. Furthermore, decreased use of 3 broad-spectrum antibiotics orclasses—vancomycin, linezolid, and carbapenems—was more pronounced in hospitals with a formal ASP. As the number of pediatric centers with a formal ASP continues to grow [4], it is imperative to identify the best strategies for antimicrobial stewardship in the pediatric setting. In this issue of the Journal of Pediatric Infectious Diseases, 2 articles, inwhich theauthors describe 2 different but complementary approaches, focus on pediatric antimicrobial stewardship. The first study measuredutilizationof a specific antimicrobial agent at a single institution and assessed its appropriateness in various clinical scenarios [5]. The other study started with a set of clinical conditions and aimed to evaluate antimicrobial use across multiple institutions [6]. Janowski et al [5] performed a retrospective snapshot audit of piperacillintazobactam use at their institution between September 2011 and August 2012. In the randomly selected 200 of 1554 total courses of piperacillintazobactam, the authors found that the drug was initiated appropriately in approximately 93% of the courses and that the median duration of administration was 3 days; 55% of the courses were discontinued before or at 72 hours. Therefore, the authors postulated that the potential stewardship effects of initiating a preapproval process for the use of piperacillintazobactam at their institution may have been modest at best and that this process may not be the initial stewardship method of choice for this drug. The authors also found that most patients who received piperacillintazobactam had a medically complex condition and that coadministration of vancomycin was common (62%). These factors can complicate retrospective assessments of the appropriateness of antibiotic use, but in their review, the investigators disagreed with the continuation of piperacillintazobactam beyond 72 hours in 23 (25.6%) of 90 courses. Assuming that a 3-day audit would curb antibiotic use, the discontinuation of piperacillintazobactam would have resulted in a cost savings of $18 796.56 over the course of 1 year. Such potential cost savings with a single agent and the proportion of courses discontinued by 72 hours lend support to the 72-hour audit for pediatric ASPs. Kronman et al [6] used data from 37 freestanding children’s hospitals participating in the Pediatric Health Information System (PHIS) to identify potential stewardship targets among patients whowere undergoing surgery and did not have evidence of systemic infection. The authors focused on surgical procedures that were common, that were associated with antimicrobial use, and for which there was variation in the choice and duration of Editorial Commentary