Antimicrobial Stewardship in Paediatrics Across Different Settings
Speaker: Dr Taylor Morrisette, USA
Introduction:
The Uniqueness of Paediatric Stewardship:
It was emphasised that paediatric antimicrobial stewardship (AMS) should be customised to account for age-specific physiology, pharmacokinetics (PK), and infectious disease patterns. This is because common adult practices like IV-to-PO switch protocols and the diagnostic protocols may not directly be translatable.
Apart from this, children show differences in drug use and resistance trends. Drug-resistant pathogens like CRE and carbapenem-resistant Pseudomonas are rising in children and coagulase-negative staph, often dismissed as a contaminant in adults, is a true pathogen in preterm infants.
Paediatric dosing and formulation barriers are also unique. Paediatric dosing relies on complex weight- and age-based calculations. Novel agents often lack paediatric data; PK modelling is used, but extrapolation from adults may under-dose e.g., daptomycin dosing fails to reach adult targets.
Scope + Variability in Paediatric Antibiotic Use and stewardship program penetration:
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60% of hospitalised children receive at least one antibiotic, 26% get suboptimal therapy
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Major drivers of inappropriate use include bug-drug mismatch, prolonged surgical prophylaxis and unnecessary broad-spectrum use
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Only 38% of hospitalized children in the U.S.had formal AMS programs in 2012
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There was a global disparity observed which showed that 76% of high-income countries had AMS structures as compared to the hospitals of low and middle income countries, which included only 46% of hospitals.
The outpatient paediatric stewardship challenges include the following:
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80-90% consumption of antibiotics occurs in the outpatient settings
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30% are deemed to be unnecessary and 50% are considered to be inappropriate (wrong drug, dose, or longer duration).
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Drug Restrictions + Labelling Challenges and stewardship process metric for paediatric:
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Legacy concerns limit use of tetracyclines, TMP-SMX, and quinolones despite evolving evidence
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AAP now permits quinolone use when alternatives are not available
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Defined Daily Dose (DDD) is inappropriate for paediatrics due to weight-based dosing
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Days of Therapy (DOT) is the preferred metric in children
Some effective implementation strategies:
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Prepopulated order panels (e.g., for bronchitis) was seen to reduce inappropriate prescribing from 22% to 11%.
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Handshake Stewardship (or “Dap Stewardship”) which means that there will be an in-person prospective audit and feedback on rounds. It was seen that there was a reduced vancomycin and meropenem use by 25% and 22%, respectively.
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Some important core elements for Paediatric Stewardship include: Accountability, action, tracking, education, and reporting.
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Paediatric-specific antibiograms are still lacking in many centres.
Conclusion:
The clinical, logistical and pharmacologic complexities of paediatric stewardship was highlighted. Key gaps include a lack of paediatric-specific data, inconsistent program implementation, and formulation challenges. Strategic AMS interventions tailored to age, setting, and available evidence were proven to be essential to optimize antibiotic use across pediatric populations.
Stewardship in Geriatrics: An Exceedingly Important Target
Speaker: Dr Dafna Yahav, Israel
Key Challenges in Geriatric Antimicrobial Use:
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Antibiotics are the second most common drug class associated with in-hospital adverse events in older adults, following diuretics. Beta-lactams are frequently seen to cause GI, renal, and neurotoxicity.
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Antibiotic-induced diarrhea may occur in up to 30% of older adults.
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Clostridioides difficile infection (CDI) is more severe, recurrent, and often lethal in this group.
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Fluoroquinolone-related risks include aortic aneurysms, tendon rupture, arrhythmia, hepatotoxicity.
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Colistin is associated with a nearly fourfold increased risk of acute kidney injury in patients >65 years.
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In long-term care facilities, high antibiotic use correlates with increased adverse events and MDRO colonization.
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>80% of CDI-related deaths occur in older adults.
What are the patterns of inappropriate drug use?
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WHO recommends ≥60% of antibiotic use from the "Access" category (narrow spectrum), however, older adults receive high rates of "Watch" and "Reserve" class antibiotics, often inappropriately.
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≥40% of outpatient and long-term care antibiotic prescriptions are considered inappropriate.
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Common agents that include fluoroquinolones, cephalosporins, and piperacillin-tazobactam are frequently associated with CDI and resistance.
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Polypharmacy increases risks of dangerous interactions (e.g., macrolides with statins causing rhabdomyolysis).
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Antibiotics used during acute care hospitalization (e.g., ceftriaxone, quinolones) contribute to multidrug-resistant organism (MDRO) colonization upon return to long-term care.
Targeted Stewardship Interventions:
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Detrest Trial (Inpatient Opt-Out Strategy)
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In hospitalized patients, empiric antibiotics (started before a confirmed infection) were discontinued after 48–72 hours, if the safety check was passed
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This led to reduced broad-spectrum use without increasing mortality or ICU admission.
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“Less is More” ASB Algorithm (VA System)
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This is a diagnostic guide to avoid treating asymptomatic bacteriuria (ASB)—when bacteria are in the urine but the patient has no symptoms.
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Only if the patient had clear urinary symptoms and bacteria ≥10⁵ CFU/mL the patient was treated.
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This led to fewer urine cultures and shorter antibiotic duration in >10,000 patients.
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Four Moments Model (AHRQ LTC Initiative)
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This framework was applied in >400 long term care facilities and emphasised on including these steps: emphasized brief duration (≤7 days), symptom-based prescribing, patient/family engagement.
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This resulted in decreased antibiotic initiation, especially fluoroquinolones, and fewer urine cultures.
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Antibiotic Time-Out (Acute Care)
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This included daily reassessment from in order to evaluate indication, de-escalation, IV-to-oral switch, and adherence to guidelines.
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This in turn led to reduced days of therapy and hospital-onset CDI.
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Early Oral Switch (Uncomplicated Bacteremia)
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It was an observational study that included 900+ patients with a median age of 75 years
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It was concluded that 30-day mortality was lower in early-switch group (7%) vs. delayed-switch group (14%)
Conclusion:
It was concluded that though antibiotics are life-saving, they are risky in older adults hence stewardship is essential in order to minimize adverse events, resistance, and unnecessary exposure.
ESCMID Global, April 11-15, 2025, Vienna
