PAEDIATRIC ANTIMICROBIAL STEWARDSHIP
GOOD PRACTICE RECOMMENDATIONS
Evidence based good practice recommendations to improve effective antimicrobial prescribing in paediatric settings
These recommendations, which are accompanied by examples of good practice, aim to help healthcare professionals who manage children to hospital settings to deliver high quality infection management that adheres to the principles of antimicrobial stewardship.
They were developed in partnership with professionals with expertise in paediatric infection management from Australasia, Europe and North America. These recommendations should be implemented in hospitals to improve antibiotic therapy for children and to stimulate research into future improvements in care.
For more information about how the recommendations were derived, click here
McMullan B, Bryant PA, Duffy E, Bielicki J, De Cock P, Science M, Zembles T, Timberlake K, Monsees E, Hamdy RF, Tribble AC, Newland J, Patel S. Multinational consensus antimicrobial stewardship recommendations for children managed in hospital settings. Lancet Infect Dis. 2023 Jun;23(6):e199-e207. doi: 10.1016/S1473-3099(22)00726-5.
For examples of paediatric AMS quality improvement projects, click here
Endorsements
1
Hospitals should provide prescribers with access to current, evidence-based, endorsed antimicrobial guidelines suitable for paediatric patients
Prescribers refers to all those who prescribe antimicrobials. This may include medical practitioners, nurse practitioners, and physician aides. Comprehensive guidelines contain information about when antimicrobials are indicated (including the use of evidence-based guidelines and clinical scoring systems where available), the route of initial treatment, dosing and frequency information suitable for neonates, infants, children, and adolescents as appropriate, duration of antibiotics, and the timing of IV-to-oral switch (if applicable).
Paediatric guidelines should also take into account availability and palatability of oral formulations, where relevant. Other issues for guidelines may include cost/reimbursement information, IV-to-oral switch, therapeutic drug monitoring, and common adverse reactions and interactions.
Examples of evidence-based guidelines are below.
2
Hospitals should ensure prescribers have access to expert advice in paediatric infection management
Experts in paediatric infection management are paediatric infectious diseases physicians and clinical microbiologists or adult infectious diseases physicians with appropriate experience. Other expertise includes that of paediatric pharmacists, general and specialist paediatricians, nurses, infection prevention and control professionals, and general practitioners with experience in managing paediatric infections. For smaller and regional centres this requirement may require the additional education of staff and formal or informal liaison with dedicated paediatric centres.
Hospitals should have established pathways for clinicians to seek specialist opinions, such as in complex infections like osteoarticular infection, endocarditis, and brain abscesses, where infection is not responding as expected, or where the diagnosis is unclear and may involve an inflammatory process.
3
Hospitals should provide access to education on the management of common infections in children and AMS for prescribers
Educational resources should be provided by local teams or by national or other networks. Hospitals should ensure prescribers and other clinicians can access this education by providing paid protected time and incorporating this into core training/competencies.
Examples of high quality educational resources are below.
*Note with the BSAC Interactive e-learning resources you can filter to view only Paediatric courses by using the filter on the left of the website.
4
AMS committees with hospitals which care for both adults and children should include representatives from the paediatric service. Paediatric hospitals should include representatives from clinician groups relevant to that hospital
This recommendation requires adequate representation of those with specific expertise and stakeholder status in the management of infections in children. Other groups to consider include neonatology, surgery, emergency medicine, paediatric intensive care, oncology, and others, as relevant to the individual setting. Some group representatives may not be part of AMS committees but should be invited to participate and/or comment on issues which affect these groups. Smaller hospitals may not have their own AMS committees but should participate in AMS strategies within regional networks.
5
AMS committees should have access to prescribing data and data on local antimicrobial resistance in children. For quantitative antimicrobial use in children, if available this should be measured in dot/1000 bed days or dot/1000 patient days
Auditing of paediatric prescribing should include overall prescribing and targeted analysis as appropriate for the setting. This may include review of subpopulations (e.g., neonates, children in emergency departments), target indications (e.g., pneumonia), or drugs (e.g., WHO Reserve agents). In specialist children’s hospitals, this should also include auditing of prescribing for children in oncology units and in paediatric or neonatal intensive care units.
Metrics used to benchmark antimicrobial prescribing in children include: Quantitative measures of use, e.g., days of therapy (DOT)/1000 bed days) and;
Quality of prescribing (appropriateness assessments on point-prevalence or longitudinal surveys, measures of guideline- adherent prescribing, documentation of indication, IV-to-oral switch, and de-escalation timelines).
These need to be appropriate to the paediatric population from which data are collected and require executive level support for ongoing collection and action, which may include dedicated resources. Defined daily doses (DDD), commonly used in adults, are not appropriate for the measurement of paediatric antimicrobial use due to the variation of weight and age-specific doses in children.
6
Hospitals should ensure antimicrobial prescribing for children is audited periodically and reported to relevant stakeholders within the hospital
Stakeholders include hospital clinicians and executive as well as regional and national government bodies as relevant to that setting. AMS committees should also consider children, parents, and carers as important stakeholders in antimicrobial use and stewardship.
7
Hospitals should have access to government funding and appropriate resources to undertake AMS for children
Human resources to support AMS generally include an infectious diseases physician or clinical microbiologist and hospital pharmacist but may involve other physicians, nurses, or infection prevention and control professionals.
For paediatric AMS, those running the program require experience in assessing antimicrobial prescribing for children. For smaller and regional centres this may require additional education and formal liaison with dedicated paediatric centres. Funding is also required for AMS activities, such as the development and implementation of guidelines.
Routine data collection and provision of audits with feedback are important AMS activities which require time, personnel, and IT system resources. AMS should be incorporated into the prescribing process and culture, including electronic medication management, where available.
Examples of staffing models to deliver AMS in regional children’s hospitals as well as in local hospitals can be found below:
8
Hospitals which care for adults and children, and which have access to funding for AMS, should include provision of AMS for children
This may be facilitated by government targets for prescribing, education, or program elements which may be required for hospital accreditation and access to ongoing funding.
Examples of provision of AMS to children in specialist and non-specialist hospitals are below.
9
Hospitals should have access to regional and/or national networks for benchmarking of paediatric AMS indicators and sharing of practice improvements
Paediatric AMS networks can improve benchmarking, education, and the development of best practice, as well as the establishment of clinical networks and preceptorship models, as research has demonstrated (for example, see Newland et al, 2017).
Examples of networks include non-governmental regional or national networks are below
Networks may also be government-led or sponsored. These can be used for benchmarking between hospitals with dedicated paediatric tools or with tools appropriate for children and adults, such as the Australian National Antimicrobial Prescribing Survey.
10
Hospitals should be provided with incentives to promote paediatric AMS, with requirements for national reporting and accreditation, and with explicit criteria
Incentives include access to funding and requirements for accreditation. Examples of accreditation standards include are below.
Note that none of these standards currently identifies paediatric AMS as a specific requirement.
Share good practice
Submit information about a quality improvement project that you have performed
Access resourceThese recommendations, which are accompanied by examples of good practice, aim to help healthcare professionals who manage children to hospital settings to deliver high quality infection management that adheres to the principles of antimicrobial stewardship.
They were developed in partnership with professionals with expertise in paediatric infection management from Australasia, Europe and North America. These recommendations should be implemented in hospitals to improve antibiotic therapy for children and to stimulate research into future improvements in care.
For more information about how the recommendations were derived, click here
McMullan B, Bryant PA, Duffy E, Bielicki J, De Cock P, Science M, Zembles T, Timberlake K, Monsees E, Hamdy RF, Tribble AC, Newland J, Patel S. Multinational consensus antimicrobial stewardship recommendations for children managed in hospital settings. Lancet Infect Dis. 2023 Jun;23(6):e199-e207. doi: 10.1016/S1473-3099(22)00726-5.
For examples of paediatric AMS quality improvement projects, click here
Endorsements
Share good practice
Submit information about a quality improvement project that you have performed
Access resource1
Hospitals should provide prescribers with access to current, evidence-based, endorsed antimicrobial guidelines suitable for paediatric patients
Prescribers refers to all those who prescribe antimicrobials. This may include medical practitioners, nurse practitioners, and physician aides. Comprehensive guidelines contain information about when antimicrobials are indicated (including the use of evidence-based guidelines and clinical scoring systems where available), the route of initial treatment, dosing and frequency information suitable for neonates, infants, children, and adolescents as appropriate, duration of antibiotics, and the timing of IV-to-oral switch (if applicable).
Paediatric guidelines should also take into account availability and palatability of oral formulations, where relevant. Other issues for guidelines may include cost/reimbursement information, IV-to-oral switch, therapeutic drug monitoring, and common adverse reactions and interactions.
Examples of evidence-based guidelines are below.
2
Hospitals should ensure prescribers have access to expert advice in paediatric infection management
Experts in paediatric infection management are paediatric infectious diseases physicians and clinical microbiologists or adult infectious diseases physicians with appropriate experience. Other expertise includes that of paediatric pharmacists, general and specialist paediatricians, nurses, infection prevention and control professionals, and general practitioners with experience in managing paediatric infections. For smaller and regional centres this requirement may require the additional education of staff and formal or informal liaison with dedicated paediatric centres.
Hospitals should have established pathways for clinicians to seek specialist opinions, such as in complex infections like osteoarticular infection, endocarditis, and brain abscesses, where infection is not responding as expected, or where the diagnosis is unclear and may involve an inflammatory process.
3
Hospitals should provide access to education on the management of common infections in children and AMS for prescribers
Educational resources should be provided by local teams or by national or other networks. Hospitals should ensure prescribers and other clinicians can access this education by providing paid protected time and incorporating this into core training/competencies.
Examples of high quality educational resources are below.
*Note with the BSAC Interactive e-learning resources you can filter to view only Paediatric courses by using the filter on the left of the website.
4
AMS committees with hospitals which care for both adults and children should include representatives from the paediatric service. Paediatric hospitals should include representatives from clinician groups relevant to that hospital
This recommendation requires adequate representation of those with specific expertise and stakeholder status in the management of infections in children. Other groups to consider include neonatology, surgery, emergency medicine, paediatric intensive care, oncology, and others, as relevant to the individual setting. Some group representatives may not be part of AMS committees but should be invited to participate and/or comment on issues which affect these groups. Smaller hospitals may not have their own AMS committees but should participate in AMS strategies within regional networks.
5
AMS committees should have access to prescribing data and data on local antimicrobial resistance in children. For quantitative antimicrobial use in children, if available this should be measured in dot/1000 bed days or dot/1000 patient days
Auditing of paediatric prescribing should include overall prescribing and targeted analysis as appropriate for the setting. This may include review of subpopulations (e.g., neonates, children in emergency departments), target indications (e.g., pneumonia), or drugs (e.g., WHO Reserve agents). In specialist children’s hospitals, this should also include auditing of prescribing for children in oncology units and in paediatric or neonatal intensive care units.
Metrics used to benchmark antimicrobial prescribing in children include: Quantitative measures of use, e.g., days of therapy (DOT)/1000 bed days) and;
Quality of prescribing (appropriateness assessments on point-prevalence or longitudinal surveys, measures of guideline- adherent prescribing, documentation of indication, IV-to-oral switch, and de-escalation timelines).
These need to be appropriate to the paediatric population from which data are collected and require executive level support for ongoing collection and action, which may include dedicated resources. Defined daily doses (DDD), commonly used in adults, are not appropriate for the measurement of paediatric antimicrobial use due to the variation of weight and age-specific doses in children.
6
Hospitals should ensure antimicrobial prescribing for children is audited periodically and reported to relevant stakeholders within the hospital
Stakeholders include hospital clinicians and executive as well as regional and national government bodies as relevant to that setting. AMS committees should also consider children, parents, and carers as important stakeholders in antimicrobial use and stewardship.
7
Hospitals should have access to government funding and appropriate resources to undertake AMS for children
Human resources to support AMS generally include an infectious diseases physician or clinical microbiologist and hospital pharmacist but may involve other physicians, nurses, or infection prevention and control professionals.
For paediatric AMS, those running the program require experience in assessing antimicrobial prescribing for children. For smaller and regional centres this may require additional education and formal liaison with dedicated paediatric centres. Funding is also required for AMS activities, such as the development and implementation of guidelines.
Routine data collection and provision of audits with feedback are important AMS activities which require time, personnel, and IT system resources. AMS should be incorporated into the prescribing process and culture, including electronic medication management, where available.
Examples of staffing models to deliver AMS in regional children’s hospitals as well as in local hospitals can be found below:
8
Hospitals which care for adults and children, and which have access to funding for AMS, should include provision of AMS for children
This may be facilitated by government targets for prescribing, education, or program elements which may be required for hospital accreditation and access to ongoing funding.
Examples of provision of AMS to children in specialist and non-specialist hospitals are below.
9
Hospitals should have access to regional and/or national networks for benchmarking of paediatric AMS indicators and sharing of practice improvements
Paediatric AMS networks can improve benchmarking, education, and the development of best practice, as well as the establishment of clinical networks and preceptorship models, as research has demonstrated (for example, see Newland et al, 2017).
Examples of networks include non-governmental regional or national networks are below
Networks may also be government-led or sponsored. These can be used for benchmarking between hospitals with dedicated paediatric tools or with tools appropriate for children and adults, such as the Australian National Antimicrobial Prescribing Survey.
10
Hospitals should be provided with incentives to promote paediatric AMS, with requirements for national reporting and accreditation, and with explicit criteria
Incentives include access to funding and requirements for accreditation. Examples of accreditation standards include are below.
Note that none of these standards currently identifies paediatric AMS as a specific requirement.