Identifying targets for antimicrobial stewardship in children's hospitals

OBJECTIVE. Antimicrobial stewardship programs (ASPs) are recommended to optimize antimicrobial use for hospitalized patients.Although mechanisms for the implementation of ASPs have been described, data-driven approaches to prioritize specific conditions and antimicrobials for intervention have not been established. We aimed to develop a strategy for identifying high-impact targets for antimicrobial stewardship efforts. DESIGN. Retrospective cross-sectional study. setting and patients. Children admitted to 32 freestanding children's hospitals in the United States in 2010. METHODS. We identified the conditions with the largest proportional contribution to the total days of antibiotic therapy prescribedto all hospitalized children. For the 4 highest-using conditions, we examined variability between hospitals in antibiotic selection patterns for use of either firs tor second-line therapies depending on the condition. Antibiotic use was determined using standardized probability of exposure to selected agents and standardized days of therapy per 1,000 patient-days, adjusting for patient demographics and severity of illness. RESULTS. In 2010, 524,364 children received 2,082,929 days of antibiotic therapy. Surgical patients received 43% of all antibiotics. The 4 highest-using conditions-pneumonia, appendicitis, cystic fibrosis, and skin and soft-tissue infection-represent 1% of all conditions yet accounted for more than 10% of all antibiotic use. Wide variability in antibiotic use occurred for 3 of these 4 conditions. conclusions. Antibiotic use in children's hospitals varied broadly across institutions when examining diagnoses individually and adjusting for severity of illness. Identifying conditions with both frequent and variable antimicrobial use informs the prioritization of highimpact targets for future antimicrobial stewardship interventions.