Antibiotics | Establishing Priority Pediatric Antimicrobial Stewardship Interventions in the US: Findings from a Delphi Consensus Study

This study systematically identified and prioritized key antimicrobial stewardship program (ASP) intervention areas for pediatrics in the US using the Delphi consensus method, providing a critical foundation for future antimicrobial management policies and practices. The study highlights the importance of optimizing antibiotic use in outpatient and ICU settings, developing more effective prescription strategies, and creating outcome-based metrics.

 

Literature Overview
This article, 'Establishing Priority Pediatric Antimicrobial Stewardship Interventions in the US: Findings from a Delphi Consensus Study', published in the journal Antibiotics, reviews and summarizes the challenges and potential solutions in implementing pediatric antimicrobial stewardship programs (ASP). The research team employed a multi-round Delphi expert consensus approach to identify priority areas for optimizing antibiotic use in pediatric settings, including antimicrobial stewardship in outpatient and ICU environments, prescription durations, narrow-spectrum versus broad-spectrum antibiotic selection, and more effective outcome tracking and diagnostic management strategies.

Background Knowledge
Antimicrobial resistance (AMR) has become a major global health threat, with children being particularly vulnerable due to physiological differences in drug metabolism, limited treatment options, and inappropriate antibiotic use. Although progress has been made in hospital and adult ASP guidelines in recent years, evidence and optimized prescription strategies specifically tailored for pediatrics remain limited. The study notes that approximately 50% of antibiotic prescriptions for children in the US are redundant or inappropriate, with outpatient and ICU settings being especially critical due to high prescription volumes and inconsistent guideline adherence. Furthermore, traditional metrics like Days of Therapy (DOT) fail to adequately capture the clinical impact of antimicrobial stewardship, necessitating more precise, outcome-oriented measurement approaches. The study also underscores the importance of diagnostic management, including the reduction of unnecessary testing to improve antibiotic use decisions. These challenges formed the basis of the study, which aimed to determine priority areas for pediatric ASP through expert consensus, thereby informing future policy and resource allocation.

 

 

Research Methods and Experiments
The study utilized a four-round modified Delphi method to achieve expert consensus on priority areas for pediatric antimicrobial stewardship programs (ASP). The Delphi method is a systematic approach involving multiple rounds of anonymous surveys and real-time feedback to progressively refine and focus on core issues. In the first round, 20 experts (including infectious disease specialists and pharmacists) provided initial recommendations, generating 25 priority interventions. Subsequently, structured voting and discussions narrowed these down to 7 core priority areas, categorized thematically into care settings, prescription management, and strategic directions (including metric development). In each round, experts independently scored each intervention, and group discussions further refined the prioritization. Ultimately, the study identified three primary domains: care settings, prescription management, and strategic directions, with specific intervention focuses including outpatient ASP, ICU ASP, antibiotic duration, narrow-spectrum versus broad-spectrum selection, diagnostic management, outcome tracking, and metric development.

Key Conclusions and Perspectives

• During the Delphi consensus process, experts agreed that the duration of antibiotic use is the most critical aspect of prescription management. In outpatient settings, the lack of standardized guidelines and updated research awareness leads to excessively long prescriptions, while the continuation of antibiotic use post-discharge in hospitalized patients is also significant.
• The selection between narrow-spectrum and broad-spectrum antibiotics remains an issue in community-acquired infections, with experts emphasizing the need for clearer prescription guidance to reduce the overuse of broad-spectrum antibiotics.
• Outpatient and ICU settings were identified as high-priority areas for ASP implementation. Outpatient prescriptions are abundant but lack regulation, while ICU environments are complex, with frequent empirical treatments and insufficient culture result assessments.
• Experts generally agreed that current metrics like Days of Therapy (DOT) fail to effectively measure the real clinical impact of antimicrobial stewardship, thus calling for the development of more practical, outcome-oriented metrics such as the Antibiotic Harm Index.
• Diagnostic management was highlighted as a crucial strategy for reducing unnecessary antibiotic use. Experts recommend optimizing diagnostic workflows and test utilization to minimize false positives, patient anxiety, and subsequent unnecessary treatments.
• The study calls for future research specifically targeting pediatric antimicrobial stewardship, particularly in areas such as prescription duration, narrow-spectrum versus broad-spectrum selection, ASP optimization in outpatient and ICU settings, and the development of diagnostics and metrics.

Research Significance and Prospects
The study provides a prioritization framework for pediatric ASP, which can guide the development of standardized metrics, improved prescription guidelines, and stronger ASP implementation in outpatient and ICU settings. Moreover, the research emphasizes the connection between antimicrobial stewardship and patient safety, suggesting that ASP should be framed as a patient safety issue to heighten clinical awareness. Through further clinical trials and implementation research, more effective antimicrobial stewardship strategies can be established to reduce the risk of AMR development in children and enhance treatment safety.

 

 

Conclusion
This study systematically identified key priority areas for pediatric antimicrobial stewardship programs (ASP) using the Delphi expert consensus method, including optimizing prescription durations, selecting between narrow-spectrum and broad-spectrum antibiotics, implementing ASP in outpatient and ICU settings, improving diagnostic management, and enhancing outcome tracking. These findings lay the foundation for improving future antimicrobial policies and clinical practices, while highlighting the unique challenges in pediatric antimicrobial stewardship. The study also notes that current ASP metrics, such as DOT, are insufficient for capturing the real clinical impact, thus necessitating the development of more precise, outcome-based indicators. Additionally, experts recommend integrating antimicrobial stewardship with patient safety initiatives to raise awareness among clinicians regarding the risks of inappropriate prescribing. Strengthening ASP strategies can effectively reduce the development of antimicrobial resistance in children, improve the appropriateness of antibiotic use, and ultimately enhance patient outcomes.

 

Harry Obeng, Emmanuel Tetteh, Sara Malone, Jason G Newland, and Virginia R McKay. Establishing Priority Pediatric Antimicrobial Stewardship Interventions in the US: Findings from a Delphi Consensus Study. Antibiotics.