“Not just small adults”: Our development of a pediatric antimicrobial stewardship program within a non-freestanding children’s hospital
Erin K McCreary, Pharm D and Sheryl L Henderson, MD, PhD
American Family Children’s Hospital and University of Wisconsin School of Medicine
 Since 2002, our hospital has successfully operated a robust, multidisciplinary antimicrobial stewardship program (ASP) for a 500+ bed adult population. We have recently embarked on the journey of ASP development within the associated 88-bed children’s hospital, with the support of senior leadership. A pediatric infectious disease specialist has long been a member of the Antimicrobial Use Subcommittee, but traditionally the focus of P&T has been on adult medicine. While all realize the importance of pediatric medicine, very few are trained in this art. Those with pediatric specialty training are inherently creative in the practice of medicine since far less evidence exists to guide therapeutic decisions. Implementing a pediatric ASP requires a union of imagination and standardization.
 Growing pains lead to significant gains
We currently find ourselves facing exciting opportunities and challenges that come with the establishment of a formal ASP in the children’s hospital.  A common challenge within academic medical centers is the regular interface with providers whose experience is primarily adult medicine. For example, pharmacy, surgical, and emergency care residents are often at the forefront of patient care decisions when working at the children’s hospital, even though they may have only one rotation dedicated to pediatrics. There is a desire from these trainees to learn the intricacies of pediatric care, turning challenge into opportunity and providing a niche for education; a foundational tenant of stewardship.
As a pharmacy resident, I quickly discovered that what works in the adult world does not always correlate to success in the pediatric realm. For example, IV to PO interchange may simply not be possible because a child does not like the flavoring of the medication. It is refreshing to focus on the humanistic aspects along with the scientific nature of antimicrobial stewardship.
Teamwork makes the dream work
To build a successful ASP, it is crucial to harness the energy of those most passionate about change and to also gain input from those that may not know about or believe in the value of stewardship. To choose our program’s priorities, we are listening to questions raised by pediatric providers and pharmacy staff. We are also meeting with several stakeholders (MDs, PharmDs, RNs, etc.) and have distributed an implementation survey to discern what is known about benefits of an ASP and assess what respondents would like to gain from our ASP.
The goal of an ASP is to fine-tune antimicrobial prescribing in order to provide the safest, most effective and judicious antimicrobial-related patient care. We recognize that all providers can be stewards. We also collaborate with microbiology laboratory directors to promote rapid diagnostic testing and information technology pharmacists to facilitate order set development and electronic health record alerts. Some aspects of the program, such as daily prospective audit and feedback of all patients on antimicrobials by a pharmacist and physician pair, mirror our adult program. Other priorities are not unique to the pediatric population, but require a different approach to stewardship than in adults. These include: optimization of the use of vancomycin and vancomycin alternatives, standardization of antimicrobial use for managing neutropenic fever in pediatric oncology patients, and promotion of IV-to-PO conversion through an interactive clinical decision support tool.
Remarkable care that we can share
A conference speaker once stated that no one wakes up wanting to use antimicrobials inappropriately. This simple statement resonates with us. No one wants to do things wrong, but we need guidance on how to do things the best way. The desire to implement positive change does not imply an underlying failure or brokenness of the current system. It simply indicates that opportunities exist to go from good to great.
It is easy amidst all the rules and paperwork we face from U.S. News and World Report, The Centers of Disease Control, The Joint Commission, and Centers for Medicare & Medicaid Services to lose sight of the most important piece of the stewardship puzzle: the patient. Regulations exist to ensure safe and optimal care is provided to every single patient. Keeping the patient at the core of all conversations and using objective data to drive key decisions leads to meaningful stewardship interventions that are more readily accepted. Our journey has just begun, and unparalleled patient care is our destination. Â We look forward to the opportunity to build a stewardship network across our health system.
