Scott J. Weissmann

We implemented an institutional guideline to facilitate extended-interval amikacin dosing for multidrug-resistant urinary tract infections. Amikacin was recommended as a single dose for uncomplicated cystitis and as three once-daily doses for pyelonephritis. After policy implementation, use of extended-interval amikacin became routine, and approximately one-quarter of amikacin-treated patients avoided admission.

Lay Summary: Vancomycin is the first line antibiotic for resistant gram-positive infections, but can cause nephrotoxicity, ototoxicity, increased cost and healthcare utilization. We present an honorable memorial to this agent given the availability of similarly effective and less toxic alternatives.

Background/Objectives: Antimicrobial resistance (AMR) is a major global health threat, with children at higher risk due to developmental differences in drug metabolism, limited treatment options and inappropriate antibiotic use. Pediatric antimicrobial stewardship programs (ASPs) face implementation challenges, often relying on adult-based guidelines and limited pediatric-specific evidence. This study aimed to identify and prioritize the most critical areas for pediatric ASP intervention development through a structured, multi-round Delphi consensus process with experts in antimicrobial stewardship and infectious diseases. Method: A four-round modified Delphi process was conducted to identify and prioritize key pediatric ASP interventions. Experts in antimicrobial stewardship and infectious diseases were recruited through an existing clinical trial. Using an iterative survey and in-person discussions, experts provided input on priority areas, which were thematically grouped and refined across rounds. Structured feedback supported real-time refinement and consensus-building. Results: Twenty experts participated in the process, generating 25 priority items in Round 1 through open-ended responses. These were narrowed to seven key priorities through structured voting and discussion. The final items were clustered into three intersecting themes: Care Settings, Prescriptions, and Strategies. Care Settings focused on high-impact areas such as outpatient clinics and intensive care units, where misuse is common and/or care is complex. The prescriptions theme prioritized shorter durations and narrow-spectrum agents. The strategy theme highlighted the need for outcome-based metrics, improved diagnostic stewardship, and routine tracking of patient outcomes to guide and assess stewardship efforts. Conclusions: This expert consensus identified key priorities for pediatric ASPs, providing a foundation for future interventions. Findings can be used to inform policy and practice, improving the appropriate use of antimicrobials in pediatrics and combating AMR.

We assessed implementation of a local intravenous-to-enteral antimicrobial transition protocol for pediatric hematology/oncology and bone marrow transplant patients with bacterial or candidal bloodstream infection and central line removal. Among 76 cases, 57 met protocol criteria. Enteral antimicrobials were used in 29 (50.8%) cases meeting eligibility criteria for conversion.

This study included deidentified antibiotic susceptibility results from outpatient urinary Escherichia coli isolates from Washington state which were tested at a large clinical laboratory during 2013–2019. Isolates were categorized as representing the first, second, third, or fourth-or-greater occurrence of infection in data from individual patients. We used logistic regression with the outcome of resistance, adjusting for year of antimicrobial susceptibility test, patient sex, patient age, and facility type. In cases of subsequent infection, we found a significant risk of resistance to levofloxacin, ciprofloxacin, ceftriaxone, trimethoprim-sulfa, nitrofurantoin, ampicillin, gentamicin, and amoxicillin-clavulanate. Our findings suggest that Escherichia coli isolates from recurrent urinary tract infections have a higher rate of resistance to most tested antibiotics than isolates from the first urinary tract infection in a given year. However, susceptibility frequencies did not differ significantly between antibiograms constructed using only the first occurrence in a patient and those constructed using all subsequent occurrences. These findings suggest that the traditional approach of including only the first occurrence of urinary Escherichia coli in a patient may underestimate levels of antibiotic resistance in a community. Such underestimation could negatively affect empiric therapeutic choices, health outcomes, and treatment costs.

A survey of pediatric infectious diseases clinicians from 49 children’s hospitals demonstrated variability across institutions in the treatment of epidural empyema from sinus extension, including antibiotic route, selection, and impact of neuroimaging on determining duration of therapy.

We sought to evaluate whether children hospitalized with acute respiratory infections experienced differences in antibiotic use by race and ethnicity. We found that likelihood of broad-spectrum antibiotic receipt differed across racial and ethnic groups. Future work should confirm this finding, evaluate causes, and ensure equitable antibiotic use.

Antimicrobial resistance (AMR) is a global health problem stemming from the use of antibiotics in humans, animals, and the environment. This study used whole-genome sequencing (WGS) of E. coli to explore patterns of AMR across sectors in Washington State, USA (WA). The WGS data from 1449 E. coli isolates were evaluated for isolation source (humans, animals, food, or the environment) and the presence of antibiotic resistance genes (ARGs). We performed sequence typing using PubMLST and used ResFinder to identify ARGs. We categorized isolates as being pan-susceptible, resistant, or multidrug-resistant (MDR), defined as carrying resistance genes for at least three or more antimicrobial drug classes. In total, 60% of isolates were pan-susceptible, while 18% were resistant, and 22% exhibited MDR. The proportion of resistant isolates varied significantly according to the source of the isolates (p < 0.001). The greatest resistance was detected in isolates from humans and then animals, while environmental isolates showed the least resistance. This study demonstrates the feasibility of comparing AMR across various sectors in Washington using WGS and a One Health approach. Such analysis can complement other efforts for AMR surveillance and potentially lead to targeted interventions and monitoring activities to reduce the overall burden of AMR.

Providers must balance effective empiric therapy against toxicity risks and collateral damage when selecting antibiotic therapy for patients receiving hematopoietic cell transplant (HCT). Antimicrobial stewardship (AMS) interventions during HCT are often challenging due to concern for undertreating potential infections. In an effort to decrease unnecessary carbapenem exposure for patients undergoing HCT at our pediatric center, we implemented individualized antibiotic plans (IAPs) to provide recommendations for pre-engraftment neutropenia prophylaxis, empiric treatment of febrile neutropenia, and empiric treatment for hemodynamic instability. We compared monthly antibiotic days of therapy adjusted per 1000 patient days (DOT/1000 pt-days) for carbapenems, anti-pseudomonal cephalosporins, and all antibiotics during two 3-year periods immediately before and after the implementation of IAPs to measure the impact of IAP on prescribing behavior. Bloodstream infections (BSI) and Clostridioides difficile (CD) positive test rates were also compared between cohorts. Lastly, providers were surveyed to assess their experience of using IAPs in antibiotic decision-making. Overall antibiotic use decreased after the implementation of IAP (monthly reduction of 19.6 DOT/1000 pt-days, p=0.004) with carbapenems showing a continuing decline after IAP implementation. BSI and CD positivity rates were unchanged. Over 90% of providers found IAPs to be either extremely or very valuable for their practice. Implementation of IAPs in this high-risk HCT population led to reduction in overall antibiotic use without increase in rate of BSI or CD test positivity. The program was well-received by providers.