Matthew M. Sattler

Background: Vancomycin is frequently administered empirically for suspected serious bacterial infections (SBIs) in the pediatric intensive care unit (PICU), despite the low prevalence of methicillin-resistant Staphylococcus aureus (MRSA). Methods: We performed a multicenter interrupted time series (ITS) study including 5 PICUs in 3 US children's hospitals evaluating the impact of a multifaceted stewardship intervention including consensus guidelines, education, and group-level audit and feedback on reducing empiric vancomycin use. The primary outcomes were (1) vancomycin administration within 12 hours of suspected SBI onset and (2) empiric vancomycin days of therapy (DOT) during the first 3 days after suspected SBI onset. Secondary outcomes included overall vancomycin DOT/1000 patient days; organ dysfunction at Days 3 and 7; 14-day mortality; and invasive MRSA infection not covered empirically. Empiric vancomycin use was modeled using mixed-effects logistic regression, and vancomycin DOT was modeled using mixed-effects Poisson regression. Results: Among 4549 episodes targeted by the intervention, there was an immediate reduction in empiric vancomycin use after the intervention (OR 0.71, 95% CI .54–.95, P = .02), with no significant change in the postintervention slope. Empiric vancomycin days after suspected SBI onset decreased by 24% immediately after the intervention (IRR: 0.76, 95% CI .65–.89, P < .01), with no significant change in the postintervention slope. There were no increases in mortality, organ dysfunction, or missed MRSA infections postintervention. Conclusions: A multifaceted stewardship intervention reduced empiric vancomycin use without evidence of harm, supporting the safety and feasibility of targeting empiric antibiotic prescribing in the PICU setting.

Objective: To evaluate the clinical and implementation outcomes of an antimicrobial stewardship program (ASP) intervention to improve antibiotic therapy for a rapid diagnostic test (RDT) for bloodstream infections (BSIs). Design: Retrospective pre and postintervention study. Setting: Single pediatric tertiary center from August 2022 to May 2024. Participants: Patients presenting with a positive blood culture accompanied by the Verigene (VG) Gram-positive Blood Culture Nucleic Acid (BC-GP) assay. Implementation outcomes surveys were completed by infectious diseases (ID) clinicians and non-ID clinicians. Methods: We implemented a 24 hours a day, 7 days a week (24/7) ASP intervention to improve response to BC-GP assay results. The primary clinical end point was time to optimal antimicrobial therapy (OAT). Secondary endpoints included duration of bacteremia, hospital length of stay (LOS), and mortality. We assessed our intervention’s acceptability, appropriateness, and feasibility using validated implementation outcomes surveys. Results: Among 211 pre and 91 postimplementation BC-GP results, the median time to OAT decreased from 20.3 hours (95% CI:14.2–26.4) to 1.3 hours (95% CI: 0.0–2.7), p = .002. No significant differences were found in duration of bacteremia, LOS, or mortality. Implementation surveys from 23 ID and 47 non-ID clinicians demonstrated over 80% agreement on intervention appropriateness and acceptability. ID clinicians rated feasibility measures lower than non-ID clinicians (3.58 vs 4.51 on a five-point Likert scale, p < .001). Conclusions: 24/7 ASP intervention paired with RDTs for Gram-positive BSIs is associated with reduced time to OAT. Feasibility differences between ID and non-ID clinicians highlight implementation challenges and the need for future strategy evaluation.

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 conducted a national survey of current pediatric infectious diseases (PID) fellows and PID fellowship graduates from the past 10 years to assess satisfaction with existing PID initial certifying exam preparatory materials. Satisfaction with existing resources was low. The most desired new resource was additional board-style questions.

Objective: Identify essential components of a curriculum on antimicrobial stewardship (AS) for pediatric residents. Design: Survey. Setting: Academic tertiary care children’s hospital. Participants: Pediatric residents and infectious diseases (ID)/AS content experts (CE), including pediatric ID faculty, fellows, nurse practitioners, and pharmacists. Methods: Residents were surveyed to assess prior AS experiences and usefulness of education in different AS domains (e.g., antimicrobial resistance [AMR]). CE was surveyed to identify content to include in an AS curriculum. A specific topic (e.g., resistance in Staphylococcus aureus) achieved consensus if ≥80% of CE identified the topic as “very” or “extremely” important. Results: Thirty-three of 110 pediatric residents responded to the resident survey (response rate 30%). Spectrum of activity (97%), empiric therapy (94%), and duration of therapy (94%) were the domains identified by the most residents as “very” or “extremely” useful. All CE responded to the CE survey (n=26). Thirty-nine of 105 topics (37%) met the consensus threshold. The domains with most topics achieving consensus were empiric therapy (11/13 topics, 85%) and duration of therapy (5/8 topics, 63%). Only one topic was identified within the domains of antibiotic allergies, diagnostics, and AMR, reflecting 18%, 14%, and 6% of the potential topics within each domain, respectively. Conclusions: A pediatric AS curriculum focused on empiric therapy and duration of therapy is likely to meet the needs of both learners and CEs.

This article will highlight recent efforts published in the medical literature to promote environmental sustainability in the outpatient clinic setting, which are likely to be feasible for health professionals to implement in their own practices. These potential efforts are divided into 3 broad categories: (1) reducing travel to the clinic when feasible, (2) reducing waste production in the clinic, and (3) optimizing the use of high-value diagnostics and therapeutics. As research specifically related to interventions to promote environmental sustainability in outpatient clinics is relatively limited, health professionals are encouraged to continue sharing success stories from their own practice.

There are limited resources for guidance on the transition from fellowship into a new faculty role in pediatric infectious diseases. This review aims to address this gap and provides a framework for a successful transition that is composed of four essential pillars—(1) stepping into your role, (2) finding your niche, (3) building your network, and (4) self-care—all of which are supported by strong mentorship/sponsorship and continual realignment with one’s personal mission statement. In addition to providing general principles and guidance, this review also outlines specific steps that a junior faculty member can take to expand their influence and build a successful, fulfilling career in pediatric infectious diseases.

We share the work of the ACGME Pediatric Infectious Diseases Working Group in creating the Pediatric Infectious Diseases-Specific Milestones and discuss key considerations that lead to the reformation of competencies to better assess learners in Pediatric Infectious Diseases.

Children with Clostridioides difficile infection (CDI) can experience recurrent or severe disease. Recurrent CDI occurs in 20%-30% of children with an initial CDI episode. A careful clinical evaluation is important to distinguish recurrent CDI from other disorders that cause recurring gastrointestinal symptoms. Multiple treatment options exist for recurrent CDI, but the optimal therapeutic approach remains undefined. Severe or fulminant CDI can result in poor outcomes and significant morbidity in children. Since there is not a validated definition for severe CDI in children, physicians must use their clinical judgment to identify patients with severe CDI to institute appropriate therapy. In this review, we describe the diagnostic and management challenges in caring for children with recurrent and severe CDI.