What are the differences in antibiotic stewardship between neonates, pediatric, and adult populations?

Differences in Antibiotic Stewardship Between Neonatal, Pediatric, and Adult Populations

Antibiotic stewardship programs (ASPs) must be tailored specifically to neonatal, pediatric, and adult populations due to their unique physiological characteristics, infection patterns, and risk factors. 1

Core Principles Across All Populations

All effective ASPs share fundamental elements regardless of population:

• Leadership commitment and accountability
• Pharmacy expertise
• Implementation of specific interventions (preauthorization and/or prospective audit and feedback)
• Tracking and reporting antibiotic use and outcomes
• Education of healthcare providers 1

Neonatal-Specific Antibiotic Stewardship

Unique Considerations

• Immature immune systems requiring earlier empiric therapy
• Limited diagnostic capabilities (small blood volumes for cultures)
• Altered pharmacokinetics requiring specialized dosing
• Higher risk of long-term consequences from antibiotic exposure 2

Key Strategies

• Focus on early discontinuation of empiric antibiotics when cultures remain negative at 36-48 hours
• Standardized approaches to common scenarios like rule-out sepsis
• Special attention to dosing based on gestational age, postnatal age, and weight
• Restricted formularies with limited broad-spectrum options 2

Implementation Challenges

• Limited microbiological data due to small sample volumes
• Difficulty distinguishing between colonization and infection
• Higher stakes for missed infections
• Limited antibiotic options with established safety profiles 2

Pediatric-Specific Antibiotic Stewardship

Unique Considerations

• Different common infections (otitis media, pharyngitis, viral respiratory infections)
• Different pathogens for common syndromes compared to adults
• Developmental pharmacokinetics requiring weight-based dosing
• Greater parental influence on prescribing decisions 1

Key Strategies

• Targeted interventions for common pediatric conditions (e.g., CAP guidelines with ampicillin as first-line therapy) 1
• Education of parents about appropriate antibiotic use
• Specialized weight-based dosing protocols
• Taste/palatability considerations for oral formulations
• Specialized clinical pathways for common pediatric infections 1

Implementation Challenges

• Parental expectations and pressure for antibiotics
• Limited ability of younger children to report symptoms
• Need for liquid formulations and palatability concerns
• School/daycare policies requiring treatment before return 1

Adult-Specific Antibiotic Stewardship

Unique Considerations

• Greater comorbidity burden affecting antibiotic selection
• More drug-drug interactions to consider
• Higher prevalence of antimicrobial resistance
• More diverse infection types requiring specialized approaches 1

Key Strategies

• Syndrome-specific interventions (e.g., CAP, UTI, SSTI guidelines)
• IV to oral conversion protocols
• Duration optimization (shorter courses when appropriate)
• Integration with antimicrobial resistance surveillance
• Specialized approaches for specific settings (ICU, long-term care) 1, 3

Implementation Challenges

• Complex comorbidities affecting antibiotic selection
• Greater polypharmacy leading to drug interactions
• Higher prevalence of antimicrobial resistance
• Diverse practice settings requiring different approaches 1

Measuring Success Across Populations

Process Measures

• Appropriateness of prescribing (indication, drug choice, dose, duration)
• Adherence to guidelines
• Time to appropriate therapy
• Documentation quality

Outcome Measures

• Mortality
• Length of stay
• Readmission rates
• Adverse drug events
• Clostridium difficile infection rates
• Antimicrobial resistance patterns 1, 4

Resource Requirements by Population

Resource needs vary by population:

• Neonatal ASPs: Require specialized neonatology and pediatric infectious diseases expertise
• Pediatric ASPs: Benefit from pediatric-specific pharmacists and infectious diseases physicians
• Adult ASPs: May require more diverse expertise for specialized populations (oncology, transplant, critical care) 5

Common Pitfalls to Avoid

• One-size-fits-all approaches that don't account for population differences
• Focusing only on restriction without education and feedback
• Neglecting diagnostic stewardship alongside antibiotic stewardship
• Failing to engage key stakeholders specific to each population
• Not accounting for unique resistance patterns in different populations 1

Implementation Framework

1. Assess local needs and resources specific to population
2. Identify high-priority targets based on local antibiotic use patterns
3. Implement core interventions (preauthorization and/or prospective audit and feedback)
4. Develop population-specific guidelines and clinical pathways
5. Measure outcomes relevant to the specific population
6. Provide feedback to prescribers in a constructive manner
7. Continuously refine the program based on outcomes 1