AMS Programs and IPC Programs in the Pediatric Population: Where are We?

Speaker: Walter A. Goycochea Valdivia, Spain

Introduction:

The session, delivered by a pediatrician from Seville, Spain, focused on the current status and challenges of antimicrobial stewardship programs (ASPs) and infection prevention and control (IPC) efforts in pediatric settings, supported by a real-life case from the NICU.

Case Study: Luis and Salma:

• Luis: Extremely premature infant (26 weeks, 850g), multiple complications including NEC (necrotizing enterocolitis) and short bowel syndrome, prolonged broad-spectrum antibiotic use (vancomycin, meropenem), later developed sepsis from Klebsiella pneumoniae (NDM-1 producer), an extensively drug-resistant organism—necessitating last-line treatment with cefiderocol.
• Salma: Preterm with congenital heart disease, transferred from another hospital, unknowingly colonized with MDR bacteria. Due to delayed MDR screening—conducted six days post-admission—she was not identified early, and IPC precautions were not implemented. By the time her colonization was detected, Luis had already developed sepsis, likely from cross-transmission.

Takeaway: Missed opportunities in early detection, IPC breaches, and prolonged antibiotic exposure contributed to MDR infection risk.

Why Pediatric ASPs and IPC Matter?

• Rising antimicrobial resistance (AMR) is a global threat.
• 2016 O'Neill Report and 2019 Lancet study estimated 4.95 million deaths linked to AMR.
• MDR pathogens (e.g., E. coli, K. pneumoniae) increasingly difficult to treat with available antibiotics.
• Limited pipeline for new antibiotic classes highlights the importance of preserving current antimicrobials.

Gaps in Pediatric Guidelines:

Pediatric ASP and IPC guidelines lag behind adult protocols. ASP guidelines for children came over a decade after adult versions. IPC protocols are still often extrapolated from adult practices, lacking child-specific recommendations.

Principles of Antimicrobial Stewardship:

Five key questions in evaluating antibiotic therapy:

1. Is antimicrobial use still indicated?
2. What is the likely infectious syndrome?
3. Which samples are needed?
4. What is the optimal drug, route, dose, and duration?
5. Has infection source control been achieved?

Four Moments of ASP:

1. Diagnosis and empirical therapy
2. Microbiological results to narrow/stop/change therapy
3. Set appropriate duration
4. Monitor and reassess therapy

Effective ASP Strategies in Pediatrics:

1. Before prescription: Guidelines, restrictive formularies
2. After prescription:
   1. Educational & consensus-based interventions (most effective in pediatrics)
   2. Peer review and expert consultation
3. Ongoing: Active/passive education for long-term impact

Monitoring ASP Impact:

• Process indicators (easier to measure): e.g., antimicrobial consumption, adherence to guidelines
• Outcome indicators: harder to measure in children (e.g., mortality, AMR trends)
• Preferred pediatric metric: Days of Therapy (DOT) over Daily Defined Dose (DDD) (weight-independent)
• Example from Barcelona: ASP implementation led to a clear drop in antibiotic consumption

Challenges in Pediatric ASP/IPC:

• Low mortality and low toxicity incidence make outcome tracking harder
• Few long-term studies, limited data from primary care
• Most existing studies focus on hospital settings with variable quality and heterogeneity

Improving IPC Implementation:

• Evidence exists for effective IPC bundles in children, but:
• Implementation barriers include lack of buy-in from staff and families
• Need for better training, behavioral change, and multidisciplinary involvement

Future Directions:

Emphasis on:

• Continuous education
• Digital tools and AI
• Behavioral science-based interventions
• Collaborative global research

ESPID 2025, 26-30 May, Bucharest