Advancing Antimicrobial Stewardship for Children

Reviewed by Emily Thorell, MD, MSCI, University of Utah Health, Salt Lake City, UT and Zachary Willis, MD, MPH, University of North Carolina School of Medicine, Raleigh, NC

The American Academy of Pediatrics (AAP) and Pediatric Infectious Diseases Society (PIDS) jointly developed a policy statement on antimicrobial stewardship (AS) in pediatrics, published in both Pediatrics and the Journal of the Pediatric Infectious Diseases Society. While existing AS guidelines from IDSA, SHEA, and PIDS certainly apply in pediatric care, the new policy directly addresses aspects of AS unique to children. The policy includes nine recommendations covering ASP structure, personnel, and recommended strategies; importantly, both inpatient and outpatient settings are included. With more than 45,000 board-certified pediatricians in its membership, the AAP has substantial influence across all fields of pediatric medicine. The societies’ joint advocacy is likely to accelerate the uptake of antimicrobial stewardship in pediatrics, including outside the walls of children’s hospitals.

An important knowledge gap highlighted by the policy is “defining the optimal treatment of common bacterial infections specific to the pediatric population.” In the aptly named “SAFER” trial, Pernica et al conducted a noninferiority trial in two Canadian children’s emergency departments involving 281 children aged 6 months to 10 years with community acquired pneumonia, who were well enough to be treated as an outpatient and without confounding conditions. They either received an initial five days of high-dose amoxicillin therapy followed by five days of placebo (intervention) or five days of high-dose amoxicillin followed by another five days of high-dose amoxicillin with a different appearance (control group). They found that 88.6% of children in the intervention group and 90.8% in the control group had clinical cure in the per-protocol analysis (risk difference, −0.016; 97.5% confidence limit, −0.087). At 14 to 21 days, clinical cure was observed in 85.7% and 84.1% of the intervention and control groups, respectively, in the intention-to-treat analysis (risk difference, 0.023; 97.5% confidence limit, −0.061)

While it is difficult to be certain about the diagnosis of bacterial pneumonia in this age group given the burden of viral illnesses, this study has real world implications as many of these children would likely receive a long course of antibiotics. This study shows us that a shorter, “SAFER” course is a reasonable strategy and would limit overall antibiotic exposure for a large population of children with a common diagnosis. As we are learning with most conditions treated with antibiotics, shorter is better.


  • Gerber JS, Jackson MA, Tamma PD, Zaoutis TE, Committee on Infectious Diseases PIDS. Antibiotic Stewardship in Pediatrics. Pediatrics. 2021;147(1). doi:10.1542/peds.2020-040295
  • Pernica JM, Harman S, Kam AJ, et al. Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial. JAMA Pediatr. Published online March 08, 2021. doi:10.1001/jamapediatrics.2020.6735
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