Discussion

Our study provides a current understanding of the prevalence, staffing, resources, composition, and activities of US pediatric ASPs. While the percentage of ASPs reporting formal programs markedly increased from 38% to 94% from 2014 to 2018, our study found a further increase to 98%.^{Reference McPherson, Lee and Terrill5,Reference Newland, Gerber and Weissman15} TJC began requiring hospital ASPs in 2017, perhaps helping to drive this change and reflecting the potential positive impact of evidence-based regulatory requirements.¹⁶

We found that 88% of programs were multidisciplinary, with 80% co-led by pharmacists and physicians—a leadership structure highlighted in the 2019 update of the CDC Core Elements as particularly effective (Table 1).⁶ A mixed-methods study determined that leadership by ID pharmacists and physicians with higher dedicated effort for stewardship was among the factors associated with stewardship excellence.^{Reference Vaughn, Krein and Hersh17,Reference Cosgrove, Hermsen, Rybak, File, Parker and Barlam18} At the same time, a white paper on the knowledge and skills required for ASP leaders noted that while deep ID expertise is valuable, skills and knowledge in other domains such as microbiology, infection control, measurement and analysis, and IT are also key, underscoring the need for multidisciplinary teams.^{Reference Vaughn, Krein and Hersh17}

Our study revealed similar dedicated FTEs for expert personnel as McPherson et al (2018).^{Reference McPherson, Lee and Terrill5} The median physician FTEs was slightly higher in our study at 0.36 (IQR: 0.26–0.5), compared with 0.3 (IQR: 0.2–0.5), while the median pharmacist FTEs was unchanged at 1.0 FTE (IQR: 0.5–1.0).^{Reference McPherson, Lee and Terrill5} Our results showed 47% of programs had a data analyst, an increase from 35% in 2018,^{Reference McPherson, Lee and Terrill5} with a current reported median data analyst FTE of 0.2 (IQR: 0.2–0.3); 24 programs had 1 funded analyst, while 3 programs had 2 analysts (Table 2). Examining the relationship between staffing support and hospital size, we determined that overall and pharmacist FTEs increased with number of beds for all hospital types. Physician FTE actually decreased with number of beds for pediatric hospitals within larger hospital systems (Fig. 2, Panel B), but this could be due to 1 outlier, as the trend increased with that program’s response removed.

Even with improvements in staffing support, over half of programs (35 [58%]) still reported insufficient resources for staffing from hospital leadership. Optimal ASP staffing ratios have not yet been defined. While the 2023 TJC requirements state, “The hospital allocates financial resources for staffing and information technology to support the antibiotic stewardship program,” neither TJC requirements nor the CDC Core Elements specify a target FTE/bed ratio or specific FTE standards per stewardship role.^6,7 The median FTEs/bed for programs reporting adequate staffing support was 0.0074 (e.g., 2.22 FTEs for a 300-bed hospital), suggesting a rough target. However, this crude calculation fails to capture nuances such as types of FTE (e.g., pharmacist, analyst) and hospital case-mix (e.g., acuity, complexity). Examining how ASP effectiveness, as measured by performance on measures such as case-mix-adjusted antibiotic use, correlates with staffing ratios would be a valuable question for further study.

Both TJC and the CDC emphasize preauthorization and/or PAF as key antimicrobial stewardship interventions.^6,7 While all participants in our study reported using 1 or both of these strategies, programs varied in their relative emphasis, with a small fraction focusing on preauthorization, about half focusing on PAF, and approximately 40% using a hybrid. This finding was consistent with those from our prior focus group study with a smaller sample of ASPs.^{Reference Manice, Muralidhar, Campbell and Nakamura13} Programs also varied in relative emphasis on preauthorization versus PAF for specific antimicrobial classes or antimicrobials, with preauthorization used somewhat less frequently than PAF for many antimicrobial classes/antimicrobials (Table 4, Fig. 3).

Most programs (95% [n = 59]) met TJC’s requirement of using ≥2 evidence-based guidelines for common infections, but fewer (73% [n = 44]) reported tracking guideline adherence. This gap may reflect challenges of such measures, which entail not just evaluating antibiotic use, but also assessing appropriateness of use—a more difficult task to accomplish with automated methods. Increased support for IT and data analysis, collaboration with hospital quality improvement programs, and innovative measurement techniques such as use of natural language processing to facilitate chart review could aid in these efforts.^{Reference Yarahuan, Kisvarday and Kim19}

Our study was the first to examine the self-reported composition of pediatric ASPs with regard to race, ethnicity, and gender identity. We found low racial diversity and low inclusion of historically underrepresented groups among ASPs, with a majority of respondents (71%) self-reporting their race as White, fewer as Asian (15%), and only 3% as Black (Table 3). This finding may reflect underrepresentation more generally among pediatricians: According to 2023 US Census data, 13.7% of the population identifies as Black or African American, whereas 2017 American Association of Medical Colleges (AAMC) data demonstrated that only 7.4% of pediatricians identified as Black or African American.^20,21 With regard to gender identity, 67% of respondents reported female gender, with 63% of physicians reporting female gender, similar to the AAMC statistic that women comprised 72.3% of pediatrics residents and 63.3% of physicians in practice.^{22–Reference Spector, Asante and Marcelin24} We believe that ASPs, like hospitals, as urged by the American Academy of Pediatrics, should advocate for programs that diversify the pediatric workforce as a way to reduce implicit bias and improve the safety and quality of pediatric care.^{Reference Trent, Dooley and Dougé25} A key strategy is improving recruitment, development, and retention of a diverse ASP workforce, which will in turn help ASPs to eliminate structural racism from antimicrobial stewardship guidelines and practices and to lead in development and tracking of metrics for diversity, equity, and inclusion in antimicrobial stewardship.

Our study had multiple strengths, including representation from 62 geographically diverse pediatric ASPs out of the 83 programs invited to participate. Survey responses provided comprehensive information regarding staffing, funding, and activities performed by ASPs. Moreover, our survey was the first to investigate the composition of ASPs and identify a lack of racial representation within the ASP workforce so that it can be further studied and addressed.

Our study also had limitations. Given the survey’s descriptive nature and the relatively small number of US children’s hospitals and thus pediatric ASPs, we lacked power for quantitative comparisons. There is potential for bias as ASPs that participated in the survey may differ from non-participants. For example, programs with inadequate staffing or other support might have been more compelled to share this issue by completing the survey than adequately resourced programs. Finally, while Part II of the study was anonymous, given the potentially sensitive nature of the questions, it is possible that some ASP professionals did not feel comfortable representing themselves candidly and either chose “prefer not to answer” responses or did not complete the survey at all.

In conclusion, we found that US pediatric ASPs have made great progress toward meeting the 2019 CDC Core Elements and the TJC’s 2023 requirements for hospital antimicrobial stewardship, though most still report insufficient resources. We identified underrepresentation in the ASP work force and hope that future studies can explore improving representation and equitable pediatric care within antimicrobial stewardship. We hope that understanding the current state of pediatric ASPs will spur studies on how stewardship funding and activities (e.g., preauthorization versus PAF) relate to outcomes, thus illuminating the comparative effectiveness of different ASP structures and strategies.