Discussion

This initiative is an attempt to improve empiric antimicrobial prescribing for frontline pediatricians prescribing the bulk of antibiotics in the United States. ^{Reference Hersh, Shapiro, Pavia and Shah14} Provision of antibiograms to community pediatricians is an important antibiotic stewardship strategy, particularly because outpatient antibiotic prescribing is highly variable and/or is often inappropriate and because access to an antibiogram is perceived as valuable for identifying antimicrobial resistance and guiding empiric antibiotic selection. ^{Reference Spiekerman, Patel, Patel and Availability15} Education will accompany the antibiogram to optimize antimicrobial prescribing. We have distributed the antibiograms via our website and by email to appropriate providers, and we have provided information sessions about antibiograms through the ASC-SC webinar series.

Evidence should drive the practice of medicine, yet practitioners frequently do not have the evidence they need to provide the best care. A cross-sectional survey of 85 pediatric medical residents from 2 pediatric hospitals showed that only 57% of the residents had ever utilized an antibiogram. ^{Reference Shukla, Behnam-Terneus, Cunill-De Sautu and Perez16} Similarly, a second survey of pediatric medical residents at a single pediatric hospital identified that 50.9% of residents had never utilized an antibiogram. ^{Reference Alhinai, Molloy, Wang and McGrath17} In general practice, a survey of Illinois pediatricians demonstrated that only 25% had access to a pediatric-specific antibiogram, and this access was associated with access to subspecialty training and Chicago-based practitioners. ^{Reference Spiekerman, Patel, Patel and Availability15} In the same study, 40% of respondents indicated that they did not feel well informed about national or local antibiotic resistance rates for pathogens causing common pediatrics infections. ^{Reference Spiekerman, Patel, Patel and Availability15}

In terms of antimicrobial resistance and organisms that may be more clinically concerning, a few isolates (Pseudomonas aeruginosa, Citrobacter koserii, and Acinetobacter baumannii) were isolated in only 1 NICU. Furthermore, previous literature noted a national trend in pediatric Staphylococcus aureus to be 50% MSSA and 50% MRSA. ^{Reference Tamma, Robinson and Gerber13} However, this statewide antibiogram shows MSSA with a higher prevalence rate than MRSA. These data may be important in regard to neonatal transfers; no other NICUs in the state have isolated such organisms. Furthermore, NICU data can be strongly patient specific via hospital-acquired mechanisms, which may limit its applicability statewide. A footnote on the antibiogram directs users to preferentially utilize the institution’s antibiogram should it be available to the prescriber because that information is likely more specific for their individual patient. In the educational initiatives, we emphasize that the antibiogram provides important information to consider when prescribing empiric antimicrobials, but clinical judgment in individual situations is critical.

The limitations of antibiograms include that they can be heavily influenced by a chronically ill population, especially if the number of isolates is small. This factor significantly affects use. Some pediatricians indicated that they would not use antibiograms due to generalizability to their population because the antibiograms represent hospitalized patients, frequently reflect adults only, or are poorly representative of their geographic area. ^{Reference Spiekerman, Patel, Patel and Availability15} Traditional (ie, inpatient hospital) antibiograms may also miss differences in the syndromes under treatment (ie, respiratory vs blood vs urine), special populations like pediatrics or chronically hospitalized patients, or treatment setting (ie, inpatient vs outpatient). ^{Reference Chao, Kociolek, Zheng, Scardina and Patel9,Reference Spiekerman, Patel, Patel and Availability15, Reference Hebert, Ridgway, Vekhter, Brown, Weber and Robicsek18} Some pediatric antibiograms have been built that separate healthy children from more medically complex children, and pediatricians strongly favor antibiograms that separate medically complex patient from healthy populations. ^{Reference Chao, Kociolek, Zheng, Scardina and Patel9,Reference Chao, Kociolek and Patel19} Research into syndromic antibiograms (ie, bloodstream, respiratory infections) to further personalize empiric antibiotic prescribing guided by the antibiogram is ongoing. ^{Reference Chao, Kociolek, Zheng, Scardina and Patel9}

Although constructing a statewide antibiogram did increase some numbers of isolates, further understanding of their applicability in clinical practice is warranted. A division remains between outpatient and inpatient representation in the data in the antibiogram. Also, antibiograms should not be the sole driving force for selecting empiric therapy; a patient’s individual microbiologic history can provide a greater insight. Other factors to consider outside of using an antibiogram include pediatric pharmacodynamic and pharmacokinetic data and pediatric safety data.

Additionally, guideline adherence and a better understanding of outpatient antimicrobial prescribing practices is critical to appropriate antimicrobial prescribing. A better understanding of these aspects will help drive antimicrobial stewardship initiatives and quality improvement projects like ASC-SC. Additionally, there are significant racial disparities in antimicrobial prescribing in pediatrics that need to be further explored. ^{Reference Goyal, Johnson and Chamberlain20} The COVID-19 pandemic has disrupted significant strides made in inpatient stewardship; however, outpatient prescriptions have decreased which may have interesting implications. ^{Reference Katz, Spencer, Zhang and Banerjee21}

The limitations of this project include potentially different methodologies used to collect and report each institution’s antibiogram, as noted in the CLSI standards warning against cumulative antibiograms. ⁷ Some facilities’ antibiograms had <30 isolates (most frequently seen in the NICU), and these were all included to provide numerical significance. Additionally, we collected completed antibiograms from facilities, which may have been modified to exclude information at the facility level that was not consistent across all 4 facilities.

In conclusion, statewide pediatric antibiograms can be a helpful tool to improve antimicrobial prescribing and monitor antimicrobial resistance trends throughout the state. In addition to providing a statewide antibiogram, education will be required to maximize appropriate antimicrobial prescribing in this population.