Purpose To evaluate the effectiveness and safety of mandatory antimicrobial indications and durations (MAID) and a pharmacist-driven 48-hour time-out in a pediatric hospital. Methods MAID and a 48-hour time-out were implemented on February 14, 2017. Antibiotic days of therapy (DOT) per 1,000 patient days were compared between the pre- and postperiod for select antibiotics using unadjusted Poisson models. A prepost comparison was used to compare antimicrobial stewardship program (ASP) intervention rates between time periods. A 2-step process, including distribution of a discontinuation (DC) report to pharmacists and ASP-prompted reorders, was instituted to reduce unintentional antimicrobial discontinuation with MAID. ASP-prompted reorders occurred only when a discrepancy persisted between the order and provider-desired duration. Missed antimicrobial doses were identified by ASP and the institutional event reporting system. Safety of MAID was assessed by reviewing the rate and details of ASP-prompted reorders and missed antimicrobial doses. Results A significant decrease in DOT per 1,000 patient days was observed for cefazolin (39.7 to 36.9; P < 0.001), ampicillin (39.9 to 35.7; P < 0.001), clindamycin (38.2 to 35.9; P < 0.001), ceftriaxone (46.5 to 43.4; P < 0.001), and meropenem (8.7 to 6.6; P < 0.001) following implementation. No change in ASP intervention rate occurred between the pre- and postperiod (16.9 vs 16.8%; P = 0.94). With MAID, ASP-prompted reorder occurred on 7.3% of orders. Unintentional discontinuations resulting in missed antimicrobial doses occurred in 3 orders (0.07%); no patient harm resulted. Conclusion MAID and a 48-hour time-out significantly reduced DOT of select antibiotics. No patient harm occurred with the 2-step safety process.

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Therapeutic drug monitoring (TDM) has been a common practice to optimize efficacy and safety of vancomycin. While vancomycin trough-only TDM has widely been integrated into pediatric clinical practice since 2009, recently updated vancomycin TDM guidelines published in March 2020 recommend area under the curve (AUC) based TDM for vancomycin instead of trough-only TDM. In this review, we discuss the rationale behind the change in TDM recommendations, describe two approaches for calculating vancomycin AUC in clinical practice, and address considerations for integrating vancomycin AUC TDM into pediatric clinical practice. Our primary goal is to provide pediatric clinicians with a resource for implementing vancomycin AUC monitoring into clinical care.