By Julia Wilson, PharmD Candidate

In a recently published study, Chiotos and colleagues sought to approach vancomycin overuse and stewardship at three major children’s hospitals (Children’s Hospital of Philadelphia, Children’s Healthcare of Atlanta, and Nationwide Children’s Hospital) from a multipronged approach to reduce initial empiric vancomycin overprescribing.¹

CDC MRSA Reports and Core Elements of Stewardship

Vancomycin is often utilized for its anti-methicillin resistant Staphylococcus aureus (MRSA) activity (for information on treatment of MRSA infections in children – please click here for Dr. Kenyon’s blog post), although the Center of Disease Control (CDC) reported that as of 2024, in recent years, MRSA rates have decreased to about 25% of S. aureus in those under 18.² In a cross-sectional analysis of thirty-two U.S. children’s hospitals, approximately 25% of vancomycin use was found to be suboptimal, including those that are inappropriate and/or needing modification.³

As of 2024, 97% of hospitals report integrating all 7 pillars from the CDC’s Core Elements of hospital stewardship quite an improvement from 41% in 2014.⁴ Thus it is not participation, but including at least one component from all 7 elements improve. Action section, specifically preauthorization or audit and feedback, is an active area for improvement-science research. Although many hospitals utilize preauthorization for vancomycin, this recent study looks at the impact of group audit and feedback, in-person education, and consensus-based guidelines to reduce vancomycin overuse.³

Combination of Guidelines, Education, and Group Audit and Feedback on Pediatric  Vancomycin Stewardship

Chiotos and colleagues incorporated group audit and feedback, provider education, and consensus-based guidelines for 3 months (compared to 18-month pre- and post-intervention) to reduce empiric vancomycin prescribing.³

Table 1. Interventions Used in the Chotos Vancomycin Multicenter Study.³

Intervention	Details
Consensus based guideline	Guidelines integrated into either a web-based clinical pathway or posted in PICU workrooms. Incorporated national guidelines, recent published literature, and local MRSA prevalence information.
Provider education	Data provided on MRSA prevalence, recommended indications, and institutional vancomycin usage and presented bimonthly-quarterly and emailed to PICU clinicians.
Group audit and feedback	Group audit and performance feedback was shared in-person with PICU champions (monthly) and clinicians (quarterly) at each site. Each feedback report included a summary of overall vancomycin days of therapy per 1000 patient days and the proportion of suspected serious bacterial infection episodes that received vancomycin.

 

Their study reduced initiation of empiric vancomycin use within 12 hours of suspected bacterial infection evaluation [29% lower odds (OR 0.71, P=0.02)] and vancomycin days of therapy (DOT) within the first 3 days [24% (IRR 0.76, P<0.01)]. Overall PICU vancomycin usage also decreased from 97 to 80 DOT/1000 patient days [3% monthly decrease (IRR 0.97, P<0.01)]. By day 3 and 7, there were no differences reported in renal or respiratory dysfunction. There was no reported difference in cardiovascular dysfunction (e.g., requirement of one or more vasoactive medication) on day 3 (p=0.50), but researchers did report a difference on day 7 (p=0.05). There was also no difference reported in missed MRSA infections but did not receive vancomycin treatment, or use of an alternative anti-MRSA agent (p=0.36 and 0.38, respectively).

Previous Vancomycin Stewardship Research

This study adds to the previous pediatric vancomycin stewardship research.  These previously published studies (summarized in Table 2) have utilized provider education, consensus-based guidelines, order sets and clinical decision support, antimicrobial timeouts, and utilization of MRSA nasal PCR. Overall, these have demonstrated excellent results.

Table 2: Recent evidence summarizing antimicrobial stewardship interventions utilized in critically ill children receiving vancomycin

Author	Design and Population	Intervention	Results
Chiotos5	Single center quality improvement (n=1276) suspected bacterial infections in PICU July 2017 – June 2020	Stakeholder education, consensus-based guidelines, and clinical decision support tools for empiric treatment	· 40% reduction in vancomycin DOT /1000 patient days · No cases of MRSA bacteremia that did not receive vancomycin (only 1.5% overall required vancomycin)
Lanata6	Quality improvement (n=1620 PICU with suspected community acquired bacterial infection), freestanding children’s hospital May 2017 – July 2019	Guideline and order set development for empiric vancomycin use in community acquired bacterial infections	· 38% relative reduction in empiric vancomycin use · No missed MRSA infections
Adams7	Single center study of children receiving vancomycin, meropenem, or piperacillin/tazobactam for ≥48 hours compared pre-intervention July 1, 2015 – March 31, 2016 (n=95) to post-intervention July 1, 2016 – March 31, 2017 (n=95)	Pharmacist initiated antibiotic time-out during rounds 48-72 hours after initiation of therapy	· Reduction in vancomycin DOT (138.1 vs 81.3, p=0.037) · 29% of time-outs resulted in de-escalation or discontinuation
Bridges8	Retrospective single center PICU study (n= 251) of vancomycin use January 1, 2019 – June 30, 2024	Addition of prospective audit and feedback and MRSA nasal PCR (January 2022), and later a coverage guidance document (June 2022)	· Shorter vancomycin duration in those without confirmed MRSA infection (4 vs 3 days, p=0.009) · Increased vancomycin discontinuation at 72 hours (38.9% vs 61.6%, p<0.001) · No significant difference in acute kidney injury (20% vs 14%, p=0.279), hospital length of stay (15 days vs 14 days, p=0.826), or inpatient mortality (2% vs 5%, p=0.281)

Implementing Pediatric Vancomycin Stewardship Interventions

Various strategies are available for pharmacists to optimize vancomycin usage. Data from prior studies show that provider education, antimicrobial timeouts, uptake of MRSA nasal probes, and decision-making tools such as consensus-based guidelines, order sets and clinical decision support tools are effective ways to decrease vancomycin overuse. Chiotos and colleagues report that group designed interventions can be implemented across various types of hospitals, despite differences in existing stewardship resources and coverage. The potential of adapting resources created by larger children’s hospitals is intriguing, as this could benefit hospitals with fewer resources, although further studies are needed to determine effectiveness, since the impact varied across the sites in the recent Chiotos study.

About the author: Julia Wilson, is a Doctor of Pharmacy candidate at the University of Connecticut. This article was written as part of her Advanced Pharmacy Practice Experience under guidance from her professor, Jennifer Girotto PharmD, BCPPS, BCIBP, who also reviewed and edited this piece.

References

1. Chiotos K, Jaggi P, Facer EE, et al. Reducing Empiric Vancomycin Use in the Pediatric Intensive Care Unit: a Multicenter Study. Clin Infect Dis. 2026. doi:10.1093/cid/ciag545
2. Center of Disease Control. Antimicrobial Resistance: Methicillin-resistant Staphylococcus aureus. https://arpsp.cdc.gov/psp/listing/antimicrobial-resistance/profile/methicillin-resistant-staphylococcus-aureus. Updated 2024. Accessed October 9, 2026
3. Tribble AC, Lee BR, Flett KB, et al. Appropriateness of Antibiotic Prescribing in United States Children’s Hospitals: A National Point Prevalence Survey. Clin Infect Dis. 2020;71(8):e226–e234. doi:10.1093/cid/ciaa036
4. Center of Disease Control. Antibiotic Use and Stewardship in the United States, 2024
   Update: Progress and Opportunities. 2024. https://www.cdc.gov/antibiotic-use/media/pdfs/2024-stewardship-report-508.pdf. Accessed October 11, 2026
5. Chiotos K, Fitzgerald JC, Hayes M, et al. Improving Vancomycin Stewardship in Critically Ill Children. Pediatrics. 2022;149(4):e2021052165. doi: 10.1542/peds.2021–052165. doi:10.1542/peds.2021-052165
6. Lanata MM, Diaz A, Hecht SM, et al. Empiric Vancomycin Reduction in a Pediatric Intensive Care Unit. Pediatrics. 2021;148(3):e2020009142. doi: 10.1542/peds.2020–009142. doi:10.1542/peds.2020-009142
7. Adams SM, Ngo L, Morphew T, Babbitt CJ. Does an Antimicrobial Time-Out Impact the Duration of Therapy of Antimicrobials in the PICU? Pediatr Crit Care Med. 2019;20(6):560–567. doi:10.1097/PCC.0000000000001925
8. Bridges B, Jones S, Mays W, Wingler MJB. Targeted Antimicrobial Stewardship in a Pediatric Intensive Care Unit: Using the Methicillin-Resistant Staphylococcus aureus (MRSA) Nasal Polymerase Chain Reaction (PCR) to Reduce Vancomycin Days of Therapy. J Am Coll Clin Pharm. 2026;9(1):e70169. doi:10.1002/jac5.70169