Paeds · infectious-diseases

Antimicrobial pharmacology, selection, dosing and stewardship in children

Also known as Paediatric antimicrobial stewardship · Antibiotic dosing in children · Antimicrobial selection in children · Paediatric antimicrobial pharmacology · WHO AWaRe in children

A fellowship approach to antimicrobial pharmacology, selection, dosing and stewardship in children covering developmental pharmacokinetics, pharmacodynamic killing patterns, empiric and targeted drug selection, weight-based and age-adjusted dosing, therapeutic drug monitoring, the stewardship cycle of de-escalation, IV-to-oral stepdown and duration review, and the WHO AWaRe framework.

high17 referencesUpdated 12 July 202619 min readVerification in progress

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Target exams

RACP General PaediatricsRACP DWERACP DCERCPCH Progress+MRCPCH TheoryMRCPCH ClinicalABP General PediatricsACGME PediatricsRCPSC Pediatrics

Red flags

Antibiotic prescribed without a documented clinical indication or planned durationBroad-spectrum empiric therapy continued beyond 48–72 hours without de-escalation reviewVancomycin or aminoglycoside prescribed without weight-based dosing or therapeutic drug monitoringBeta-lactam prescribed to a child with a reported penicillin allergy without assessment or delabelingNeonate dosed using older-child or adult mg/kg values without age-adjustment for PK maturationAntibiotic continued when no infection is confirmed and no clear clinical response endpoint exists

Life stages

neonateinfanttoddlerpreschoolschool-ageadolescentyoung-adult-transition

Care settings

preventive-medical-homecommunity-schooloutpatientwarded-acutenicupicurural-remote

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written-only

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General and Community PaediatricsCurrent 2026 PREP curriculum — Learning Objective 2.4.4: Assess and manage infants, children and young people with potential cardiac, respiratory or neurological emergencies or acute sepsisCurrent 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young personRenewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatricsRenewed curriculum for first-year trainees from 2027 — Learning goal 9: Quality and safety, including medication safetyClinical ApplicationsMedical SciencesLong CasesShort Cases4. Professional skills and knowledge: Patient management7. Patient safety, including safe prescribing8. Quality improvement and patient safetyGeneral Paediatrics: Uses antimicrobials safely and judiciously, following local and national guidanceFoundation of Practice (FOP)Theory and Science (TAS)Applied Knowledge in Practice (AKP)ClinicalHistoryCommunicationGeneral Pediatrics Content Outline — Domain 9: Infectious DiseasesGeneral Pediatrics Content Outline — Domain 10: Principles of Pharmacology and Medication ManagementGeneral Pediatrics Content Outline — Universal Task 4: Management and TreatmentGeneral Pediatrics Content Outline — Universal Task 5: Health Equity and PromotionSystems-Based Practice 2: Antimicrobial StewardshipPatient Safety/Quality Improvement 1: Medication SafetyPractice-Based Learning and Improvement 2: Quality Improvement MethodsMedical Knowledge 2: Diagnostic and Therapeutic Decision MakingMedical ExpertPharmacistPediatrics: Core EPA #5 — Recommending and Initiating Pharmacologic Interventions

Your progress

Saved locally on this device.

Practise this topic

Target exams

RACP General PaediatricsRACP DWERACP DCERCPCH Progress+MRCPCH TheoryMRCPCH ClinicalABP General PediatricsACGME PediatricsRCPSC Pediatrics

Red flags

Life stages

neonateinfanttoddlerpreschoolschool-ageadolescentyoung-adult-transition

Care settings

preventive-medical-homecommunity-schooloutpatientwarded-acutenicupicurural-remote

Clinical exam formats

written-only

Board mappings

Overview & Definition

A six-month-old with meningitis who needs the right dose of a third-generation cephalosporin to penetrate the CSF, a toddler on an aminoglycoside whose interval is set to match her renal maturity, and a teenager on broad empiric cover whose antibiotics are narrowed the moment an organism returns — these are the faces of antimicrobial stewardship at the bedside. Stewardship is not restriction for its own sake. It is the organised, evidence-driven effort to ensure that every child receives the antimicrobial most likely to work, at a dose that achieves it, for just long enough, and no longer. [1] [8]

The four decisions at the heart of every antimicrobial prescription are the right drug (empiric then targeted, chosen by spectrum, tissue penetration, host factors, and local antibiogram), the right dose (weight-based, age-adjusted for developmental pharmacokinetics, with therapeutic drug monitoring where required), the right duration (the shortest course supported by evidence, with biomarker or clinical endpoints), and the right route (intravenous for severe illness, with early oral switch when the child improves). A fifth cross-cutting element — the stewardship cycle of daily review, audit, and feedback — binds the four together. [1] [2] [8]

From first prescription to safe cessation

1 · Select empirically

Cover the likely organism and focus narrowly, guided by host risk, immunisation status, and local resistance data. Use WHO Access antibiotics first-line where possible.

2 · Dose correctly

Calculate weight-based mg/kg, adjust for age and PK maturation, account for renal and hepatic function, and plan therapeutic drug monitoring where indicated.

3 · Specimen and review

Obtain cultures before or early in therapy. At 48–72 hours, review: is infection confirmed? Can the drug be narrowed? Is the child improving?

4 · De-escalate and switch

Narrow to the organism and sensitivities. Switch from IV to oral when the child is improving, afebrile, and tolerating oral. Use a high-bioavailability agent for stepdown.

5 · Set duration and stop

Prescribe the shortest evidence-based duration. Use a biomarker (CRP, procalcitonin) or clinical endpoint. Document the indication, start, stop, and outcome.

[1] [8]

Paediatrics Fellowship Pro

You have read the opening of this topic. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References17Show ledger

[1]Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 2016.PMID 27080992
[2]Moja L, Zanichelli V, Mertz D, et al. WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases, 2024.PMID 38342438
[3]Rybak MJ, Le J, Lodise TP, et al. Therapeutic Monitoring of Vancomycin for Serious Methicillin-resistant Staphylococcus aureus Infections: A Revised Consensus Guideline and Review. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 2020.PMID 32658968
[4]Nestaas E, Bangstad HJ, Sandvik L, et al. Aminoglycoside extended interval dosing in neonates is safe and effective: a meta-analysis. Archives of disease in childhood Fetal and neonatal edition, 2005.PMID 15857879
[5]Contopoulos-Ioannidis DG, Giotis ND, Baliatsa DV, et al. Extended-interval aminoglycoside administration for children: a meta-analysis. Pediatrics, 2004.PMID 15231982
[6]Jenh AM, Tamma PD, Milstone AM Extended-interval aminoglycoside dosing in pediatrics. The Pediatric infectious disease journal, 2011.PMID 21407038
[7]Mascarenhas D, Ho MSP, Ting J, et al. Antimicrobial Stewardship Programs in Neonates: A Meta-Analysis. Pediatrics, 2024.PMID 38766702
[8]Bielicki J, Lundin R, Patel S, et al. Antimicrobial stewardship for neonates and children: a global approach. The Pediatric infectious disease journal, 2015.PMID 25584443
[9]Williams PCM, Isaacs D, Berkley JA Antimicrobial resistance among children in sub-Saharan Africa. The Lancet infectious diseases, 2018.PMID 29033034
[10]Vyles D, Antoon JW, Norton A, et al. Children with reported penicillin allergy: Public health impact and safety of delabeling. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology, 2020.PMID 32224207
[11]Copaescu AM, Vogrin S, James F, et al. Efficacy of a Clinical Decision Rule to Enable Direct Oral Challenge in Patients With Low-Risk Penicillin Allergy: The PALACE Randomized Clinical Trial. JAMA internal medicine, 2023.PMID 37459086
[12]He CY, Ye PP, Liu B, et al. Population Pharmacokinetics and Dosing Optimization of Vancomycin in Infants, Children, and Adolescents with Augmented Renal Clearance. Antimicrobial agents and chemotherapy, 2021.PMID 34339268
[13]Hersh AL, Beekmann SE, Polgreen PM, et al. Antimicrobial stewardship programs in pediatrics. Infection control and hospital epidemiology, 2009.PMID 19852666
[14]Schuetz P, Wirz Y, Sager R, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Evidence-based child health : a Cochrane review journal, 2017.PMID 29025194
[15]Pineda LC, Watt KM New antibiotic dosing in infants. Clinics in perinatology, 2015.PMID 25678003
[16]Zhao W, Leroux S, Jacqz-Aigrain E Dosage individualization in children: integration of pharmacometrics in clinical practice. World journal of pediatrics : WJP, 2014.PMID 25124969
[17]Weiss SL, Peters MJ, Oczkowski SJW, et al. Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2026.PMID 41869844

Antimicrobial pharmacology, selection, dosing and stewardship in children

Also known as Paediatric antimicrobial stewardship · Antibiotic dosing in children · Antimicrobial selection in children · Paediatric antimicrobial pharmacology · WHO AWaRe in children

high17 referencesUpdated 12 July 202619 min readVerification in progress

Practise this topic

Overview & Definition

From first prescription to safe cessation

1 · Select empirically

Cover the likely organism and focus narrowly, guided by host risk, immunisation status, and local resistance data. Use WHO Access antibiotics first-line where possible.

2 · Dose correctly

Calculate weight-based mg/kg, adjust for age and PK maturation, account for renal and hepatic function, and plan therapeutic drug monitoring where indicated.

3 · Specimen and review

Obtain cultures before or early in therapy. At 48–72 hours, review: is infection confirmed? Can the drug be narrowed? Is the child improving?

4 · De-escalate and switch

Narrow to the organism and sensitivities. Switch from IV to oral when the child is improving, afebrile, and tolerating oral. Use a high-bioavailability agent for stepdown.

5 · Set duration and stop

Prescribe the shortest evidence-based duration. Use a biomarker (CRP, procalcitonin) or clinical endpoint. Document the indication, start, stop, and outcome.

[1]

[8]

Paediatrics Fellowship Pro

You have read the opening of this topic. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References17Show ledger

[1]Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 2016.PMID 27080992
[2]Moja L, Zanichelli V, Mertz D, et al. WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases, 2024.PMID 38342438
[3]Rybak MJ, Le J, Lodise TP, et al. Therapeutic Monitoring of Vancomycin for Serious Methicillin-resistant Staphylococcus aureus Infections: A Revised Consensus Guideline and Review. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 2020.PMID 32658968
[4]Nestaas E, Bangstad HJ, Sandvik L, et al. Aminoglycoside extended interval dosing in neonates is safe and effective: a meta-analysis. Archives of disease in childhood Fetal and neonatal edition, 2005.PMID 15857879
[5]Contopoulos-Ioannidis DG, Giotis ND, Baliatsa DV, et al. Extended-interval aminoglycoside administration for children: a meta-analysis. Pediatrics, 2004.PMID 15231982
[6]Jenh AM, Tamma PD, Milstone AM Extended-interval aminoglycoside dosing in pediatrics. The Pediatric infectious disease journal, 2011.PMID 21407038
[7]Mascarenhas D, Ho MSP, Ting J, et al. Antimicrobial Stewardship Programs in Neonates: A Meta-Analysis. Pediatrics, 2024.PMID 38766702
[8]Bielicki J, Lundin R, Patel S, et al. Antimicrobial stewardship for neonates and children: a global approach. The Pediatric infectious disease journal, 2015.PMID 25584443
[9]Williams PCM, Isaacs D, Berkley JA Antimicrobial resistance among children in sub-Saharan Africa. The Lancet infectious diseases, 2018.PMID 29033034
[10]Vyles D, Antoon JW, Norton A, et al. Children with reported penicillin allergy: Public health impact and safety of delabeling. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology, 2020.PMID 32224207
[11]Copaescu AM, Vogrin S, James F, et al. Efficacy of a Clinical Decision Rule to Enable Direct Oral Challenge in Patients With Low-Risk Penicillin Allergy: The PALACE Randomized Clinical Trial. JAMA internal medicine, 2023.PMID 37459086
[12]He CY, Ye PP, Liu B, et al. Population Pharmacokinetics and Dosing Optimization of Vancomycin in Infants, Children, and Adolescents with Augmented Renal Clearance. Antimicrobial agents and chemotherapy, 2021.PMID 34339268
[13]Hersh AL, Beekmann SE, Polgreen PM, et al. Antimicrobial stewardship programs in pediatrics. Infection control and hospital epidemiology, 2009.PMID 19852666
[14]Schuetz P, Wirz Y, Sager R, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Evidence-based child health : a Cochrane review journal, 2017.PMID 29025194
[15]Pineda LC, Watt KM New antibiotic dosing in infants. Clinics in perinatology, 2015.PMID 25678003
[16]Zhao W, Leroux S, Jacqz-Aigrain E Dosage individualization in children: integration of pharmacometrics in clinical practice. World journal of pediatrics : WJP, 2014.PMID 25124969
[17]Weiss SL, Peters MJ, Oczkowski SJW, et al. Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2026.PMID 41869844