antibiotics Systematic Review Paediatric Antimicrobial Stewardship for Respiratory Infections in the Emergency Setting: A Systematic Review Keshani Weragama, Poonam Mudgil * and John Whitehall   Citation: Weragama, K.; Mudgil, P.; Whitehall, J. Paediatric Antimicrobial Stewardship for Respiratory Infections in the Emergency Setting: A Systematic Review. Antibiotics 2021, 10, 1366. https://doi.org/10.3390/ antibiotics10111366 Academic Editors: Holly D. Maples and Karisma Patel Received: 30 September 2021 Accepted: 5 November 2021 Published: 8 November 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- iations. Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). Department of Paediatrics, School of Medicine, Western Sydney University, Campbelltown, NSW 2560, Australia; kweragama@gmail.com(K.W.); John.Whitehall@westernsydney.edu.au (J.W.) * Correspondence: p.mudgil@westernsydney.edu.au Abstract: Antimicrobial resistance occurs due to the propensity of microbial pathogens to develop resistance to antibiotics over time. Antimicrobial stewardship programs (ASPs) have been developed in response to this growing crisis, to limit unnecessary antibiotic prescription through initiatives such as education-based seminars, prescribing guidelines, and rapid respiratory pathogen (RRP) testing. Paediatric patients who present to the emergency setting with respiratory symptoms are a particularly high-risk population susceptible to inappropriate antibiotic prescribing behaviours and are therefore an ideal cohort for focused ASPs. The purpose of this systematic review was to assess the efficacy and safety of ASPs in this clinical context. A systematic search of PubMed, Medline, EMBASE and the Cochrane Database of Systematic Reviews was conducted to review the current evidence. Thirteen studies were included in the review and these studies assessed a range of stewardship interventions and outcome measures. Overall, ASPs reduced the rates of antibiotic prescription, increased the prescription of narrow-spectrum antibiotics, and shortened the duration of antibiotic therapy. Multimodal interventions that were education-based and those that used RRP testing were found to be the most effective. Whilst we found strong evidence that ASPs are effective in reducing antibiotic prescribing, further studies are required to assess whether they translate to equivalent clinical outcomes. Keywords: paediatric antibiotic stewardship; paediatric antibiotic resistance; antimicrobial stewardship programs; ASP; antimicrobial resistance; respiratory tract infections; paediatric emergency department 1. Introduction Antimicrobial resistance (AMR) continues to present a growing public health challenge in an era of widespread antibiotic availability [1]. As resistance continues to rise, there is a substantial threat to the medical benefits of antibiotics and increasing mortality associated with drug-resistant infections [2]. Moreover, multidrug resistant bacteria have evolved over the past century as a result of their genetic capacities to exploit resistance genes and utilize horizontal gene transmission to develop numerous mechanisms of antibiotic resistance [3]. Strains including MRSA and VRE are of particular concern as they are responsible for significant morbidity and mortality in hospital and long-term care facilities and have recently become a major community-acquired pathogen [3,4]. Further, emerging strains such as Campylobacter species and Streptococcus pneumoniae pose a moderate to high risk, especially to vulnerable populations including preterm infants, those that are immunocompromised and the elderly [2,5,6]. The paediatric population in particular has become recognized as a nidus for the propagation of AMR in recent times [7]. Inappropriate rates of antibiotic prescription have been observed across several healthcare settings, from primary to secondary care, with a particular focus being placed on primary care [8]. Several studies have shown promise with regards to the use of ASP interventions in the primary care setting [9–11]. Further, recent reviews exploring paediatric ASPs in both inpatient and outpatient settings Antibiotics 2021, 10, 1366. https://doi.org/10.3390/antibiotics10111366 https://www.mdpi.com/journal/antibiotics