1244 infection control & hospital epidemiology october 2015, vol. 36, no. 10


prior studies of all acute care hospitals (not pediatric specific), which revealed that antimicrobials are in the top 3 pharmacy expenditures.1,2,11 Second, only a few drugs accounted for a third of


total antimicrobial costs; however, these differed from those identified in adult-dominated populations (where daptomycin contributed most to antimicrobial expenditures).1 Therefore, targets for antimicrobial stewardship (when similar therapeutic choices exist) can differ by patient population. Third, some drugs, especially antifungals, disproportionately contributed to cost compared with DOT, as illustrated by the cost- to-DOT ratio. For example, if DOT alone were used to identify ASP targets, antifungals and linezolid might be overlooked. Fourth, we observed greater than 20-fold differences in anti- microbial cost per patient-day with appendectomy or pneumonia —2 of the most common indications for antimicrobial use in hospitalized children4—even after standardizing for patient demographic characteristics and severity of illness. Importantly, these differences were more pronounced than those using DOT alone—the current standard antimicrobial use metric—because they were likely more driven by specific antimicrobial choice than by the number of drugs or duration of therapy. Our study has limitations. Antibiotic use was derived from


billing data, which might not always reflect drug administra- tion. Additionally, our results might not be generalizable to non-freestanding children’s hospitals. In conclusion, antimicrobials account for a large proportion


of medication spending in children’s hospitals and cost varies substantially across children’s hospitals. ASPs should collect and consider cost data to help optimize antimicrobial prescribing strategies.


acknowledgments


Financial support. None reported. Potential conflicts of interest. All authors report no conflicts of interest


relevant to this article. Affiliations: 1. Division of Infectious Diseases and Center for Pediatric


Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; 2. Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah; 3. Division of Infectious Diseases, Seattle Children’s Hospital, Seattle, Washington; 4. Division of


Infectious Diseases, Children’s Mercy Hospitals and Clinics, Kansas City, Kansas; 5. Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania Address correspondence to Jeffrey S. Gerber, MD, PhD, Division of Infec-


tious Diseases, Children’s Hospital of Philadelphia, CHOP North, Ste 1518, Philadelphia, PA 19104 (gerberj@email.chop.edu). Presented in part: ID Week 2014; Philadelphia, Pennsylvania.


Received April 2, 2015; accepted: May 25, 2015; electronically published


July 13, 2015 © 2015 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2015/3610-0018. DOI: 10.1017/ice.2015.159


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8. Suda KJ, Hicks LA, Roberts RM, Hunkler RJ, Danziger LH. A national evaluation of antibiotic expenditures by healthcare setting in the United States, 2009. J Antimicrob Chemother 2013;68:715–718.


9. Averill RF, GoldfieldN,Hughes JS, et al. All Patient Refined Diagnosis Related Groups (APR-DRGs), Version 20.0: Methodology Overview. Wallingford, CT: 3MHealth Information Systems, 2003.


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