Pediatric Antimicrobial Stewardship: Current Evidence and Emerging Challenges

Antimicrobial resistance (AMR) is a growing global health threat with important implications for pediatric populations. Children are frequently exposed to antibiotics in both hospital and community settings, where inappropriate prescribing, suboptimal dosing, and excessive use of broad-spectrum agents remain common. These practices contribute to the emergence of resistant pathogens, increase adverse drug events, and may negatively affect the developing immune system and microbiota. This narrative review summarizes current evidence on pediatric antimicrobial stewardship (AMS), highlighting recent trends in antimicrobial use and key stewardship strategies across inpatient and outpatient care. Core interventions, including prospective audit and feedback, preauthorization, guideline implementation, AWaRe-based prescribing, therapeutic drug monitoring, and early intravenous-to-oral switch, are discussed. The review also examines the expanding role of diagnostic stewardship, focusing on rapid molecular diagnostics, point-of-care testing, and host-response biomarkers to improve differentiation between bacterial and viral infections and support targeted therapy. Despite progress, pediatric AMS faces persistent challenges, such as regional variability in prescribing practices, limited pediatric-specific data for new antimicrobials and diagnostics, and organizational and behavioral barriers. Emerging tools, particularly artificial intelligence, may enhance decision-making and optimize antimicrobial use, although further validation in pediatric settings is needed. Strengthening pediatric AMS is essential to improving care quality and mitigating the impact of AMR.