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BackgroundPrior authorization, audit and feedback, and pay for performance are the three core “active” strategies of antimicrobial stewardship program (ASP), yet little is known about the individual or combined benefits of such programs, particularly in a pediatric setting.ObjectivesThe aim of this study was to compare these core ASP strategies and determine the incremental effect of financially punished audit and feedback.MethodsDuring the journey to the Joint Commission International accreditation, a tertiary pediatric medical center performed two different hospital-wide stewardship interventions in succession. The first stage without formalized ASPs served as pre-intervention period, January 2011 to April 2011. The ASP used prior authorization alone during the first-intervention period, May 2011 to September 2011. In October 2011, financially punished audit and feedback was introduced, marking the start of the second-intervention period, October 2011 to November 2012. We compared the differences of the change in monthly average use of antibiotics and expenditure on antibiotics before and after the ASP changes by using interrupted time series via dynamic regression. The main end points included the proportions of antibiotic prescriptions and expenditure on antibacterial relative to all medications.ResultsBefore the second-intervention period, neither the proportion of antibiotic prescriptions nor the proportion of expenditure on antibiotics declined significantly in both ambulatory and inpatient settings. However, after the introduction of financially punished audit and feedback, the proportion of both antibiotic prescriptions (β = −6.269, P < 0.001, and reduction = 59.4% for outpatients; β = −1.235, P < 0.001, and reduction = 19.8% for inpatients) and expenditure on antibiotics (β = −7.777, P < 0.001, and reduction = 46.7% for outpatients; β = −4.933, P = 0.001, and reduction = 16.3% for inpatients) dropped immediately.ConclusionThe combination of more than one core strategies (prior authorization, audit and feedback, and pay for performance) will be more effective than one strategy alone.

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