Asian Journal of Advances in Research

Most children admitted to paediatric intensive care units receive antimicrobials, yet a substantial share of that exposure is unnecessary, excessively broad, poorly dosed or prolonged beyond the point of benefit. Antimicrobial stewardship programmes are now widely recommended for paediatric intensive care units, but the evidence supporting specific interventions in this setting remains fragmented across quality-improvement reports, single-centre before-and-after studies, surveys and a small number of pragmatic trials. This critical narrative review examines how stewardship has been implemented in paediatric intensive care units, which strategies have been evaluated, what barriers constrain their adoption, and what the available evidence shows about clinical, microbiological and economic outcomes. Literature was identified through structured searches of biomedical and multidisciplinary scholarly databases, authoritative institutional sources and citation chasing, and was appraised thematically with attention to study design, measurement and generalisability. The synthesis indicates that persuasive, rounding-based interventions such as prospective audit with feedback, structured antimicrobial time-outs and multidisciplinary review are consistently associated with lower antimicrobial consumption without detectable harm, although most of these data derive from non-randomised designs in high-income settings. Diagnostic stewardship of blood and endotracheal cultures has the most robust multicentre evidence, while biomarker-guided algorithms show inconsistent effects that appear to depend on adherence, baseline stewardship intensity and patient mix. Pharmacokinetic evidence shows frequent failure to attain β-lactam and glycopeptide exposure targets, but the clinical benefit of routine therapeutic drug monitoring or prolonged infusion has not been established in children. Effects on antimicrobial resistance, healthcare-associated infection and cost are rarely measured with adequate designs, and evidence from low- and middle-income countries remains sparse relative to disease burden. Important unresolved questions include the safe duration of therapy for culture-negative sepsis and ventilator-associated infection, the appropriate metrics for benchmarking critically ill children, and the implementation conditions under which decision-support and machine-learning tools improve prescribing. Stewardship in paediatric intensive care is best regarded as a set of context-dependent practices with credible short-term process benefits and uncertain long-term effects, which require multicentre, adequately powered and implementation-informed evaluation.