Aside from cases of atypical pneumonia commonly caused by Mycoplasma pneumoniae, azithromycin is not considered first line therapy for pediatric acute respiratory infections (ARIs). Starting in late summer 2024, a nationwide surge in M. pneumoniae cases was reported. This study evaluated outpatient azithromycin prescriptions during that time using a nationally representative sample of institutions providing pediatric care.Figure 1Time series of the rate of antibiotic use for ARI encounters in the different practice settings.Figure 2Time series of the azithromycin index in the different practice settings. Institutions from the Sharing Antimicrobial Reports for Pediatric Stewardship outpatient (SHARPS-OP) collaborative provided aggregate quarterly data January 2021 - December 2024. We collected data on all ARI encounters, and proportions of ARIs with any oral antibiotic prescription, including the proportion of amoxicillin (amoxicillin index) and azithromycin (azithromycin index) prescriptions. We stratified data by practice setting (Emergency Department [ED], Urgent Care [UC], primary care clinics [PCC], and telehealth [TH]). We compared our metrics among the different institutions and practice settings, and evaluated change over time.Figure 3Changes in azithromycin index among the different institutions between baseline period (Q1 2021- Q2 2024), and M pneumoniae surge period (Q3-Q4 2024) A total 5.8 million ARI encounters were reported across 20 institutions. Overall antibiotic prescribing for ARI encounters had been slowly increasing over the last 8 quarters (Q1 2023- Q4 2024) in all practice settings (Figure 1). We observed a small decline in amoxicillin index in Q3-Q4 2024 (67.1% prior to Q3 2024 to 61.3% Q3-Q4 2024), but a dramatic increase in azithromycin index by 16.2% (4.1% to 20.3% in Q3-4 2024). This increase was most notable in the PCC (19.0%), followed by ED (11.6%), and UCC (10.3%) (Figure 2). Figure 3 shows the variability in azithromycin index across the institutions and practice settings, with some institutions seeing no increase, while others reached an azithromycin index of over 30% in certain settings. Despite national guidelines advising that most M. pneumoniae infections do not require antibiotic therapy, azithromycin was commonly used for ARIs during the M. pneumoniae surge. Interestingly, azithromycin index was higher in PCC compared to the ED where severity would be expected to be higher. There was substantial variability between institutions and practice settings. Rana E. El Feghaly, MD, MSCI, CPHQ, Merck and Company, Inc.: Grant/Research Support|Pfizer, Inc.: Grant review panel Michael J. Smith, MD, M.S.C.E, Pfizer: Grant/Research Support

ABSTRACT The recent development of new respiratory syncytial virus (RSV) prophylactics for the prevention of severe lower respiratory tract infections in infants and older adults promises in lowering disease burden in these vulnerable populations. However, it remains unclear if periodic breakthrough infections in these populations may drive the emergence of resistant isolates or clades and what factors might contribute to these breakthroughs. In this retrospective cohort study, we performed whole-genome sequencing of RSV isolates from infants and adults during the past two RSV seasons (2023-2025) to assess viral and clinical correlates of nirsevimab breakthrough. RSV infections from nirsevimab breakthrough cases were associated with less severe clinical outcomes in the first, but not second, season after administration. While breakthrough isolates did not share any Fusion glycoprotein mutations in predicted antigenic sites, they largely belonged to only a few circulating clades that were responsible for driving temporally distinct pediatric transmission clusters. To determine if these transmission clusters and breakthrough infections were in part driven by differences in the Fusion proteins of these clades, we compared the relative fusogenicity and neutralization susceptibility of Fusion proteins from contemporary circulating clades. Notably, RSV-A clade A.D.3 exhibited modestly reduced susceptibility to nirsevimab neutralization, though it wasn’t associated with any transmission clusters or breakthrough infections. Collectively, these data suggest that clade associations with prophylactic breakthrough are driven by pediatric transmission clusters rather than clade-associated resistance, though continued surveillance will be vital as prophylactic coverage continues to rise.

Sepsis remains a leading cause of morbidity and mortality in US hospitals despite extensive efforts to improve early recognition and treatment, particularly through implementation of the Centers for Medicare & Medicaid Services (CMS) SEP-1 quality measure. Recognizing the need for broader approaches to sepsis improvement, CMS and the Centers for Disease Control and Prevention are advancing new sepsis quality measures focused on outcomes and hospital programmatic capacity, while the Surviving Sepsis Campaign guidelines continue to provide evidence-based recommendations for bedside clinical management. However, there remains a need for practical, actionable guidance that complements existing guidelines and quality frameworks by addressing hospital-based strategies across the continuum of sepsis care. To address this gap, the Infectious Diseases Society of America convened a multidisciplinary, multisociety expert panel to develop a consensus-based position paper outlining evidence-informed recommendations for hospital-based sepsis improvement. The recommendations focus on infection-related aspects of sepsis management and span 6 domains: diagnostic testing and pathogen detection, antimicrobial management and delivery, surveillance and performance metrics, adjunctive therapy, program infrastructure and organizational support, and infection prevention. Examples include implementing multiplex nucleic acid amplification tests for positive blood cultures paired with active stewardship support; optimizing workflows for timely antibiotic delivery in septic shock; using clinical decision support to prioritize β-lactam administration before vancomycin when both are ordered; defaulting antipseudomonal β-lactams to prolonged infusion in critically ill patients; adopting EHR-based sepsis surveillance; tracking rates of inadequate empiric therapy, unnecessarily broad empiric therapy, antibiotic de-escalation, and timeliness of source control; establishing protocols for appropriate corticosteroid use in severe community-acquired pneumonia; and standardizing daily tooth brushing to prevent hospital-acquired pneumonia. The panel also highlights emerging approaches, particularly novel diagnostic strategies, that show promise but require further validation before widespread adoption. Collectively, these recommendations provide a pragmatic framework for hospitals to strengthen infection-related sepsis management and improve patient outcomes.

BACKGROUND:We evaluated the impact of benchmarking on antibiotic prescribing and identified antibiotic stewardship strategies affecting pediatric outpatient antibiotic prescribing. METHODS:The Sharing Antimicrobial Reports for Pediatric Stewardship-Outpatient Collaborative shared quarterly benchmarking reports with 22 institutions on antibiotic prescribing metrics (percentage of acute and acute respiratory infection [ARI] encounters with antibiotic prescriptions, duration of ≤ 7days, and among ARI, rates of amoxicillin and azithromycin use) for emergency departments, urgent care clinics, and primary care clinics. In January 2024, a survey assessed stewardship strategies and the impact of the benchmarking reports. We compared baseline (January 2019-December 2022) with the benchmarking period (January 2023-September 2024). RESULTS:We included 32.4 million acute encounters. Although antibiotic prescribing increased in the benchmarking period, we saw increased amoxicillin use, decreased azithromycin use, and decreased antibiotic duration. The odds of receiving antibiotics for ARI were variable across practice settings and strategies, although institutions that used guidelines, electronic record features, and quality improvement projects observed lower antibiotic and azithromycin use and higher amoxicillin use. CONCLUSIONS:Although we did not observe a decrease in antibiotic prescribing for ARI after providing benchmarking reports, there was improvement in antibiotic selection. Guidelines and quality improvement initiatives may have the biggest impact on antibiotic prescribing metrics.

IntroductionRespiratory syncytial virus (RSV) is the leading cause of viral lower respiratory tract infections. Due to the complexity of eligibility criteria, our institution used an escape room to provide an interprofessional learning experience.MethodsGroups completed four challenges and four patient cases to determine if RSV prophylaxis was warranted to complete the RSV escape room. Surveys were created to evaluate participants' comfort-level with selection of appropriate RSV prophylaxis, knowledge of eligibility criteria for RSV prophylaxis (knowledge-based), and participants' thoughts on the RSV escape room (attitude-based). Both surveys included the same comfort-level and knowledge-based questions. Attitude-based questions were only included in the post-escape room survey. The primary outcome was to compare the number of participants that correctly answered knowledge-based questions. The secondary outcomes were to assess participants' comfort-level and attitude-based questions.ResultsForty-eight participants completed the pre-escape room survey, and 44 participants completed the post-escape room survey. Most participants were pharmacists (pre-escape room: 29.2% [14/48] and post-escape room: 31.8% [14/44]). For one knowledge-based question, there was a statistically significant increase in the number of participants with the correct answer after participating in the RSV escape room (question one: 52.1% vs. 72.7%; p = 0.042). For the other knowledge-based questions, the number of participants with the correct answer was comparable (question two: 62.5% vs. 61.4%; p = 0.61; question three: 75% vs. 81.8%; p = 0.52). After completion of the RSV escape room, 68.2% (30/44) felt very comfortable with the selection of RSV prophylaxis. Eighty-nine percent (39/44) of participants strongly agreed that reviewing eligibility criteria for RSV prophylaxis within a group of pharmacists was beneficial for learning.ConclusionsAn RSV escape room is a team-based approach that modestly improves the knowledge base of health care providers in a clinical setting and was well received.

INTRODUCTION:Risk factors for COVID-19 hospitalization in children include incomplete vaccination and having high-risk chronic conditions. There is concern for a lack of vaccine equity. Our study evaluates the association between socioeconomic child opportunity index (COI), chronic conditions, and vaccine uptake. METHODS:We included all patients hospitalized with COVID-19 at Lurie Children's Hospital of Chicago until June 2022 who received remdesivir treatment. Demographic data, insurance status, socioeconomic COI, vaccination status, and chronic conditions were recorded. Chi-squared tests were performed. RESULTS:Vaccines were unavailable for most patients (112/198, 56.6 %) at the time of hospitalization. In the remaining 86 patients, those with low COI were more often unvaccinated than higher COI counterparts (60.4 % vs. 68.4 %; p = 0.040). There was no difference between groups based on chronic conditions (p = 0.487). CONCLUSIONS:Targeted outreach is needed to increase vaccination in children with chronic conditions living in neighborhoods with lower socioeconomic COI.

Prevalence of emerging fungal infections is increasing, particularly among immunocompromised persons, children, and older persons. We report 108 cases of Scheffersomyces spartinae infection in pediatric patients from Karachi and other cities in Pakistan, of which 107 were identified from blood cultures. Cultures were initially misidentified as Clavispora lusitaniae by a biochemical assay before speciation as S. spartinae by whole-genome sequencing. All isolates were from children <12 years of age, and >69% were from children <1 month of age. Isolates were genetically distinct across regions of Pakistan; however, genetic diversity was low in isolates from patients in Karachi and nearby Nawabshah and had median differences of just 9 pairwise nucleotide variants. This study demonstrates S. spartinae is a potentially emerging pathogen in neonates and young infants in Pakistan. The findings highlight the limitations of phenotypic identification for detecting emerging fungal infections and underscore the value of molecular identification approaches.

Antimicrobial stewardship benefits from federal and state regulations, collaboration with professional societies, and sharing of data and expertise. Programs should prioritize high-value interventions and highlight the impact of their work. Stewardship leaders can enhance visibility through advocacy and public outreach.

Owing to significant time spent indoors, indoor air quality (IAQ) and thermal comfort are critical to ensure occupants' well-being. Buildings already account for a considerable fraction of developed nations' energy consumption, primarily for maintaining thermal comfort. Measures to improve IAQ can further increase the energy demand. Thus, optimizing IAQ, energy consumption, and thermal comfort is critical. This work presents a dynamic optimization model to investigate the complex and interdependent relationship between personal exposure to particulate matter (PM), thermal comfort, and energy consumption in a test house during typical cooking activities and intense holiday cooking. Surface deposition dominated PM removal for both scenarios (72-78 %). During optimization of the cost function with higher weightage for exposure, exfiltration became the primary PM removal mechanism due to the increased outdoor-indoor air change rate. However, this also increased air conditioning energy consumption. Adding a filter to the recirculation system and increasing the indoor set temperature can save energy while maintaining the same level of exposure reduction achieved via exfiltration alone. Simulations corresponding to higher outdoor temperatures demonstrated that increasing the indoor set temperature from 25 degrees C to 27 degrees C reduces exposure and energy consumption relative to the benchmark without considerable compromise to the comfort level. A high normalized exposure reduction results in an energyefficient system but might not always translate to a desirable exposure reduction, thus indicating an energyexposure trade -off.

Introduction: Pulmonary abscess is a complication of lung infection with localized necrosis and purulent cavity formation. Pulmonary abscesses are typically managed using antibiotic therapy with anatomic surgical resection reserved as a rescue. Percutaneous drainage is considered relatively contraindicated in some centers due to perceived risk of bronchopleural fistula. However, drain placement has been frequently employed at our institution. The purpose of this study was to review and describe our longitudinal experience. Methods: Medical records of children diagnosed with lung abscess and treated with percutaneous drainage from 2005 through 2023 were reviewed. Patient clinical parameters, follow-up imaging, and clinical outcomes were evaluated. Results: Percutaneous drainage (n = 24) or aspiration alone (n = 4) under imaging guidance was performed by interventional radiologists for 28 children with lung abscesses. A single catheter (8-12 Fr) was deployed in the pulmonary abscess cavity and remained for a median of 6 days (IQR: 6-8 days). The median hospital stay was 10 days (IQR: 8.8-14.8 days). The technical success rate for percutaneous drainage or aspiration of primary pulmonary abscesses was 100% (26/26). Two children were later diagnosed with secondarily infected congenital pulmonary airway malformations that were both successfully drained and ultimately surgically resected. The abscess cavities resolved in all patients and catheters were removed upon clinical, radiographic, and laboratory improvement. Complications included the presence of two bronchopleural fistula, both of which were treated with immediate pleural drain placement. Conclusion: Percutaneous drainage of pulmonary abscesses is an effective therapeutic option in children and can be considered alongside antibiotics as part of the initial treatment for pulmonary abscesses. Bronchopleural fistula can occur, but at a lower frequency than previously reported. Level of Evidence: Level V. (c) 2024 Elsevier Inc. All rights reserved.

Household air pollution, primarily from solid fuels, globally caused 3.2 million premature deaths in 2020. India houses more than a quarter of global solid fuel users, and transitioning them to cleaner fuels offers an opportunity for global environmental and socio-economic impacts and addressing multiple sustainable development goals. This study compares cooking fuels from the perspective of health, environmental impacts, cost, supplydemand dynamics, and relevant policies. Liquefied petroleum gas (LPG) and piped natural gas (PNG) are being aggressively promoted as cleaner fuel alternatives. However, their sustained use, high reliance on imports, volatile prices, and environmental impacts remain a concern. Moreover, LPG and PNG might not be clean enough as NOx and ultrafine particle emissions have been associated with adverse health impacts. Replacing current solid fuels with LPG will annually add about 91 million metric tons of CO2 (just from combustion), translating to an increase of about 3.5 % of the country's CO2 emissions. Direct and indirect imports constituted 96.5 % of the total LPG consumption in 2021-22, and the same has remained above 90 % for the last decade. Furthermore, the current subsidy-based policy promoting LPG adoption doubled the active user base in just seven years. However, annual LPG consumption has steadily declined from -110 kg to -85 kg per user over the same period, indicating non-sustained adoption. Unlike developed countries, electricity for cooking has not gained popularity in India, even though it has the potential to address the shortcomings of LPG and PNG. Decentralization and integration of renewables in the power generation sector can provide energy with lower carbon intensity, lesser reliance on imports, and relatively stable prices. The cooking energy portfolio of India will be a mixed bag, but more comprehensive forward-looking policies are needed to optimize its composition.

Background Post-exposure prophylaxis (PEP) with varicella immunoglobulin is recommended to minimize risk of varicella complications for high-risk children. However, providers frequently use alternatives like acyclovir or intravenous immunoglobulin.Methods A retrospective cohort study was conducted of PEP for varicella in children from January 2009 to December 2019. Data were provided by 47 children's hospitals who participate in the Pediatric Health Information Systems database. Patients with clinical encounters for varicella exposure were reviewed. Choice of varicella PEP regimens, including differences by underlying condition and institution, and incidence of varicella disease were determined.Results A total of 1704 patients with first clinical encounters for varicella met inclusion criteria. Of these patients, 509 (29.9%) were prescribed PEP after varicella exposure, and 65 (3.8%) ultimately had a subsequent encounter for varicella disease. Of 509 patients who received PEP, acyclovir was most frequently prescribed (n = 195, 38.3%), followed by varicella immunoglobulin (n = 146, 28.7%), IVIG (n = 115, 22.6%), and combination therapy (n = 53, 10.4%). The highest proportion of varicella immunoglobulin use (10/20, 50%) was amongst children with diagnoses of rheumatological/gastrointestinal conditions. The highest proportion of acyclovir use (29/684, 4.2%) was amongst children with diagnoses of oncology/stem cell transplant conditions. The proportion of patients who subsequently had clinical encounters for varicella disease was highest for Acyclovir (30/195, 15.4%) followed by varicella immunoglobulin (5/146, 3.4%), combination therapy (2/53, 3.8%), and intravenous immunoglobulin alone (0/115) (P < .0001).Conclusions Varicella PEP in high-risk children was highly varied among children's hospitals. In our dataset, use of acyclovir was associated with a higher rate of subsequent encounters for Varicella disease.

Spatio-temporal monitoring in a multizonal apartment focussing on inter-zonal transport, multizonal exposure, and characterization of mitigation techniques (portable air cleaner, air conditioners, natural ventilation, and filter sheets).

Bacteremia can be life-threatening, and highly medicalized patients, such as those with complex congenital heart disease, are at high risk. Infectious diseases (ID) consultation is associated with improved outcomes in bacteremia. We noted an opportunity for improvement in management of positive blood cultures in our cardiac care unit (CCU). We completed a quality improvement project that included a single plan-do-study-act cycle consisting of a policy of routine ID consultation for all positive blood cultures events in the CCU. Our outcome measure of interest was percentage of appropriately managed blood culture events, the process measure was percentage of blood culture events for which the ID service was formally consulted, and the balancing measure was number of individual patients for whom the ID service was formally consulted. Appropriate antimicrobial management was determined via chart review by an ID physician. Data were analyzed via run chart and simple statistics. Following the intervention, the rate of appropriately managed positive blood culture events increased from a baseline of 86% to 98%, and the rate of ID consultation for these events increased from 75% to 98%. A shift was noted in run charts for both the outcome and process measures. There was an increase in patients for whom the ID service was consulted throughout the entire study period. We successfully implemented mandatory ID consultations in a CCU to increase proportion of appropriately managed blood cultures. While this intervention cannot be universally applied, others may find it useful in selected scenarios.

Journal Article Corrected proof Response to Evidence Still Pending: Post-exposure Prophylactic Measures Against Varicella Zoster Virus Get access Emily Shteynberg, Emily Shteynberg Division of Pediatric Infectious Disease, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois, USA Corresponding Author: Emily Shteynberg, BA, Division of Pediatric Infectious Disease, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA. E-mail: emilyshteynberg2022@u.northwestern.edu. Search for other works by this author on: Oxford Academic PubMed Google Scholar Shan Sun, Shan Sun Division of Pediatric Infectious Disease, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar Ravi Jhaveri, Ravi Jhaveri Division of Pediatric Infectious Disease, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois, USANorthwestern University Feinberg School of Medicine, Chicago, Illinois, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar Sameer J Patel Sameer J Patel Division of Pediatric Infectious Disease, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois, USANorthwestern University Feinberg School of Medicine, Chicago, Illinois, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar Journal of the Pediatric Infectious Diseases Society, piae055, https://doi.org/10.1093/jpids/piae055 Published: 15 June 2024 Article history Corrected and typeset: 15 June 2024 Published: 15 June 2024

Spatio-temporal particulate matter (PM) measurements are critical to understanding emission profiles to develop effective mitigation strategies. However, high-resolution spatio-temporal measurements using research-grade instruments are cost-prohibitive, making low-cost sensors (LCS) a promising alternative. LCS measures particle light scattering intensity (Isc) and converts it to mass and number concentrations. Such measurements are influenced by particles' physico-optical properties, which make LCS appropriate for measuring PM with similar properties to those used for calibration. This work evaluates the performance of an LCS (PurpleAir) against reference instruments (SMPS + APS) during cooking experiments performed in a test house where PM0.3/PM10 as high as 90% was observed. LCS demonstrated better correlations (R2) for PM1 (0.98-1), PM2.5 (0.96-1), and PM10 (0.88-1) compared to coarser size bins, i.e., PM1-2.5 (0.04-0.99) and PM2.5-10 (0.02-0.93). Measurements from different cooking activities show different linear fits. Isc calculated using size-resolved measurements of reference instruments also had different linear fits with corresponding mass concentrations, even after assuming the same refractive index for all cases, highlighting the dependence of size distribution on LCS measurements. On average, sub-300 nm particles accounted for up to 75 +/- 18% of the total Isc. Such dominance of sub-300 nm particles leads to size misclassification by LCS, whose algorithm assumes the inability to measure sub-300 nm particles. Moreover, the Isc calculated using the size distribution reported by LCS is considerably lower than that of reference instruments. This mismatch can be attributed to truncated angle error and positioning of particles in the sensing zone relative to the photodiode.Copyright (c) 2024 American Association for Aerosol Research

BACKGROUND:Most antibiotic use occurs in ambulatory settings. No benchmarks exist for pediatric institutions to assess their outpatient antibiotic use and compare prescribing rates to peers. We aimed to share pediatric outpatient antibiotic use reports and benchmarking metrics nationally. METHODS:We invited institutions from the Sharing Antimicrobial Reports for Pediatric Stewardship OutPatient (SHARPS-OP) Collaborative to contribute quarterly aggregate reports on antibiotic use from January 2019 to June 2022. Outpatient settings included emergency departments (ED), urgent care centers (UCC), primary care clinics (PCC) and telehealth encounters. Benchmarking metrics included the percentage of: (1) all acute encounters resulting in antibiotic prescriptions; (2) acute respiratory infection (ARI) encounters resulting in antibiotic prescriptions; and among ARI encounters receiving antibiotics, (3) the percentage receiving amoxicillin ("Amoxicillin index"); and (4) the percentage receiving azithromycin ("Azithromycin index"). We collected rates of antibiotic prescriptions with durations ≤7 days and >10 days from institutions able to provide validated duration data. RESULTS:Twenty-one institutions submitted aggregate reports. Percent ARI encounters receiving antibiotics were highest in the UCC (40.2%), and lowest in telehealth (19.1%). Amoxicillin index was highest for the ED (76.2%), and lowest for telehealth (55.8%), while the azithromycin index was similar for ED, UCC, and PCC (3.8%, 3.7%, and 5.0% respectively). Antibiotic duration of ≤7 days varied substantially (46.4% for ED, 27.8% UCC, 23.7% telehealth, and 16.4% PCC). CONCLUSIONS:We developed a benchmarking platform for key pediatric outpatient antibiotic use metrics drawing data from multiple pediatric institutions nationally. These data may serve as a baseline measurement for future improvement work.

BACKGROUND:The absence of consensus for outcomes in pediatric antibiotic trials is a major barrier to research harmonization and clinical translation. We sought to develop expert consensus on study outcomes for clinical trials of children with mild community-acquired pneumonia (CAP).METHODS:Applying the Delphi method, a multispecialty expert panel ranked the importance of various components of clinical response and treatment failure outcomes in children with mild CAP for use in research. During Round 1, panelists suggested additional outcomes in open-ended responses that were added to subsequent rounds of consensus building. For Rounds 2 and 3, panelists were provided their own prior responses and summary statistics for each item in the previous round. The consensus was defined by >70% agreement.RESULTS:The expert panel determined that response to and failure of treatment should be addressed at a median of 3 days after initiation. Complete or substantial improvement in fever, work of breathing, dyspnea, tachypnea when afebrile, oral intake, and activity should be included as components of adequate clinical response outcomes. Clinical signs and symptoms including persistent or worsening fever, work of breathing, and reduced oral intake should be included in treatment failure outcomes. Interventions including receipt of parenteral fluids, supplemental oxygen, need for high-flow nasal cannula oxygen therapy, and change in prescription of antibiotics should also be considered in treatment failure outcomes.CONCLUSIONS:Clinical response and treatment failure outcomes determined by the consensus of this multidisciplinary expert panel can be used for pediatric CAP studies to provide objective data translatable to clinical practice.

Abstract Background As FQ (fluoroquinolone) use has shifted in pediatric populations, better metrics are needed to guide targeted antibiotic stewardship interventions and limit development of adverse events and resistance, particularly in medically complex children. In this study, we identify high-utilization groups based on underlying medical conditions and describe their relative FQ use over time. Methods This study is a retrospective analysis of data from the Pediatric Health Information System database from 2016 to 2020. We identify high-utilization groups based on underlying medical conditions using International Classification of Diseases, Ninth or Tenth Revision codes. We delineate overall trends in the use of FQs in the inpatient setting, including rate and proportional use by each patient group. Results Patients with an oncology diagnosis represent a large (25%–44%) and rising proportion (+4.8%/year, P = .001) of national FQ use over the study period. Patients with intra-abdominal infections, including appendicitis, have had a significant increase in both their relative proportional use of FQs (+0.6%/year, P = .037) and proportion of FQ use per admission encounter over the study period (+0.6%/year, P = .008). Patients with cystic fibrosis represent a decreasing proportion of overall use (−2.1%/year, P = .011) and have decreasing FQ use per inpatient encounter (−0.8%/year, P = .001). Conclusions Patients with an oncology diagnosis and patients with an intra-abdominal infection appear to be targets for FQ stewardship. Patients with cystic fibrosis have decreasing inpatient FQ use. Key Points: This study describes fluoroquinolone use among hospitalized children from 2016 to 2020, stratified by underlying diagnoses. These trends are used to identify high-yield antibiotic stewardship targets.