Pediatric stewardship in Italy: a necessity, not an option - a National Multi-Society Expert Consensus on Antimicrobial and Diagnostic Stewardship (SIP, SITIP, SIMRI, SIAIP, SIMEUP, SIPPS, SICUPP, SIMIT, SIMPE, SIPINF, SIT, SIAATIP, SARNEPI, AIEOP, SIM, SITI, SIF, SIFACT, SITA, SIN).

Antimicrobial Stewardship Programs (ASPs) and Diagnostic Stewardship Programs (DSPs) are essential for optimizing infectious disease management and addressing antimicrobial resistance (AMR). However, the implementation of pediatric ASPs presents distinct challenges that set them apart from adult-focused initiatives. Additionally, many existing ASP guidelines are primarily tailored to the U.S. healthcare system, requiring significant adaptation to fit the diverse healthcare infrastructures, resources, and prescribing practices across different countries. These factors highlight the need for context-specific strategies to ensure the effective implementation of pediatric ASPs worldwide. To develop a national, intersociety consensus on pediatric ASPs in Italy, an ASP steering committee was established, bringing together a multidisciplinary group of experts. A systematic scoping review was conducted to identify relevant literature on ASPs and DSPs published between 2007 and August 2024, retrieving 260 articles. Based on this evidence, 33 recommendations were formulated, covering general ASP and DSP principles (10 recommendations), ASP interventions (14), DSP interventions (3), and monitoring strategies (6). Consensus on the importance and feasibility of each recommendation was reached using the Delphi method, with two rounds of anonymous questionnaires. The steering group defined a priori criteria for recommendation acceptance, requiring at least 80% agreement on the importance of each item. This consensus highlights the critical role of a multidisciplinary approach in ASP implementation, supported by institutional leadership. Given the variability in healthcare systems, ASP interventions must be tailored to specific settings, considering factors such as hospital resources, patient complexity, and the parent-child dynamic. Standardized metrics for assessing the impact of ASPs are essential for benchmarking and ensuring sustainability, although data collection remains a significant challenge. While there was strong agreement on the importance of the recommendations, feasibility assessments identified key areas requiring further refinement, particularly in settings with limited pediatric-specific expertise and diagnostic tools. This national consensus provides a structured framework for the implementation of pediatric ASPs in Italy, equipping clinicians with essential tools to optimize antibiotic use in both inpatient and outpatient settings. It represents a foundational step toward improving pediatric ASP, fostering national and international collaboration, and guiding future research to address implementation barriers.