LAUSR

OBJECTIVE COVID-19 treatment guidelines rapidly evolved during the pandemic. The December 2020 Infectious Diseases Society of America (IDSA) guideline, endorsed by the Pediatric Infectious Diseases Society, recommended steroids for critical disease, and suggested steroids and remdesivir for severe disease. We evaluated how medications for children hospitalized with COVID-19 changed after guideline publication. METHODS We performed a multicenter retrospective cohort study of children ages 30 days to <18 years hospitalized with acute COVID-19 at 42 tertiary care US children's hospitals April 2020 - December 2021. We compared medication use before and after the December 2020 IDSA guideline (pre- and post-guideline) stratified by COVID-19 disease severity (mild-moderate, severe, critical) with interrupted time series. RESULTS Among 18,364 patients who met selection criteria, 80.3% were discharged in the post-guideline period. Remdesivir and steroid use increased post-guideline relative to the pre-guideline period, although the trend slowed. Post-guideline, among patients with severe disease, 75.4% received steroids and 55.2% remdesivir, and in those with critical disease, 82.4% received steroids and 41.4% remdesivir. Compared to pre-guideline, enoxaparin use increased overall but decreased among patients with critical disease. Post-guideline, tocilizumab use increased and hydroxychloroquine, azithromycin, anakinra, and antibiotic use decreased. Antibiotic use remained high in severe (51.7%) and critical disease (81%). CONCLUSIONS Although utilization of COVID-19 medications changed following December 2020 IDSA guidelines, there was a decline in uptake and incomplete adherence for children with severe and critical disease. Efforts should enhance reliable delivery of guideline-directed therapies to children hospitalized with COVID-19 and assess their effectiveness.