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The use of vancomycin is common among hospitalized children. We sought to evaluate the impact of prospective audit with real-time feedback on vancomycin use and pharmacy costs.Vancomycin use was evaluated at Monroe Carell Jr Children’s Hospital at Vanderbilt (MCJCHV) before and after the implementation of prospective audit with intervention and feedback to providers in 2012. Antibiotic use was compared to academic children’s hospitals with established antimicrobial stewardship programs (ASPs). Two similar pediatric academic institutions without an ASP were used as nonintervention controls. Analysis of monthly days of antibiotic therapy (DoT) per 1000 patient-days was performed by interrupted time series analysis.Monthly vancomycin use decreased from 114 DoTs/1000 patient-days to 89 DoTs/1000 patient-days (P < .0001). We did not find significant differences in the slope of change in vancomycin use between MCJCHV and institutions with ASPs either before or after the intervention (P = .86 and P = .71, respectively). When compared to children’s hospitals without ASPs, the use of vancomycin was significantly lower at MCJCHV (P < .001).The use of vancomycin at academic children’s hospitals with an ASP is declining. In our experience, prospective audit with real-time intervention and feedback to providers significantly reduced the use and costs associated with vancomycin.