Pediatric ASP Toolkit

Antibiotic Use

Antibiotic overuse falls into three categories: 

1) Prescribing antibiotics when none are indicated

2) Prescribing antibiotic courses that are excessive in spectrum

3) Prescribing antibiotic courses with excessive duration for the infection being treated. 

There is substantial evidence suggesting that antibiotics are overused in outpatient settings, and children are no exception.

(1) Unnecessary antibiotic prescriptions

The total number of excess prescriptions for acute respiratory illnesses is estimated to be 11.5 million per year. 

There is substantial regional and state-to-state variation in outpatient antibiotic prescribing rates, suggesting greater overuse in certain regions. For children aged 2 and under, there is a nearly five-fold difference in antibiotic prescriptions per child per year between the states using the least and most antibiotics. 

(2) Use of broad-spectrum and non-first-line antibiotics

Proportion of broad-spectrum antibiotic prescribing increased from 2000 to 2010 among children and adolescents by 143%, more than in any other age group. 

Between one third and one half of children with otitis media, sinusitis, or pharyngitis receive non-first-line antibiotics, despite evidence that no more than 20% of children (and probably far less) have a contraindication to first-line antibiotics.

Community acquired Pneumonia is another target where broad spectrum antibiotics such as macrolides are often unnecessarily used. 

Additional references:

(3) Antibiotic duration

Antibiotics should be prescribed for the minimal effective duration. Recent surveillance indicates that providers default to 10 days, despite guidelines recommending shorter durations.

The following studies and guidelines support the use of shorter duration of therapy than historically used for select infectious conditions:

Skin and Soft Tissue Infections

Community-acquired Pneumonia 


  • AAP Clinical Practice Guidelines from 2011 recommend treating children with pyelonephritis for 7 to 14 days, citing insufficient data to recommend a more specific treatment duration. More recently, a multicenter retrospective cohort study of children with pyelonephritis found no difference in outcome between children treated with a short course (6-9 days) compared with those treated with a long course (10 days or more).
    • Fox MT, Amoah J, Hsu AJ, Herzke CA, Gerber JS, Tamma PD. Comparative Effectiveness of Antibiotic Treatment Duration in Children with Pyelonephritis. JAMA Netw Open. 2020;3(5):e203951. doi:10.1001/jamanetworkopen.2020.3951

Acute otitis media, age < 2 years

Acute otitis media, age > 2 years

  • Based on data suggesting that shorter antibiotic courses in children > 2 years of age with acute otitis media are equally effective, AAP Clinical Practice Guidelines from 2013 recommend a 7 day course of first-line antibiotic therapy for children ages 2-5 years and a 5-7 day course for children ages 6 years and older with mild or moderate AOM.

Antibiotic Overuse in Various Settings

Children are prescribed antibiotics in a variety of settings: primary care, outpatient subspecialty care, dentistry, emergency departments, urgent care centers, retail clinics, and direct-to-consumer telemedicine. Each presents unique challenges with overuse of antibiotics.

Direct-to-consumer telemedicine is growing in popularity, but antibiotic prescribing for children is much more common and much more likely to be guideline-discordant compared to primary-care and urgent-care settings. Five percent of children in one study were diagnosed with streptococcal pharyngitis in telemedicine visits with no testing performed in 96% of those patients.

For all age groups, urgent care centers are most likely to prescribe antibiotics inappropriately, followed by emergency departments, medical offices, and retail clinics

Primary-care practices that are not affiliated with an academic medical center may be more likely to overuse antibiotics.

  • Abuali M, Zivot A, Guerguis S, et al. Outpatient antibiotic prescribing patterns in pediatric academic and community practices. American Journal of Infection Control. 2019;47(9):1151-1153. doi:10.1016/j.ajic.2019.03.025

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