Overuse can be classified into three categories: 1) prescribing antibiotics when none are indicated, 2) prescribing antibiotic courses that are excessive in spectrum, and 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
(2) Use of broad-spectrum and non-first-line antibiotics
(3) Antibiotic duration
Antibiotics should prescribed for the minimal effective duration. The following studies and guidelines support the use of shorter duration of therapy than historically used for select infectious conditions:
- 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.
- A multicenter retrospective cohort study of children with pyelonephritis used an inverse probability of treatment weighted propensity score analysis and found the odds of treatment failure were similar in children treated with a short course (6-9 days) compared with those treated with a long course (10 days or more) (Fox MT et al 2020 ).
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.
Regional Variation in Antibiotic Prescribing
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. (Ray KN, Shi Z, Gidengil CA, Poon SJ, Uscher-Pines L, Mehrotra A. Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Pediatrics 2019; 143:e20182491.)
- For all age groups, urgent care centers are most likely to prescribe antibiotics inappropriately, followed by emergency departments, medical offices, and retail clinics. (Palms DL et al. Comparison of Antibiotic Prescribing in Retail Clinics, Urgent Care Centers, Emergency Departments, and Traditional Ambulatory Care Settings in the United States. JAMA Intern Med 2018; 178:1267–1269.)