Pediatric ASP Toolkit

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

• Overall, an estimated 1 in 3 outpatient prescriptions are unnecessary. (Fleming-Dutra K et al. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. JAMA. 2016 May 3;315(17):1864-73.) An estimated 49 million courses of antibiotics are prescribed annually in ambulatory pediatrics. (Hersh AL et al. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011 Dec;128(6):1053-61). The total number of excess prescriptions for acute respiratory illnesses is estimated to be 11.5 million. (Kronman M et al. Bacterial prevalence and Antibiotic prescribing trends for acute respiratory tract infections. Pediatrics. 2014 Oct;134(4):e956-65.)

(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. (Lee GC, Reveles KR, Attridge RT, et al. Outpatient antibiotic prescribing in the United States: 2000 to 2010. BMC Med. 2014;12:96)
• 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. (Hersh AL et al. Frequency of First-line Antibiotic Selection Among US Ambulatory Care Visits for Otitis Media, Sinusitis, and Pharyngitis. JAMA Internal Medicine 2016; 176:1870.

(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:

Pyelonephritis

• 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

• AAP Clinical Practice Guidelines from 2013 recommend 10 days of therapy for children younger than 2 years with severe symptoms, based on strong evidence.

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

• Unexplained variation in antibiotic prescribing suggests unnecessary use in certain areas. There is substantial regional and state-to-state variation in outpatient antibiotic prescribing rates. 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. (Hicks LA et al. US Outpatient Antibiotic Prescribing Variation According to Geography, Patient Population, and Provider Specialty in 2011. Clin Infect Dis 2015; 60:1308–1316.)

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.)