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Antibiotics
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Inappropriate Use of Antibiotics in Pediatrics
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Inappropriate Use of Antibiotics in Pediatrics

A special issue of Antibiotics (ISSN 2079-6382). This special issue belongs to the section "Antibiotics Use and Antimicrobial Stewardship".

Deadline for manuscript submissions: 30 September 2026 | Viewed by 23077

Special Issue Editor

Dr. Brian R. Lee

E-Mail Website
Guest Editor
Department of Health Services and Outcomes Research, Children’s Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, MO 64108, USA
Interests: antimicrobial stewardship; health disparities; epidemiology; clinical decision making; diagnostic microbiology

Special Issue Information

Dear Colleagues,

This Special Issue will collect all knowledge related to inappropriate prescriptions of antibiotics in pediatric patients. Prior research has shown that an estimated 20–50% of prescribed antibiotics are considered unnecessary. This pattern has been demonstrated in both inpatient and outpatient scenarios, though research has not focused solely on the pediatric population. Tribble and colleagues examined over 17,000 antibiotic orders among admitted pediatric patients from 32 hospitals and classified 21% of these orders as suboptimal/inappropriate [Clin Infect Dis; doi:10.1093/cid/ciaa036]. Nearly half of these suboptimal/inappropriate orders in that study would not have been routinely identified by antimicrobial stewardship programs. Diggs and colleagues conducted a similar study and reported that of the 13,000 antibiotic orders, 13.8% were considered inappropriate [Infect Control Hosp Epidemiol; doi:10.1017/ice.2023.56]. One key finding from this study was the substantial variation in inappropriate prescriptions by clinical service, including the highest levels of inappropriateness in PICU (19.4%) and surgical sub-specialty (22.5%) pediatric patients. A recent analysis of U.S. MarketScan commercial inpatient/outpatient pediatric claims data revealed that approximately 30% of the antibiotics used for bacterial infections and up to 70% of viral infections were considered inappropriate [JAMA Netw Open; doi:10/1001/jamanetworkopen.2022.14153]. More research is needed to not only fully understand the overall prevalence of inappropriate use, but also elucidate reasons for this inappropriateness, identify key drivers, and identify intervention opportunities. 

Dr. Brian R. Lee
Guest Editor

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Keywords

  • antimicrobial stewardship
  • inappropriate antibiotic prescription
  • antimicrobial resistance
  • pediatrics

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Published Papers (7 papers)

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Research

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13 pages, 322 KB  
Article
The Invisible Excess: Too Long Antibiotic Duration in the Pediatric Emergency Care
by Miguel Ángel Molina-Gutiérrez, María Camacho-Gil, Virginia Santana-Rojo and Luis Escosa-García
Antibiotics 2026, 15(2), 128; https://doi.org/10.3390/antibiotics15020128 - 27 Jan 2026
Viewed by 686
Abstract
Background/Objectives: Antibiotics are among the most commonly prescribed medicines in the Pediatric Emergency Department (PED). The overuse of antibiotics is directly linked to the emergence of resistance. Recent clinical trials have emerged in children in which short courses have proven to be [...] Read more.
Background/Objectives: Antibiotics are among the most commonly prescribed medicines in the Pediatric Emergency Department (PED). The overuse of antibiotics is directly linked to the emergence of resistance. Recent clinical trials have emerged in children in which short courses have proven to be as effective as longer courses. The aim of this study was to analyze the duration of antibiotic treatment prescribed in our PED for the most important and common infections in children and to compare with the best available evidence. Methods: A single-center retrospective study was conducted in the PED of a tertiary hospital. We evaluated outpatients from birth to 16 years who were discharged with antibiotic therapy during a 1-year period (2022) to classify duration of therapy as appropriate or inappropriate. Results: 1972 antibiotic prescriptions were analyzed. 28.3% (560/1972) of the prescriptions were classified as inappropriate according to duration of therapy; 551 (98.3%) were due to longer-than-recommended duration. The condition associated with the highest number of inappropriate prescriptions was Uncomplicated Community-acquired Pneumonia (CAP) (427/560; 76.2%). When focusing on each infectious syndrome, Uncomplicated CAP had also the highest percentage of inappropriate duration (92.6%) comparing with appropriate prescription. Regarding specific types of antibiotics, amoxicillin accounted for the highest number of inappropriate prescriptions (422/560; 75.4%). Conclusions: A longer-than-recommended prescription of antibiotics is frequent in the Pediatric Emergency Department. Uncomplicated CAP is the condition associated with the highest number of inappropriate duration of antibiotics in our setting. Full article
(This article belongs to the Special Issue Inappropriate Use of Antibiotics in Pediatrics)
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13 pages, 1017 KB  
Article
Impact of the COVID-19 Pandemic on the Outcomes of a Multifaceted Program on Antibiotic Prescribing in Primary Care Among Children Under Three Years of Age
by Gema Martín-Ayala, Santiago Alfayate-Miguélez, Casimiro Jiménez-Guillén, Manuel Alcaraz-Quiñonero, Antonio Iofrío-De Arce and José Arnau-Sánchez
Antibiotics 2026, 15(1), 101; https://doi.org/10.3390/antibiotics15010101 - 19 Jan 2026
Viewed by 538
Abstract
Background/objective: Inappropriate antibiotic use in paediatric populations is a leading driver of antimicrobial resistance. In the Murcia Region, Spain, the Purapi program promotes the rational use of antibiotics among children under 3 years of age. This study aimed to analyse antibiotic use [...] Read more.
Background/objective: Inappropriate antibiotic use in paediatric populations is a leading driver of antimicrobial resistance. In the Murcia Region, Spain, the Purapi program promotes the rational use of antibiotics among children under 3 years of age. This study aimed to analyse antibiotic use in this age group during the pandemic period (2020–2023) and to assess the impact of the COVID-19 pandemic on the effectiveness of a multifaceted program promoting appropriate antibiotic use. Methods: A retrospective, multicentre, population-based study was conducted in primary care using data from 2019 to 2024. Systemic antibiotic use (ATC J01 group) among children under three years was measured as defined daily doses per 1000 inhabitants per day (DHD). Differences across years and healthcare areas were assessed using analysis of variance (ANOVA) with Bonferroni correction. Results: Antibiotic consumption decreased by 49% in 2020 compared to 2019, coinciding with the implementation of national COVID-19 containment measures. From 2021 onward, a gradual increase was observed; however, by 2024, levels remained 9% below pre-pandemic values. Penicillins account for 75% of prescriptions, mainly amoxicillin and amoxicillin–clavulanic acid. While variability across healthcare areas decreased during the pandemic, variability among primary care centres increased. Conclusions: The pandemic resulted in a temporary reduction in antibiotic use, followed by a partial rebound. Ongoing educational and stewardship interventions within the Purapi framework were instrumental in maintaining rational prescribing and may have contributed to maintaining reduced antibiotic consumption among children under three years of age during and after the pandemic. Strengthening and harmonising these initiatives is essential to ensure consistent paediatric antibiotic stewardship in primary care. Full article
(This article belongs to the Special Issue Inappropriate Use of Antibiotics in Pediatrics)
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14 pages, 864 KB  
Article
Blood Cultures Time-to-Positivity as an Antibiotic Stewardship Tool in Immunocompromised Children with Gram-Negative Bacteraemia
by Julià Gotzens, Aina Colom-Balañà, Manuel Monsonís, Laia Alsina, María Antonia Ruiz-Cobo, María Ríos-Barnés, Anna Gamell, Eneritz Velasco-Arnaiz, Irene Martínez-de-Albéniz, Victoria Fumadó, Clàudia Fortuny, Antoni Noguera-Julian and Sílvia Simó-Nebot
Antibiotics 2025, 14(8), 847; https://doi.org/10.3390/antibiotics14080847 - 21 Aug 2025
Cited by 1 | Viewed by 3002
Abstract
Background/Objectives: Children and adolescents with haematologic malignancies or other causes of immunosuppression are at high risk of severe infections. Determining the probability of Gram-negative bacilli bloodstream infections (GNB-BSI) within 24 h of blood culture (BC) incubation could support early antibiotic de-escalation, compared [...] Read more.
Background/Objectives: Children and adolescents with haematologic malignancies or other causes of immunosuppression are at high risk of severe infections. Determining the probability of Gram-negative bacilli bloodstream infections (GNB-BSI) within 24 h of blood culture (BC) incubation could support early antibiotic de-escalation, compared to the current guidelines recommending de-escalation after 48–72 h. Methods: Retrospective, observational single-centre study describing BC time-to-positivity (TTP) in GNB-BSI in a paediatric cohort of immunocompromised children. Results: In 128 episodes (100 patients), TTP was less than 24 h in >95% cases. TTP did not differ based on sex, underlying disease, degree of neutropenia, or PICU admission. Antibiotic initiation prior to BC collection and microbiological aetiology (microbiological aetiology different from Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, or Enterobacter cloacae) were the only identified risk factors associated with BC growth beyond 24 h. No patients with late BC growth died or required PICU admission. Conclusions: If BC remains negative after 24 h of incubation, GNB-BSI is unlikely in immunocompromised children and adolescents with fever. These results support early de-escalation strategies, shortening unnecessary exposure to broader-spectrum antibiotics, and potentially decreasing adverse events and costs. Full article
(This article belongs to the Special Issue Inappropriate Use of Antibiotics in Pediatrics)
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12 pages, 1466 KB  
Article
Implementation of a Multifaceted Program to Improve the Rational Use of Antibiotics in Children under 3 Years of Age in Primary Care
by Santiago Alfayate-Miguélez, Gema Martín-Ayala, Casimiro Jiménez-Guillén, Manuel Alcaraz-Quiñonero, Rafael Herrero Delicado and José Arnau-Sánchez
Antibiotics 2024, 13(7), 572; https://doi.org/10.3390/antibiotics13070572 - 21 Jun 2024
Cited by 1 | Viewed by 2773
Abstract
A multifaceted, participatory, open program based on a qualitative and quantitative approach was developed in the Region of Murcia (Spain) aimed to reduce antibiotic use in children under 3 years of age diagnosed with upper respiratory tract infections (acute otitis media, pharyngitis, and [...] Read more.
A multifaceted, participatory, open program based on a qualitative and quantitative approach was developed in the Region of Murcia (Spain) aimed to reduce antibiotic use in children under 3 years of age diagnosed with upper respiratory tract infections (acute otitis media, pharyngitis, and common cold). Antibiotic consumption was measured using the defined daily dose per 1000 inhabitants per day (DHD). Pre-intervention data showed a prevalence of antibiotic prescriptions in the primary care setting of 45.7% and a DHD of 19.05. In 2019, after the first year of implementation of the program, antibiotic consumption was 10.25 DHD with an overall decrease of 48% as compared with 2015. Although antibiotic consumption decreased in all health areas, there was a large variability in the magnitude of decreases across health areas (e.g., 12.97 vs. 4.77 DHD). The intervention program was effective in reducing the use of antibiotics in children under 3 years of age with common upper respiratory diseases, but reductions in antibiotic consumption were not consistent among all health areas involved. Full article
(This article belongs to the Special Issue Inappropriate Use of Antibiotics in Pediatrics)
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Review

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23 pages, 917 KB  
Review
Irrational and Inappropriate Use of Antifungals in the NICU: A Narrative Review
by Niki Dermitzaki, Foteini Balomenou, Chrysoula Kosmeri, Maria Baltogianni, Aikaterini Nikolaou, Anastasios Serbis and Vasileios Giapros
Antibiotics 2026, 15(1), 73; https://doi.org/10.3390/antibiotics15010073 - 9 Jan 2026
Viewed by 967
Abstract
Invasive Candida infections in the neonatal intensive care unit (NICU) are associated with significant morbidity and mortality, particularly among extremely preterm neonates. Early treatment with antifungals is critical to improve survival rates and avoid long-term adverse outcomes. Prevention with antifungal prophylaxis in high-risk [...] Read more.
Invasive Candida infections in the neonatal intensive care unit (NICU) are associated with significant morbidity and mortality, particularly among extremely preterm neonates. Early treatment with antifungals is critical to improve survival rates and avoid long-term adverse outcomes. Prevention with antifungal prophylaxis in high-risk neonates has been shown to reduce the prevalence of invasive Candida infections effectively. However, the irrational and/or inappropriate use of antifungals has been documented. This narrative review aims to provide an overview of the rationales for the inappropriate use of antifungals in the NICU, the consequences that ensue, and the promising strategy of antifungal stewardship programs to optimize antifungal use. The nonspecific clinical presentation of systemic Candida infections and the lack of rapid, accurate diagnostic techniques for Candida identification and specification in most settings lead to a high rate of empirical treatment in neonates without a proven infection. Moreover, evidence on the optimal dosing of antifungal agents and the treatment duration in the neonatal population is lacking, which may result in excessive or subtherapeutic drug exposure. Antifungal misuse is associated with microbiological consequences, including the emergence of antifungal-resistant Candida strains, and clinical consequences, such as drug toxicities and alterations in the intestinal mycobiome. It is therefore imperative to optimize antifungal use in the NICU. The implementation of antifungal stewardship programs, which, through a multidisciplinary approach, aim to improve diagnosis and guide clinicians on antifungal selection, dosing, and duration for both prevention and treatment according to the local epidemiology, represents a promising strategy for antifungal optimization in the NICU. Full article
(This article belongs to the Special Issue Inappropriate Use of Antibiotics in Pediatrics)
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31 pages, 5237 KB  
Review
State of the Art of Antimicrobial and Diagnostic Stewardship in Pediatric Setting
by Daniele Donà, Elisa Barbieri, Giulia Brigadoi, Cecilia Liberati, Samantha Bosis, Elio Castagnola, Claudia Colomba, Luisa Galli, Laura Lancella, Andrea Lo Vecchio, Marianna Meschiari, Carlotta Montagnani, Maia De Luca, Stefania Mercadante and Susanna Esposito
Antibiotics 2025, 14(2), 132; https://doi.org/10.3390/antibiotics14020132 - 27 Jan 2025
Cited by 15 | Viewed by 10413
Abstract
Antimicrobial stewardship programs (ASPs) and diagnostic stewardship programs (DSPs) are essential strategies for effectively managing infectious diseases and tackling antimicrobial resistance (AMR). These programs can have a complementary impact, i.e., ASPs optimize antimicrobial use to prevent resistance, while DSPs enhance diagnostic accuracy to [...] Read more.
Antimicrobial stewardship programs (ASPs) and diagnostic stewardship programs (DSPs) are essential strategies for effectively managing infectious diseases and tackling antimicrobial resistance (AMR). These programs can have a complementary impact, i.e., ASPs optimize antimicrobial use to prevent resistance, while DSPs enhance diagnostic accuracy to guide appropriate treatments. This review explores the current landscape of ASPs and DSPs in pediatric care, focusing on key factors, influencing their development, implementation, and evaluation across various settings. A multidisciplinary approach is necessary, involving multiple healthcare professionals to support comprehensive stewardship practices in pediatric care. No single intervention suits all settings, or even the same setting, in different countries; interventions must be tailored to each specific context, considering factors such as hospital capacity, patient complexity, and the parent–child dynamic. It is essential to educate caregivers on optimal antibiotic use through clear, concise messages adapted to their socioeconomic status and level of understanding. The cost-effectiveness of ASPs and DSPs should also be assessed, and standardized metrics should be employed to evaluate success in pediatric settings, focusing on outcomes beyond just antibiotic consumption, such as AMR rates. This manuscript further discusses emerging opportunities and challenges in ASP implementation, offering insights into future research priorities. These include large-scale studies to evaluate the long-term impact of ASPs, cost-effectiveness assessments of pediatric-specific diagnostic tools, and the integration of artificial intelligence to support clinical decision making. Addressing these areas will enhance the effectiveness and sustainability of ASPs, contributing to global efforts to combat AMR and improve pediatric health outcomes. Full article
(This article belongs to the Special Issue Inappropriate Use of Antibiotics in Pediatrics)
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14 pages, 618 KB  
Review
Antimicrobial Stewardship Programs in Pediatric Intensive Care Units: A Systematic Scoping Review
by Cecilia Liberati, Giulia Brigadoi, Elisa Barbieri, Carlo Giaquinto and Daniele Donà
Antibiotics 2025, 14(2), 130; https://doi.org/10.3390/antibiotics14020130 - 26 Jan 2025
Cited by 4 | Viewed by 3420
Abstract
Objectives: We aimed to summarize the current state of antimicrobial stewardship (ASP) and diagnostic stewardship programs (DSPs) implemented in pediatric intensive care units (PICUs). Methods: Embase, MEDLINE, Scopus and the Cochrane Library were searched, including studies from 1 January 2007 to [...] Read more.
Objectives: We aimed to summarize the current state of antimicrobial stewardship (ASP) and diagnostic stewardship programs (DSPs) implemented in pediatric intensive care units (PICUs). Methods: Embase, MEDLINE, Scopus and the Cochrane Library were searched, including studies from 1 January 2007 to 20 February 2024. Studies were included in the review if they assessed the implementation of an ASP or a DSP in a PICU. Identified references were downloaded into Rayyan software, and data were extracted using a standardized data collection form. Results: 18 studies were included; 13 described an ASP intervention, and 5 described a diagnostic stewardship intervention. Most studies were retrospective and adopted a persuasive strategy for ASP, reporting positive effects on antimicrobial consumption. However, studies were dramatically heterogeneous in terms of intervention type, outcomes and metrics used, limiting the possibility of a broader comparison. Diagnostic stewardship studies included mainly the impact of biomarkers and pathogen testing panels without significant impact on antibiotic prescription patterns. Antimicrobial resistance changes were not described by the majority of studies. Conclusions: the implementation of ASP in PICUs is still limited, with significant variability in the metrics used to evaluate outcomes. To enhance the effectiveness of these programs, it is crucial to harmonize reporting metrics to allow an adequate comparison of results and to find the best strategies to inform ASP in PICUs. Full article
(This article belongs to the Special Issue Inappropriate Use of Antibiotics in Pediatrics)
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