Steady decline in antibiotic use for childhood respiratory infections

Steady decline in antibiotic use for childhood respiratory infections

Nationwide health data shows major progress in reducing antibiotic use for respiratory infections in children, while exposing ear infections as a persistent blind spot for health care efforts.

Study: Antibiotic prescriptions to preschool children with respiratory infections in primary health care. Photo credit: PeopleImages/Shutterstock.com

In a recent study published inJAC antimicrobial resistance,Researchers examined trends in antibiotic prescribing for respiratory infections (RTIs) among preschool children in Norway using nationwide observational registry data.

They found that antibiotic prescriptions for RTIs decreased significantly between 2012 and 2019. Nevertheless, they concluded that further improvements in adherence to treatment guidelines and antibiotic administration can be achieved, even in this country with low prescribing rates.

Why the use of antibiotics in young children is still important

Antibiotic resistance (AMR) represents a significant global threat, primarily due to the overuse and misuse of antibiotics. There is a strong connection between the level of antibiotic use in a population and the development of resistant bacteria.

Although Norway is among the countries with relatively low antibiotic prescription rates, national health authorities recognize that there remains potential for further reductions. Norway has implemented several national strategies to combat antimicrobial resistance, including guidelines recommending narrow-spectrum penicillins as first-line treatment for RTIs. RTIs are common in children, particularly those of preschool age, most of which are viral and self-limiting.

Despite clear clinical guidelines, previous studies suggest that antibiotics are often unnecessarily prescribed in this age group. Comprehensive national health registries in Norway provide a unique opportunity to examine health encounters, prescribing behavior and treatment options at the population level. Understanding these patterns can help identify gaps in guideline adherence and support targeted antibiotic stewardship initiatives.

Statewide registries record childhood RTIs before the pandemic

Researchers examined trends in RTI episodes, antibiotic prescription rates, and antibiotic selection among preschool-aged children before the coronavirus disease 2019 (COVID-19) pandemic. Data for the period 201219 come from four Norwegian health registries that record all general practitioner consultations, hospital admissions, demographic data and prescription medicines dispensed across the population.

The study population included children under five years of age who had contact with general practice for RTIs during the study period. Infants under one year of age and children admitted to hospital or specialist care on the same day as their first consultation were excluded. RTI episodes were defined by grouping healthcare encounters that occurred within 30 days of an initial RTI diagnosis, with a maximum follow-up of 90 days per episode.

Oral antibiotic prescriptions were identified using established codes and classified into phenoxymethylpenicillin, other penicillins, macrolides, and other antibiotics. Prescriptions dispensed within seven days of a consultation were linked to the corresponding episode.

Annual episode rates and prescription rates were calculated and standardized by age and gender. Trends over time were analyzed using linear regression and negative binomial regression models, with results presented as mean annual changes with 95% confidence intervals.

Otitis and URTI dominate the remaining antibiotic exposure

The study included approximately 579,000 children between the ages of one and five annually between 2012 and 2019, with boys making up 54% of the population. During the study period, more than 3.1 million GP contacts were recorded for RTIs, corresponding to just over 2 million RTI episodes.

This resulted in an average of 811 RTI episodes per 1,000 children per year, with rates higher in boys and the youngest children. One- and two-year-olds accounted for more than half of all episodes, and RTI rates declined steadily with increasing age.

Almost half of all episodes involved only a single health care encounter, although younger children were more likely to have repeat consultations. Upper RTI (URTI), cough and otitis were the most common diagnoses. Overall, RTI episode rates decreased by 17% from 2012 to 2019, with the largest relative declines observed in pneumonia and cough. However, part of this early decline coincided with a nationwide outbreak ofMycoplasma pneumoniae.

The prescription of antibiotics also fell significantly. The proportion of RTI episodes treated with antibiotics decreased from 28% (2012) to 19% (2019), with the largest decline occurring at the beginning of the study period. Otitis and URTI together accounted for over half of all antibiotic prescriptions.

While prescribing rates declined for most diagnoses, otitis, tonsillitis and pneumonia remained associated with persistently high antibiotic use. Importantly, there was a shift towards guideline-recommended treatments, with a greater proportion of prescriptions containing phenoxymethylpenicillin and a decline in the use of macrolides.

Even low-prescription countries can further reduce antibiotic use

The decline in antibiotic use in preschool children was due to a combination of fewer RTI episodes, lower prescription rates per episode, and partial improvement in adherence to treatment guidelines, reflected in increased use of narrow-spectrum penicillins.

The declines were most pronounced for illnesses likely to be viral, suggesting a combination of more cautious prescribing practices and changes in parental health-conscious behavior. However, due to the observational design, causal relationships could not be directly assessed. Prescription of antibiotics for otitis media remained consistently high despite fewer consultations. This finding could be due to continued nonadherence to guidelines or a shift toward more severe cases in primary care.

A major strength of the study is the use of high-quality nationwide registry data that covers the entire population over several years; Nevertheless, reliance on administrative data limited insight into clinical decision-making, disease severity, and diagnostic accuracy. Infectious outbreaks may also have influenced the results, not accounting for seasonal variations or repeated episodes in individual children.

Overall, the study shows that further reductions in antibiotic use can be achieved even in settings with low prescription rates. Targeted control efforts, particularly for otitis and other self-limiting RTIs, remain an important focus for future interventions to combat antimicrobial resistance.

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