Study shows impact of inappropriate antibiotic prescribing on children


Disclosures: Hyun reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

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Researchers found that inappropriate prescription antibiotics were associated with avoidable adverse drug events in children, including Clostridioides difficile, and substantial health care expenditures.

David Hyun, MDproject director of the Antibiotic Resistance Project at The Pew Charitable Trusts, and colleagues have published multiple studies on overprescribing or inappropriate selection of antibiotics. Hyun said in a Healio interview that he wanted to apply this to a common issue in children’s health.

“We really wanted to try to find out what the consequences and the impact on children’s health were for this study,” Hyun said. “Based on knowing how much inappropriate and unnecessary prescribing is occurring, we really wanted to provide a description of what that impact looks like both at the clinical level and at the economic level.”

David Hyun

The prevalence of C. difficile is greatest among infants aged between 6 and 12 months, according to the results of a symptomatic review and meta-analysis published last year in JAMA Pediatrics.

The CDC estimates that C.difficile causes more than half a million infections in the United States each year. A 2018 study published in Clinical Infectious Diseases found that the incidence of C.difficile had risen in children since 2000 — mostly among children in community and outpatient settings but also among nonhospitalized children.

Hyun and colleagues focused on a cohort of 2,804,245 children with commercial insurance between the ages of 4 and 12 years who had one of eight common infections, including the bacterial infections suppurative otitis media (OM), pharyngitis and sinusitis, as well as the viral infections influenza, viral upper respiratory infection [URI]bronchiolitis, bronchitis and nonsuppurative OM.

“The reason we focused on these seven conditions was because these were the most common types of infections or diagnoses that we knew from our past research, and that that led to inappropriate antibiotic prescribing,” Hyun said. “We really want to kind of zero in on the diagnoses that we felt had the highest yield to demonstrate the differences.”

The researchers found that 31% to 36% of the cohort received inappropriate antibiotics for bacterial infections, whereas 4% to 70% received inappropriate antibiotics for viral infections. Children with bacterial infections who experienced inappropriate antibiotic prescriptions were usually at higher risk for C. difficile infection (CDI) — for example, among children with suppurative OM or pharyngitis, the risk for CDI was increased by more than six (HR = 6.23; 95% CI, 2.24-17.32) or eight (HR = 8.42; 95% CI, 3.09-22.95) times, respectively.

They also were at an increased risk for non-C. difficile diarrhea and nausea, vomiting or abdominal pain.

“We expected to see some degree of increased adverse events and side effects but seeing a number like eight times higher risk for a single condition where an inappropriate antibiotic use could lead to a C. difficile infection … was both alarming and illuminating in terms of kind of getting a very good grasp on the magnitude of the problem,” Hyun said.

They also found that 30-day attributable health care expenditures were generally higher among children who received inappropriate antibiotics, ranging from $21 to $56 for bacterial infections and from $96 to $97 for viral infections. National annual attributable expenditure estimates were highest for suppurative OM ($25.3 million), pharyngitis ($21.3 million) and viral URI ($19.1 million).

Hyun said the results are a “call to action” for providers and health systems.

“We typically tend to focus our conversations and discussions around the consequences of inappropriate antibiotic use, around the concerns [about] the emergence of antibiotic resistance and how we could accelerate it,” Hyun said. “But the study really kind of zeroes in on the impact that inappropriate prescribing can have at the individual patient level, especially when we’re talking about adverse events and side effects that can be associated with what we’re potentially unnecessarily exposing children to.”


CDC. C. diff (Clostridioides difficile). Accessed May 26, 2021.

McDonald, LC, et al. Clin Infect Dis. 2018; doi:10.1093/cid/cix1085.

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