By Philip R. Fischer, MD, DTM&H

Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN

Dr. Fischer reports no financial relationships relevant to this field of study.

SYNOPSIS: Inappropriate antibiotic use for a child with a viral respiratory infection is not a “one and done” error. Children who receive antibiotics when diagnosed with a viral respiratory infection are more likely to seek care for viral infections subsequently and to receive inappropriate antibiotics again.

SOURCE: Morgan JR, Carey KM, Barlam TF, et al. Inappropriate antibiotic prescribing for acute bronchitis in children and impact on subsequent episodes of care and treatment. Pediatr Infect Dis J 2019;38:271-274.

Each year, children in the United States receive approximately 10 million antibiotic prescriptions for the treatment of viral respiratory infections. While this practice is ineffective against viruses, this unnecessary antibiotic use contributes to antibiotic resistance, illness due to Clostridium difficile infection, the development of asthma, and increased risks of obesity. Provider characteristics and parental expectations can contribute to the inappropriate prescription of antibiotics. However, the effect of one inappropriate antibiotic prescription on future prescriptions for the same child had not been studied. Morgan and colleagues evaluated the likelihood that using antibiotics for one viral infection would alter prescribing habits during subsequent viral illnesses.

Morgan and his collaborators in Boston analyzed data from the Truven Health Analytics MarketScan Commercial Claims and Encounters database from 2008 through 2015. This database includes medical claims from 350 payers for employed individuals and their dependents across the United States. From this database, researchers assembled a cohort of 14,683 children born in 2008. Each included child had at least one medical encounter with a primary diagnosis of “acute bronchitis” (ICD-9 codes 466.xx and 490) and continued to be followed through 2015. Children with complex chronic conditions and children who had secondary diagnoses that would warrant antibiotic treatment were excluded from the cohort. Investigators evaluated the data to determine if prescribing behavior during the initial viral respiratory infection was associated with subsequent medical visits for similar infections and whether antibiotics were used during those subsequent visits. Provider characteristics (geographical region, specialty, practice setting) and patient characteristics (age, gender, previous diagnosis of asthma) were noted.

Overall, 49.8% of children initially seen for a viral respiratory infection were treated with an antibiotic. Subsequently, 45% of children seen for an initial episode of bronchitis were seen later for another similar episode. Seventy-one percent of those who received an antibiotic with the first episode received an antibiotic again with the subsequent episode of a viral respiratory illness, compared with 43% of those who did not receive an antibiotic with the first viral infection. Antibiotic use during the first visit was more common among girls (48% vs. 44% in boys), in the Midwest, and in older children. Those with asthma and those treated by pediatricians were less likely to receive antibiotics.

If an antibiotic was given during the first episode of care for bronchitis, subsequent care for a similar visit was more likely (hazard ratio, 1.24), and repeat antibiotic use was more likely (hazard ratio, 2.13). Children with asthma were less likely to receive an antibiotic at the next visit for a viral respiratory infection.

Thus, the initial healthcare interaction for a viral respiratory infection was predictive of the risk for future visits and for subsequent antibiotic use. Specifically, those who inappropriately received an antibiotic at the first visit were more likely to return with a subsequent similar illness and were more likely to receive an inappropriate antibiotic prescription again.


During the past century, antibiotic use has reduced the morbidity and mortality of infections in children dramatically. Now, however, we are seeing problems from inappropriate overuse of antibiotics.

In discussing the limitations of their study, Morgan and colleagues acknowledged that they could not evaluate the accuracy of the diagnoses recorded in the claims database. However, they were careful to include only codes that are typical for viral infections (bronchitis, bronchiolitis, chest cold, laryngotracheobronchitis), and they were careful to exclude children with concurrent secondary diagnoses of bacterial infections (otitis media, pneumonia). Their database only included insured children of employed parents, so it might not yield results that are representative of all American children. Nonetheless, these limitations do not diminish the importance of a major finding in this study: Approximately half of children seen by a physician for a viral respiratory infection and no documented evidence of bacterial disease were treated with an antibiotic.

Whatever the (inappropriate) reason for giving an antibiotic with the initial episode of a viral respiratory infection, that initial decision to use an antibiotic seems to have been a step down a slippery slope that led to an increased risk of using medical resources (visits, antibiotics) during subsequent episodes of viral respiratory infection. Misuse of antibiotics carries consequences for individual patients and for populations, and inappropriate care risks replication. The challenge before physicians caring for children with viral respiratory infections was well summarized more than a decade ago in the New England Journal of Medicine: “Withholding therapy is much more difficult than giving it.”1 It still is better to do what is right for the child, even if that means not writing an antibiotic prescription.

Overuse of antibiotics is not just a local problem for someone else. Although there were geographic variations noted by Morgan et al, antibiotic over-prescription is common throughout the United States. Recent data also show that antibiotic use is a global problem. In Papua New Guinea, 82% of children treated for a “common cold” received antibiotics, even though healthcare providers acknowledged the viral etiology of the illness.2 Whether in the United States or New Guinea, antibiotic overuse is common.

Morgan noted that pediatricians were slightly less likely to give antibiotics for viral respiratory infections than were other physicians. Earlier this year, Poole and colleagues reported a comparison of antibiotic prescribing habits in U.S. emergency departments.3 They noted that emergency departments staffed by non-pediatric providers were more likely to prescribe antibiotics than were pediatric emergency departments. Also, non-pediatric emergency departments were twice as likely to use macrolides rather than more specific, targeted antibiotics. Poole encouraged a wider spread of pediatric antibiotic stewardship efforts.3

Similarly, this year Papenburg and colleagues reported about bronchiolitis management in emergency departments.4 They sampled 612 children younger than 2 years of age who were treated for bronchiolitis in an emergency department. Of those children, 12% had an identified bacterial co-infection, but 26% of the children were treated with antibiotics. The rate of overuse of antibiotics did not decline during the nine years of that study. The authors astutely noted that, “Antibiotic use did not decrease after national recommendations against routine prescribing.” They suggested that “efforts are needed to reduce unnecessary and inappropriate antibiotic use for bronchiolitis.”4

The data are clear — antibiotics are prescribed inappropriately for viral respiratory tract infections in children in the United States and around the world. The recommendations are also clear — antibiotics should not be used for viral infections. Our efforts toward judicious antibiotic use and wise antibiotic stewardship should continue.


  1. Hall CB. Therapy for bronchiolitis: When some becomes none. N Engl J Med 2007;357:402-404.
  2. Zamunu A, Pameh W, Ripa P, et al. Antibiotic use in the management of children with the common cold at a provincial hospital in Papua New Guinea: A point-prevalence study. Paediatr Int Child Health 2018;38:261-265.
  3. Poole NM, Shapiro DJ, Fleming-Dutra KE, et al. Antibiotic prescribing for children in United States emergency departments: 2009-2014. Pediatrics 2019; Jan. 8. doi: 10.1542/peds.2018-1056. [Epub ahead of print].
  4. Papenburg J, Fontela PS, Freitas RR, Burstein B. Inappropriate antibiotic prescribing for acute bronchiolitis in US emergency departments, 2007-2015. J Pediatr Infect Dis Soc 2019; Jan. 17. doi: 10.1093/jpids/piy131. [Epub ahead of print].