Antibiotic overuse in a contemporary cohort of children hospitalized with influenza, RSV, or SARS-CoV-2: a retrospective cohort study

Background Children hospitalized with viral lower respiratory tract infections (LRTIs) are often prescribed antibiotics due to concern for bacterial co-infection, although most do not have concurrent bacterial infections. This unnecessary antibiotic treatment can lead to bacterial resistance and adverse events. The extent of antibiotic overuse in hospitalized children with community-onset viral LRTIs has not been described in recent years. To identify antibiotic stewardship opportunities in this population, we quantified the extent of antibiotic overtreatment and determined predictors of antibiotic use among children hospitalized with influenza, respiratory syncytial virus (RSV), or SARS-CoV-2 (COVID-19). Methods We performed a single-center retrospective study evaluating antibiotic use and culture-confirmed bacterial co-infection among children and adolescents hospitalized with influenza, RSV, or COVID-19 between April 2020 and May 2023. Predictors of antibiotic treatment were determined using logistic regression. Results We included 1,718 patients (influenza: 188; RSV: 1,022; COVID-19: 535). Patients with RSV were younger and more likely to be in intensive care. While only 8% of patients had culture-confirmed bacterial co-infection, the proportion receiving antibiotics was high and varied by virus (influenza: 60.6%, RSV:41.2%, COVID-19: 48.6%, p < 0.001). Independent predictors for receipt of > 3 days of antibiotics were elevated inflammatory markers, comorbidities, mechanical ventilation, intensive care unit admission, influenza infection, and a concurrent non-respiratory infection. Conclusions In children hospitalized with community-onset viral LRTIs, antibiotic treatment is substantially higher than the burden of culture-confirmed bacterial infection, especially for influenza, suggesting antibiotic overuse and antibiotic stewardship opportunities.