Antibiotic overuse in children with viral infections: lessons from the SARS-CoV-2 pandemic

Background Although COVID-19 is usually mild in children, antibiotics are frequently prescribed during hospitalisation, often without evidence of bacterial infection. Objective To assess the frequency and predictors of antibiotic use in children hospitalised with SARS-CoV-2 infection in Switzerland. Methods In this nationwide prospective study, children aged 0–18 years hospitalised with confirmed SARS-CoV-2 infection or symptoms compatible with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) between January 2022 and March 2023 were included. Univariable and multivariable logistic regression analyses were used to identify risk and protective factors for antibiotic use. A sensitivity analysis was conducted excluding high-risk patients. Results Among 1944 hospitalised children, 586 (30%) received antibiotics. Of these, 71 (12%) had a clinically suspected bacterial infection without microbiological confirmation and 41 (7%) had microbiologically confirmed infection. Predictors of antibiotic use were microbiologically confirmed bacterial infection (aOR 138.08), clinically suspected bacterial infection (aOR 114.48), haematologic/oncologic disease (aOR 6.77), PIMS-TS (aOR 5.36), fever (aOR 2.98), neonatal age (aOR 2.80) and treatment in tertiary centres (aOR 1.65). After excluding high-risk patients, however, treatment in tertiary centres and PIMS-TS were no longer significant predictors in the sensitivity analysis. Respiratory distress/tachypnoea (aOR 0.72) and admission with confirmed SARS-CoV-2 as the primary diagnosis (aOR 0.42) were associated with lower antibiotic use in the primary analysis. After excluding high-risk patients, this association was no longer observed and nasal symptoms (aOR 0.68) and seizures (aOR 0.34) emerged as protective factors. Conclusion Antibiotics were frequently prescribed to children hospitalised with SARS-CoV-2 despite limited evidence of bacterial infection. Our findings underscore the need to strengthen antimicrobial stewardship in paediatric COVID-19 care.