Ambulatory Antibiotic Prescribing for Children with Pneumonia After Publication of National Guidelines: A Cross-Sectional Retrospective Study

INTRODUCTION: National guidelines published in 2011 recommend amoxicillin as first-line treatment for non-hospitalized children with community-acquired pneumonia (CAP). We aimed to understand visit rates, antibiotic selection, and factors associated with amoxicillin prescribing for children with CAP since guideline publication. METHODS: We performed a cross-sectional retrospective study of patients aged 90 days–18 years with an outpatient clinic or emergency department (ED) visit from 2008 to 2015 using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey ED data files, respectively. We estimated the incidence rates of ambulatory CAP visits, examined time trends in antibiotics prescribed at CAP visits, and determined factors independently associated with first-line guideline-recommended antibiotic prescribing using multivariable logistic regression, including patient age, setting, and US census region. RESULTS: From 2008 to 2015, there were an estimated 1.5 million [95% confidence interval (CI) 1.3–1.7 million] pediatric CAP visits annually. Amoxicillin was prescribed in 23% (95% CI 18–30%), azithromycin was prescribed in 47% (95% CI 41–54%), and cephalosporins were prescribed in 26% (95% CI 21–31%) of antibiotic visits for CAP. There were no significant differences in annual CAP visits or prescribing by antibiotic class since guideline publication. Amoxicillin prescribing was significantly less likely in visits by older children, aged 5–18 years, [adjusted odds ratio (aOR) 0.22, 95% CI 0.10–0.49] compared to visits by younger children aged 90 days–4 years with CAP. Compared with the Northeast, amoxicillin prescribing was significantly lower in the Midwest (aOR 0.35, 95% CI 0.13–0.98) and South (aOR 0.23, 95% CI 0.08–0.63). Azithromycin prescribing was significantly more likely in visits to EDs (aOR 1.46, 95% CI 1.07–1.98) compared to physician offices. CONCLUSION: Despite national guideline recommendations, amoxicillin prescribing for CAP in outpatient settings is low and azithromycin remains the predominant antibiotic prescribed, highlighting the need for dedicated antibiotic stewardship efforts in ambulatory settings.