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Children’s antibiotic use soars with medical complexity

baneoflere 0


April 25, 2026

2 min read

Key takeaways:

  • Children with 3 or more complex conditions filled antibiotic prescriptions at 5 times the rate of healthy children.
  • Children with medical complexity were also 10 times more likely to have high antibiotic usage.

BOSTON — Children with multiple complex medical conditions receive more than 5 times the amount of antibiotics compared with healthy children and double that of the elderly, according to a large study.

“Antibiotics are the most commonly prescribed class of medications in children,” Kathleen D. Snow, MD, MPH, instructor of pediatrics at Boston Children’s Hospital, told attendees at the Pediatric Academic Societies annual meeting. “Unfortunately, little research has been done to identify which specific patient populations are at the highest risk for antibiotic exposure.”



Antibiotic pills

Children with 3 or more complex conditions filled antibiotic prescriptions at 5 times the rate of healthy children. Image: Adobe Stock.

Snow and colleagues studied antibiotic prescription fill rates among 2,357,642 children enrolled in Medicaid in 11 states in 2023. They compared how many prescriptions — and which type of antibiotics — were dispensed to healthy children, children with a non-complex chronic condition and children with one or more complex chronic conditions.

Overall, 2 in 5 children filled at least one antibiotic prescription (n = 926,025; 787 per 1,000 people). According to Snow, the percentage of children who received antibiotics rose proportionately with medical complexity, ranging from 30.9% in healthy children to 63.9% in children with three or more complex conditions. The annual fill rate per 1,000 people also rose with medical complexity from 514 (95% CI, 513-516) among healthy children to 2,882 (95% CI, 2,850-2,915) among children with multiple complex chronic conditions.

“These children had greater than 5 times higher antibiotic fill rates compared with otherwise healthy children and more than double the antibiotic fill rates compared with the elderly, which is a population that has previously been thought to have the highest antibiotic utilization,” Snow said during her presentation.

Snow and colleagues also identified the proportion of children in each medical complexity category who were “high antibiotic utilizers,” meaning they had 50 days of antibiotic exposure or more in 1 year. Compared with children who have no chronic conditions, the odds of high antibiotic usage were:

  • more than 2 1/2 times higher (OR = 2.61; 95% CI, 2.54-2.67) for children with noncomplex chronic conditions;
  • nearly 4 times higher (OR = 3.67; 95% CI, 3.54-3.8) for kids with one complex chronic condition;
  • almost 6 times higher (OR = 5.61; 95% CI, 5.3-5.95) for two complex conditions; and
  • more than 10 times higher (OR = 10.22; 95% CI, 9.49-11) if the child had three or more complex conditions.

“As a practicing pediatrician, I was not surprised to see that children with medical complexity receive more prescriptions than their otherwise healthy peers,” Snow told Healio. “I was surprised to see the magnitude of difference in prescribing rates.”

According to the researchers, the median duration per prescription was 10 days across all groups. The most common drug type prescribed in all children were penicillins, cephalosporins and macrolides. Notably, these drugs comprise 93% of prescriptions among healthy children, but only 64% of children with three or more chronic conditions.

“These children were much more likely to receive prescriptions for sulfonamides, quinolones and aminoglycosides, which are less commonly used antibiotics in pediatrics, cover a broad spectrum of infectious pathogens and have a different side effect profile,” Snow said.

She noted that future research should investigate how appropriate these antibiotic prescriptions were and what the outcomes are for children with high antibiotic utilization. Her team is currently conducting a pilot study to see how children with medical complexity respond to shorter antibiotic durations for pneumonia.

For more information:

Kathleen D. Snow, MD, MPH, can be reached at kathleen.snow@childrens.harvard.edu.

Perspective

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Rana E. El Feghaly, MD, MSCI, CPHQ, FPIDS

These findings are significant, though not entirely surprising. Prior studies have suggested that children with medical complexity or multiple chronic conditions receive more antibiotics overall, often driven by higher health care utilization, device dependence, and diagnostic uncertainty. However, much of the pediatric antibiotic literature, including some of my own prior work, has intentionally excluded children with substantial medical complexity to avoid biasing results, or has focused on aggregate measures of exposure in otherwise healthy children or singlecondition cohorts. This study addresses a longstanding gap by directly examining outpatient antibiotic use in this population at scale.
The findings closely align with clinical experience. Caring for children with multiple chronic conditions often involves profound diagnostic uncertainty: Baseline symptoms may be atypical, laboratory values difficult to interpret, and the consequences of missing a serious infection potentially severe. Not surprisingly, clinicians’ fear of undertreatment lowers thresholds for prescribing antibiotics and favors repeated or broadspectrum use. Importantly, this study shows that antibiotic exposure in these children is not just higher in volume, but qualitatively different, with distinct and heterogeneous patterns.
Pediatricians can use these findings to rethink antibiotic stewardship for children with medical complexity. Stewardship strategies designed for otherwise healthy children may not translate directly to this population. Instead, care teams should focus on longitudinal patterns of exposure, subspecialty-driven prescribing, and cumulative risk, particularly given these children’s heightened susceptibility to harms such as Clostridioides difficile infection and adverse drug events. Applying stewardship principles thoughtfully, such as reassessing indications, minimizing duration when appropriate, and engaging subspecialists and families in shared decisionmaking, may help accomplish this difficult task.
I see the next steps in this research as possibly linking specific antibiotic exposure patterns to clinical outcomes. Understanding which patterns confer the greatest risk is essential for designing stewardship interventions that acknowledge diagnostic uncertainty while minimizing preventable harm.

Rana E. El Feghaly, MD, MSCI, CPHQ, FPIDS

  • Director, Division of Infectious Diseases
  • Director, Quality and Safety
  • Children’s Mercy Kansas City


Disclosures: El Feghaly reports that her institution receives grant funding from Merck for outpatient antibiotic prescription research.

Sources/Disclosures

Source:

Snow KD, et al. Medical Complexity and High Rates of Outpatient Antibiotic Exposure. Presented at: Pediatric Academic Societies Annual Meeting; April 24-27, 2026; Boston.


Disclosures:
Snow reports no relevant financial disclosures.

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