A new study from Boston Children’s Hospital found that annual prescription rates increased nonlinearly as a child’s level of underlying medical complexity increased, raising concerns about outpatient antibiotic exposure.
Continuous use of antibiotics not only increases the likelihood of antibiotic-related complications, but also increases the likelihood of antibiotic resistance. Children with medical complications (CMC) are more vulnerable to infections, but there is limited knowledge about the impact of frequent antibiotic use on this group.
Using outpatient antibiotic prescription claims data from the multistate MarketScan Medicaid database, Boston Children’s Hospital observed that children with three or more complex chronic conditions were more likely to receive prescriptions for broad-spectrum antibiotics with less favorable safety profiles. Children with three or more complex chronic conditions have the highest annual prescription rates of any population group (adult or pediatric).
This study examined outpatient prescription rates for more than 2 million children.
Children aged 0 to 18 years who were continuously enrolled in Medicaid in 2023 were categorized into five mutually exclusive categories of underlying medical complexity: healthy (no chronic conditions), uncomplicated chronic conditions (NC-C), and one, two, or three or more complex chronic conditions (CCC). Poisson regression was used to compare antibiotic filling rates per 1,000 people between groups.
Of the 2,357,642 children included in the analysis, 926,025 (39.3%) received at least one antibiotic prescription. [annual antibiotic prescription fill rate of 787 per 1,000 persons (95% CI: 786-788)]. Annual antibiotic prescription fill rates per 1,000 people increased with higher levels of medical complexity (p<.001). The number increased from 514 (95% CI: 513, 516) in healthy children to 2,882 (95% CI: 2850, 2915) in children with three or more CCCs. Antibiotic exposure by drug class varied by healthcare complexity category (Figure 1).
Penicillins, cephalosporins, and macrolides accounted for 93% of antibiotic prescriptions in healthy children, but only 64% of antibiotics prescribed in children with three or more CCCs. Children with 3 or more CCCs were significantly more likely to be prescribed sulfonamides, quinolones, and aminoglycosides than other children.
Children with complex medical conditions represent an important target population for future antibiotic stewardship efforts
“This national analysis of outpatient antibiotic prescription fills among Medicaid-enabled children shows that antibiotic use is common, with more than one-third of children filling at least one antibiotic prescription in 2023,” said Kathleen D. Snow, M.D., instructor of pediatrics at Boston Children’s Hospital and lead author of the study. “Children with multiple complex chronic conditions had significantly higher antibiotic prescription filling rates, higher annual exposure to antibiotics, and more frequent use of a broad spectrum of antibiotic classes than healthy children. These findings suggest that children with complex medical conditions may be a population with significant implications for future antibiotic stewardship efforts.”
The findings will be presented at the Pediatric Society of America (PAS) 2026 Conference, April 24-27 in Boston.
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