Steady decline in antibiotics for childhood respiratory infections

By Priyanjana Pramanik, MSc.Reviewed by Lauren HardakerJan 13 2026

Nationwide health data reveal major progress in reducing antibiotics for childhood respiratory infections, while exposing ear infections as a persistent blind spot for stewardship efforts.

Study: Antibiotic prescriptions to preschool children with respiratory tract infections in primary healthcare. Image credit: PeopleImages/Shutterstock.com

In a recent study published in JAC Antimicrobial Resistance, researchers examined trends in antibiotic prescriptions for respiratory tract infections (RTIs) among preschool children in Norway, using nationwide observational registry data.

They found that antibiotic prescriptions for RTIs decreased significantly between 2012 and 2019. Still, they concluded that further improvements are achievable in adherence to treatment guidelines and antibiotic stewardship, even in this low-prescribing country.

Why antibiotic use in young children still matters

Antimicrobial resistance (AMR) poses a significant global threat, primarily driven by overuse and misuse of antibiotics. A strong association exists between the volume of antibiotic consumption in a population and the development of resistant bacteria.

Although Norway is among the countries with relatively low antibiotic prescribing rates, national health authorities acknowledge ongoing potential for further reductions. Norway has implemented several national strategies to combat AMR, including guidelines that recommend narrow-spectrum penicillins as first-line treatment for RTIs. Children, especially those of preschool age, experience frequent RTIs, most of which are viral and self-limiting.

Despite clear clinical guidelines, previous studies indicate that antibiotics are often prescribed unnecessarily in this age group. Comprehensive national health registries in Norway provide a unique opportunity to examine healthcare contacts, prescribing behavior, and treatment choices at the population level. Understanding these patterns can help identify gaps in guideline adherence and inform targeted antibiotic stewardship initiatives.

Nationwide registries track childhood RTIs before the pandemic

Researchers assessed trends in RTI episodes, antibiotic prescribing rates, and antibiotic selection among preschool-aged children before the coronavirus disease 2019 (COVID-19) pandemic. Data for the period 2012,19 were drawn from four Norwegian health registries, which capture all general practitioner consultations, hospital admissions, demographic data, and dispensed prescription medications across the entire population.

The study population included children aged under five years who had contact with general practice for RTIs during the study period. Infants under one year of age and children admitted to hospital or specialist care on the same day as their first consultation were excluded. RTI episodes were defined by grouping healthcare contacts occurring within 30 days of an initial RTI diagnosis, with a maximum follow-up of 90 days per episode.

Antibiotic prescriptions for oral use were identified using established codes and grouped into phenoxymethylpenicillin, other penicillins, macrolides, and other antibiotics. Prescriptions dispensed within seven days of a consultation were linked to the corresponding episode.

Annual episode rates and prescribing rates were calculated and standardized by age and sex. Trends over time were analyzed using linear regression and negative binomial regression models, with results presented as mean annual changes with 95 % confidence intervals.

Otitis and URTI dominate remaining antibiotic exposure

The study included approximately 579,000 children aged between one and five years annually between 2012 and 2019, with boys accounting for 54 % of the population. Over the study period, more than 3.1 million general practice contacts for RTIs were recorded, corresponding to just over 2 million RTI episodes.

This resulted in an average of 811 RTI episodes per 1,000 children per year, with higher rates among boys and the youngest children. One- and two-year-olds accounted for more than half of all episodes, and RTI rates declined steadily with age.

Nearly half of all episodes involved only a single healthcare contact, although younger children had more repeat consultations. Upper RTI (URTI), cough, and otitis were the most common diagnoses. Overall RTI episode rates declined by 17 % from 2012 to 2019, with the largest relative reductions observed for pneumonia and cough. However, some of this early decline coincided with a national outbreak of Mycoplasma pneumoniae.

Antibiotic prescribing also decreased substantially. The proportion of RTI episodes treated with antibiotics fell from 28 % (2012) to 19 % (2019), with the steepest decline occurring early in the study period. Otitis and URTI together accounted for over half of all antibiotic prescriptions.

While prescription rates declined for most diagnoses, otitis, tonsillitis, and pneumonia remained associated with consistently high antibiotic use. Importantly, there was a shift toward guideline-recommended treatment, with a greater proportion of prescriptions using phenoxymethylpenicillin and declining macrolide use.

Even low-prescribing countries can reduce antibiotic use further

The reduction in antibiotic use among preschool children was driven by a combination of fewer RTI episodes, lower prescribing rates per episode, and partial improvement in alignment with treatment guidelines, as reflected by an increased use of narrow-spectrum penicillins.

Declines were most pronounced for conditions likely to be viral, suggesting a combination of more cautious prescribing practices and changes in parental health-seeking behaviour. However, the observational design means causal relationships could not be directly assessed. Antibiotic prescribing for otitis remained consistently high despite fewer consultations. This finding may reflect persistent non-adherence to guidelines or a shift toward more severe cases presenting in primary care.

A major strength of the study is its use of high-quality nationwide registry data covering the entire population over several years; nevertheless, reliance on administrative data limited insight into clinical decision-making, disease severity, and diagnostic accuracy. Infection outbreaks may have also influenced the findings and did not account for seasonal variation or repeated episodes within individual children.

Overall, the study demonstrates that further reductions in antibiotic use are achievable even in low-prescribing settings. Targeted stewardship efforts, particularly for otitis and other self-limiting RTIs, remain an important focus for future interventions to combat antimicrobial resistance.

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