Objective To determine the rate and appropriateness of antibiotic prescribing for acutely ill children in ambulatory care in high-income countries. Design On 10 February 2021, we systematically searched articles published since 2000 in MEDLINE, Embase, CENTRAL, Web Of Science and grey literature databases. We included cross-sectional and longitudinal studies, time-series analyses, randomised controlled trials and non-randomised studies of interventions with acutely ill children up to and including 12 years of age in ambulatory care settings in high-income countries. Pooled antibiotic prescribing and appropriateness rates were calculated using random-effects models. Meta-regression was performed to describe the relationship between the antibiotic prescribing rate and study-level covariates. Results We included 86 studies comprising 11 114 863 children. We found a pooled antibiotic prescribing rate of 45.4% (95% CI 38.2% to 52.8%) for all acutely ill children, and 85.6% (95% CI 73.3% to 92.9%) for acute otitis media, 37.4% (95% CI 30.9% to 44.3%) for respiratory tract infections, and 40.4% (95% CI 29.9% to 51.9%) for other diagnoses. Considerable heterogeneity can only partly be explained by differences in diagnoses. The overall pooled appropriateness rate is 68.5% (95% CI 55.8% to 78.9%, I²=99.8%; 19 studies, 119 995 participants). 38.3% of all prescribed antibiotics were aminopenicillins. Conclusions Antibiotic prescribing rates for acutely ill children in ambulatory care in high-income countries remain high. Large differences in prescription rates between studies can only partly be explained by differences in diagnoses. Better registration and further research are needed to investigate patient-level data on diagnosis and appropriateness.

Background: It is crucial to understand the trends in paediatric antibiotic prescribing and serious and nonserious infections to improve antibiotic prescribing practices for children in ambulatory care.Objectives: Assessing trends in paediatric antibiotic prescribing and infection incidence in general practice from 2002 to 2022.Methods: In this retrospective cohort study using INTEGO network data from 162 507 patients in Flanders (Belgium), we calculated antibiotic prescribing rates and proportions alongside incidence rates of serious and nonserious infections, stratified by age (0–1, 2–6, 7–12 years) and municipality. We performed autoregressive moving average time-series analyses and seasonality analyses.Results: From 2002 to 2022, antibiotic prescribing rate decreased significantly: 584/1000 person-years (PY) (95% CI 571–597) to 484/1000PY (95% CI 478–491); so did antibiotic overall prescribing proportion: 46.3% (95% CI 45.1–47.6) to 23.3% (95% CI 22.9–23.7) (59.3% amoxicillin and 17.8% broad spectrum). Prescribing proportions dropped significantly for nonserious (45.6% to 20.9%) and increased for serious infections (64.1% to 69.8%). Proportions significantly dropped for acute suppurative otitis media (74.7% to 64.1%), upper respiratory tract infections (44.9% to 16.6%), bronchitis/bronchiolitis (73.6% to 44.1%) and acute tonsillopharyngitis (59.5% to 21.7%), while significantly increasing for pneumonia (65.2% to 80.2%). Nonserious and serious infection incidence rates increased from 785/1000PY and 34.2/1000PY to 1223/1000PY and 64.1/1000PY, respectively. Blood and CRP testing proportions increased significantly.Conclusions: Antibiotic prescribing in general practice for children declined from 2002 to 2022. Further targeted antibiotic stewardship initiatives are needed to reduce the use of broad-spectrum antibiotics and antibiotic prescribing for conditions such as otitis media and bronchitis/bronchiolitis.

Background: Safety-netting advice (SNA) can help in the management of acutely ill children. Aim: To assess the effectiveness of different SNA methods on antibiotic prescription and consumption in acutely ill children. Design and setting: Systematic review and network meta-analysis of randomised controlled trials, cluster randomised trials, non-randomised studies of interventions, and controlled before–after studies in ambulatory care in high-income countries. Method: MEDLINE, Embase, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials were searched (22 January 2024). Risk of bias (RoB) was assessed with Cochrane’s RoB 2 tool, the Revised Cochrane Tool for Cluster-Randomised Trials, and the Risk Of Bias In Non-randomised Studies — of Interventions tool. Certainty of evidence was assessed using the Confidence in Network Meta-Analysis approach. Sensitivity analyses and network meta-regression were performed. Results: In total, 30 studies (20 interventions) were included. Compared with usual care, paper SNA may reduce: antibiotic prescribing (odds ratio [OR] 0.66, 95% confidence interval [CI] = 0.53 to 0.82, I ² = 92%, very low certainty, three studies, 35 988 participants), especially when combined with oral SNA (OR 0.40, 95% CI = 0.08 to 2.00, P -score = 0.86); antibiotic consumption (OR 0.39, 95% CI = 0.27 to 0.58, low RoB, one study, 509 participants); and return visits (OR 0.74, 95% CI = 0.63 to 0.87). Compared with usual care, video SNA, read-only websites, oral SNA, and web-based SNA (in descending order of effectiveness) may increase parental knowledge (ORs 2.33–4.52), while paper SNA may not (ORs 1.18–1.62). Similarly, compared with usual care, video SNA and web-based modules may improve parental satisfaction (ORs 1.94–4.08), while paper SNA may not (OR 1.85, 95% CI = 0.48 to 7.08). Conclusion: Paper SNA (with oral SNA) may reduce antibiotic use and return visits. Video, oral, and online SNA may improve parental knowledge, whereas video SNA and web-based modules may increase parental satisfaction.

Safety netting advice (SNA) is an essential component of the management of acutely ill children in ambulatory care. However, healthcare professionals use a variety of SNA methods, leading to inconsistencies within and across organisations. Much research has explored the perspective on SNA of parents from the UK, but such research is lacking outside the UK context. We conducted focus groups with Belgian parents of children 6 months to 12 years old, who were recruited through maximum variation sampling. We transcribed the interviews verbatim. Using a combination of inductive and deductive ‘in vivo’ coding we developed themes from the data. As per the Grounded Theory approach, we reiterated between data collection, coding, and analysis. After participant validation of provisional themes, we constructed the final thematic framework. Through six focus groups with 30 parents, we identified five themes: (1) Relevant background information; (2) To know what to expect, what to look out for; (3) Instructions on child homecare and when to revisit a physician; (4) Physicians who consider parents’ perspectives and contexts; (5) A reliable source that provides SNA only when necessary, possibly in a multimodal way. We identified five themes from Belgian parents’ views on SNA, aligning with prior UK research. These findings form an evidence base for developing a consensus statement on the content and form of SNA supported by both parents and experts from high-income countries.

Objective Develop a consensus on the content and form of safety netting advice (SNA) for parents of acutely ill children. Design Four-round modified e-Delphi using online questionnaires and feedback among clinical and research experts. Setting Ambulatory care in high-income countries. Participants Forty-one experts from 13 countries: 3 emergency physicians, 15 general practitioners, 4 nurses and 19 paediatricians. Results The experts defined the content of SNA as advice on the normal, expected disease course of the provisional diagnosis, diagnostic uncertainty, alarm signs that indicate the need for medical help and information on where and how to find such help. Regarding the form of the SNA, the experts agree that a reliable source should give SNA verbally with paper or digital written or video/image resources at every appropriate healthcare encounter in a short and simple empowering fashion, specific to the child’s situation and seek confirmatory feedback from parents. Conclusions SNA needs to contain advice on the expected disease course, alarm signs and where and how to find help. It should be given verbally with written resources by a reliable healthcare professional or digital platform. Short, simple and specific, SNA needs to empower the parent whose understanding of the advice should be checked. The effectiveness of SNA resources coproduced by parents and experts should be assessed in different settings and those providing SNA require up-to-date and reliable training.

Background: Antibiotics are commonly prescribed in older community-dwelling adults, contributing to adverse effects, antimicrobial resistance and increased healthcare costs. Prescribing patterns in dementia are unclear, although healthcare use and goals of care change around diagnosis. Objective: To describe trends in antibiotic dispensing and prevalence amongst Australians aged ≥70 years, compare dispensing between those with and without dementia and identify factors associated with dispensing. Methods: We analysed data from 13 659 ASPREE and ASPREE-XT participants (2010–20). Antibiotic dispensing was assessed using Pharmaceutical Benefits Scheme records, with rates stratified by age group. Interrupted time-series analysis compared dispensing rates and the proportion of broad- versus narrow-spectrum antibiotics dementia case and matched controls (matched on time since randomisation, age and sex). Negative binomial regression identified factors associated with dispensing. Results: Dispensing rates increased to 1651 per 1000 person-years (95% CI: 1604–99) by year 9. Annual prevalence averaged 47%. Broad-spectrum antibiotics were dispensed twice as often as narrow-spectrum. Individuals with dementia had higher dispensing both before and after diagnosis, but dementia was not independently associated with dispensing (IRR 1.06, 95% CI: 0.95–1.18). Female sex, polypharmacy, pre-frailty and higher depressive symptom scores were linked to higher dispensing, whilst hypertension, dyslipidaemia and alcohol use were linked to lower dispensing. Conclusions: Antibiotic dispensing in older adults remains high, dominated by broad-spectrum agents. Dementia was not independently associated with increased dispensing. Female sex, polypharmacy, pre-frailty and depressive symptoms identified groups who may benefit most from targeted antimicrobial stewardship interventions.