Dialling back antibiotic prescribing in children

Antibiotic prescriptions for children in primary care in England have risen sharply since the COVID-19 pandemic. 

Before the COVID-19 pandemic, 27% of children in England aged under ten years received antibiotics annually. By 2022, this figure reached 35% and stayed above that level until 2024. In 2023, the figure peaked at 39% (see Figure 1). 

This worrying trend undermines efforts to curb inappropriate antibiotic use, which is an issue NHS England is keen to address^​1​. 

“It is not entirely clear what has driven the rise in antibiotic use in children,” says Conor Jamieson, regional antimicrobial stewardship lead for NHS England (Midlands region), who is spearheading national work on appropriate paediatric antibiotic prescribing.

This phenomenon is concerning: antimicrobial resistance (AMR) is a growing burden on public health. It’s also unclear whether this high level of antibiotic prescribing is warranted, as most prescriptions are related to respiratory tract infections, where evidence of benefit is limited, Jamieson adds. 

Data also reveal significant variation between integrated care boards (ICBs), indicating room for improvement. 

This worrying trend undermines efforts to curb inappropriate antibiotic use. NHS England has set a target of 27% for the proportion of children aged under ten years who have been prescribed an antibiotic in primary care in the past 12 months, to which ICBs are assessed as having ‘met’ or ‘not met’.

In addition, the UK government has set a target of a 5% total reduction in UK antibiotic use from a 2019 baseline by 2029; however, the statistics on paediatric antibiotic prescribing could well threaten this. Pharmacists have emphasised to The Pharmaceutical Journal that there is now an urgent need to return to pre-COVID-19-pandemic levels.

Increased antibiotic prescribing

The surge in antibiotic prescribing began in 2022, following an initial drop during lockdowns, according to data from the NHS Oversight Framework dashboard. The 27% target for children aged up to nine years in England was exceeded in April 2022, climbing to 35% by December 2022 amid a group A streptococcus outbreak (see Figure 2)^​2​.

For the subsequent year, over 38% of children aged up to nine years had received antibiotics within the prior 12 months. The latest data show a modest improvement: 31.7% exposure by March 2025, down from 34.9% in March 2024.

Jamieson suggests behaviour change from both healthcare professionals and patients, increased infections and healthcare access are all likely play a role. 

During the group A streptococcus outbreak in 2022/2023, clinicians were advised to lower their prescribing threshold and issue antibiotics more readily. Associated media coverage likely shifted public expectations and prescriber caution, “the impact of which may still be playing out in the data”, Jamieson adds.

Regional disparities

Prescribing rates for children aged up to nine years from August 2024 to July 2025 vary significantly by region, from 20.9% in NHS Bristol, North Somerset and South Gloucestershire to 44.8% in NHS Bedfordshire, Luton and Milton Keynes. Only six ICBs met the 27% target (see Figure 2).

Factors influencing this variation include regional campaigns on broader issues, such as hygiene and vaccination, and clinical leaders promoting prudent prescribing. 

Socioeconomic deprivation — linked to higher prescribing and resistance — is also a likely factor. Higher prescribing is also observed among ethnic minority groups, Jamieson says, though the extent to which this reflects differing infection rates or comorbidities remains unclear.

“The AMR national action plan includes commitments to identify and address the impact of health inequalities, which will be relevant here,” Jamieson notes.

Alicia Demirjian, clinical lead for AMR and prescribing at the UK Health Security Agency and a consultant in paediatric infectious disease, believes the COVID-19 pandemic led clinicians to prescribe more frequently.

“We have not gone back to how things were before,” she says. “We’ve adjusted to a new baseline of prescribing, especially for children aged 0-4 years.” 

Better understanding is now needed on whether patient and professionals’ perception of risk has shifted, she adds. “We’ve known for decades now that respiratory infections are the number one area where antibiotics are overused or misused, and that’s what I think we can change, certainly in terms of just the quantity.”

Weighing up the benefits

Winter illnesses place significant demand on primary care workloads, with up to one in ten children aged under five years consulting their GP during peak periods, Jamieson points out. 

Around 60% of antibiotic prescribing in children occurs up to the age of four years, he adds. Amoxicillin is the main choice, accounting for over 50% of paediatric prescriptions^​3​.

However, understanding of the benefit–risk balance of antibiotics here is evolving. 

Emerging evidence suggests that antibiotic exposure before a child’s second birthday is associated with an increased risk of developing long-term immune-related conditions, including asthma and allergies, as well as impaired intellectual development and being overweight^​4,5​.

More parents need to understand this, says Orlagh McGarrity, senior antimicrobial pharmacist at Great Ormond Street Children’s Hospital for Children NHS Foundation Trust. She feels she might be considered reckless by other parents because her children, aged three and five years, have never had an antibiotic. 

Even for a bacterial throat infection, antibiotics only reduce symptoms by half a day on average, she adds. “People with a normal immune system will fight a bacterial infection, you’re built to fight these things off.”

“My personal belief is that in most cases the evidence is that reduction in symptoms is just not worth the pay-off.” For McGarrity, the risk is very real, as she observes increasing numbers of children admitted with drug-resistant infections — some imported from abroad.

Andrew Taylor, former lead antimicrobial pharmacist at Alder Hey Children’s Hospital in Liverpool, collaborated with Cheshire and Merseyside ICB on a ‘Superbodies’ campaign^​6​. This initiative educated parents that children’s immune systems are capable of fighting off infections. 

“Historically Merseyside has been one of the worst prescribers of antibiotics,” Taylor says. “We have some of the most deprived areas in the country and that is also correlated to amount of prescribing.”

Antibiotic resistance is a major concern at Alder Hey Children’s Hospital, where significant effort is dedicated to appropriate antibiotic use within the hospital and limiting treatment durations. 

“Two years ago, I was concerned we were going to lose a couple of our patients due to AMR, which would have been the first time it had been a primary cause of death,” says Taylor.

Prescribing behaviour

Research indicates that while anxiety drives parents or carers to the GP, they are primarily seeking clinical examination and reassurance, not necessarily antibiotics.

Chloe Lim, who succeeded Taylor as lead antimicrobial pharmacist at Alder Hey Children’s Hospital, explains that clinicians have greater concerns about children, with sepsis at the front of people’s minds. 

“When it comes to younger children or babies, people are more worried because they can’t speak to you, they can’t communicate, it’s hard to get clues, and then they can get unwell really quickly,” she says.

However, Lim believes significant work is needed to help patients and health professionals recognise that AMR is an immediate threat. “People don’t realise how serious it is. It’s very scary because drug companies don’t want to invest in new antibiotics. Bugs are getting more resistant, they change, and we’re not quick enough to adapt to that.”

The group A streptococcus outbreak could have made parents and clinicians more cautious and, therefore, more willing to prescribe antibiotics, says Sarah Tonkin-Crine, health psychologist at the Oxford University Nuffield Department of Primary Care Health Sciences.

The shift in prescribing does not appear to relate to children being sicker, she explains. The factors that do influence prescribing include appointment waiting times, whether the consultation is done online, on the phone or face-to-face, parental concern, GP or healthcare professional workload and consultation length. There is also evidence that prior antibiotic use increases future expectations.

These factors can collectively lead prescribers to err on the side of caution “more often than we would like them to”, she says.

This caution may be misplaced. One study found that for children aged up to four years consulting primary care for a respiratory tract infection, a clinician would need to prescribe between 27,000–29,000 courses of antibiotics to prevent just one case of sepsis^​7​.

In future, it will be important to track the impact of Pharmacy First and other primary care prescribers, such as nurses and physician associates, who, while following the same guidelines, may have different risk tolerances than GPs or community or practice-based pharmacists.

Delayed or back-up prescriptions can be effective, Tonkin-Crine adds. “Research indicates that about one-third of delayed prescriptions are used, so 60% of people are making that decision they don’t need it. You’re saving a lot of unnecessary antibiotic use and you’re empowering people.”

Charlotte Gurr

Tackling the issue

The expectation is for all ICBs to be at or below the 27% target by the end of 2028/2029, says Jamieson.

“The majority of them are above it and it will present a significant challenge for those ICBs at the higher end of the variation range,” he admits.

There are some signs of improvement, with figures for May 2025 showing a rate of 30% for England and all ICBs on a downward trajectory. Yet, the disparity between the best and worst ICBs may be growing, as they currently range between 19–42%.

Some areas are gathering data to inform these improvements. One targeted programme with 49 practices in the south of England reduced the median prescribing rate for children aged under five years from 49 per 1,000 patients to 39 per 1,000 patients. There was no increase in paediatric presentations to primary care after the intervention^​8​.

Study author Liz Corteville, who was lead pharmacist with the West Hampshire Clinical Commissioning Group (CCG) at the time, said it presented data to practices and offered practical tips for improvement, rather than giving them a “ticking-off” about high antibiotic prescribing rates.

“You agree an action plan with the practice so they’re the ones who are suggesting what they can do and who’s going to actually do it,” she advises.

The West Hampshire CCG initially suggested practices cut prescriptions by one in ten, but many went further. “We had improvement in all practices, irrespective of whether they were on the higher or lower end of the prescribing spectrum.”

Practices also found it very valuable to have the NHS Healthier Together information that they could text to parents, she adds, but all of this takes resourcing and focus^​9​.

Nationally, a suite of resources has been published on the FutureNHS collaboration platform for primary care networks, including around improving antimicrobial prescribing in children with respiratory tract infection and cough^​10​.

FutureNHS also offers suggested quality improvement strategies, along with approaches for measuring and monitoring impact and outcomes. 

The Royal College of General Practitioners (RCGP) says the rising rate of antibiotic prescribing is largely a result of temporary changes to prescribing thresholds during the group A streptococcus outbreak. It has worked with the UK Health Security Agency on the TARGET antibiotics toolkit, which is freely available and supports clinicians to adopt more “responsible” antibiotic use^​11​.

“GPs are always looking for ways to safely reduce use of antibiotics, and we will only prescribe them in line with clinical guidance,” says Kamila Hawthorne, chair of the RCGP.

The role of pharmacists

To address regional variation, the South East and Midlands regions recently brought together a multidisciplinary team of pharmacists, nurses and doctors, Jamieson explains. The team conducted surveys of primary care clinicians and found gaps in awareness of prescribing guidance for children, limited coding of back-up antibiotic prescriptions and a desire for education.

Using this research, they have developed resources that include a poster for children about the gut microbiome, guidance on how to use back-up prescriptions and a bespoke training session on paediatric respiratory tract infections.

Pharmacists working in general practice and independent prescribers in the community also need to ensure they are following guidelines for antibiotic prescribing, and bear in mind the natural progression of infections, he adds.

“For example, for most respiratory tract infections, it will take at least a week for 90% of children to feel better. For acute cough, symptoms can last for up to three weeks.”

Pharmacists should also challenge any antibiotic durations longer than the recommended course for respiratory tract infections, he says. Draft pneumonia guidance from the National Institute for Health and Care Excellence (NICE), published on 2 September 2025, does not recommend antibiotic prescribing for uncomplicated pneumonia in the community to three days for patients aged 3 months to 11 years^​12​.

Under the 2025 Pharmacy Quality Scheme, pharmacists are being asked to complete an audit to assess the appropriateness and rationale for the non-supply of antibiotics in sore throat consultations. They will also need to evaluate how they are applying clinical assessment criteria — for example, FeverPAIN in making decisions under Pharmacy First. 

However, there is still work to do, says Rakhi Aggarwal, head of medicines optimisation at NHS Staffordshire and Stoke on Trent. From her extensive experience, building relationships is the most important part. “One of the first things I’ve done is set up a multidisciplinary approach to antimicrobial stewardship.”

The team has developed primary care guidelines for adults and is about to start working on the same for children, she explains, which will highlight the newer evidence around increased risk of long-term conditions among those who have had antibiotics in the first two years of life.

This approach has so far been successful: antibiotic prescribing figures in NHS Staffordshire and Stoke on Trent are falling. The latest data from May 2025 show antibiotic prescribing rates in this trust now stand at 37% — from a high of 45% in October 2023.

What’s next for the team? Doing audits of prescribing in children will be important to find those pockets of high antibiotic use, she adds.

“It’s just about ensuring we’re all singing from the same hymn sheet.”