Patterns of Antibiotic Use in Young Children Hospitalized with RSV in Amman, Jordan
Authors: Hamdan Olla , Stopczynski Tess , Stahl Anna , Rankin Danielle A , Haddadin Zaid , Yanis Ahmad , Shawareb Yanal , Hayek Haya , Amarin Justin Z , Qwaider Yasmeen Z , AlHajajra Ahmad , Marrar Basima , Spieker Andrew J , Chappell James D , Khuri-Bulos Najwa , Halasa Natasha B 
Published: November 2023

Abstract

Introduction
Antibiotic misuse is associated with the emergence of antimicrobial-resistant bacteria. It is therefore important to limit antibiotic use for respiratory infections, especially those that are virus-associated. In developing countries, without point-of-care testing for common respiratory viruses (e.g., respiratory syncytial virus, or RSV), clinicians rely on clinical judgment clinicians relay on clinical judgement to distinguish between viral and bacterial causes of illness. We sought to evaluate patterns of antibiotic use in young, hospitalized children with RSV in Amman, Jordan.

Methods
A prospective acute respiratory viral surveillance study was conducted between January 8 and March 17, 2020. Eligible children were &lt;2 years old presenting with fever and/or respiratory symptoms within 72 hours of hospitalization. Nasal or throat swabs were collected from each child. Research molecular testing for RSV and other respiratory viruses was performed. Demographic and clinical data were collected through parental interviews and chart abstractions. For this analysis, we restricted our study to children with RSV detected by research molecular testing. We classified antibiotic patterns into three categories: 1) 1st line/empiric: ampicillin, ceftriaxone, cefuroxime, cefotaxime, and gentamycin; 2) azithromycin; 3) expanded: vancomycin, amikacin, imipenem/meropenem, and metronidazole. We compared clinical characteristics and outcomes between the three antibiotic groups using Pearson's χ2 test for categorical variables and linear regression with robust standard errors for continuous variables.

Results
Of the 531 children who were enrolled, 400 (75.3%) were RSV-positive by research molecular testing: 221 (55.3%) were male, median age was 2.9 months (IQR, 1.7–6.4), 174/390 (44.6%) reported consuming an antibiotic prior to hospitalization, and 387 (96.8%) received at least one antibiotic during their hospitalization. The most common antibiotic category was empiric 261 (67.4%), followed by azithromycin (n=106; 27.4%) and expanded (n=16; 4.1%). Table 1 compares clinical and demographic data between antibiotic categories for RSV-positive children during hospitalization. Children in the empiric group had higher mean age and were more likely to be diagnosed with bronchopneumonia at admission, while those in the azithromycin group were more likely to be diagnosed with pertussis-like cough or bronchiolitis at admission. Children in the expanded group were more likely to have fever, be diagnosed with pneumonia at admission, require oxygen, and be admitted to the intensive care unit. Among those who had a blood, urine, and/or CSF culture performed (n=209; 54%), a total of 10 (2.6%) were positive for gram-positive bacteria.

Conclusion
In our study, most children received an antibiotic during their hospital stay. Antibiotic stewardship programs and the implementation of point-of-care testing in Jordanian hospitals are needed to help limit antibiotic use for RSV.