Highlights
- Large multicenter study reveals that minority and low Childhood Opportunity Index (COI) children hospitalized for pneumonia are more likely to receive antibiotics, including broad-spectrum and intravenous formulations, compared to non-Hispanic White children and those from higher-resource areas.
- Contrasts sharply with outpatient data, where White and higher-COI children are more likely to receive excessive or broad-spectrum antibiotics.
- Findings suggest system-level and implicit bias factors may uniquely influence inpatient antibiotic stewardship.
- Study underscores the need for targeted stewardship and bias-mitigation strategies in pediatric inpatient settings.
Study Background and Disease Burden
Pneumonia remains a leading cause of pediatric hospitalization and morbidity in the United States, accounting for thousands of admissions annually. While antibiotics are critical for managing bacterial pneumonia, their overuse—especially broad-spectrum agents—contributes to antimicrobial resistance, adverse drug reactions, and unnecessary healthcare costs. Prior research has identified disparities in outpatient antibiotic prescribing, with evidence of both over- and under-treatment among minority and socioeconomically disadvantaged children. However, little was known about whether these disparities extend to inpatient care, where clinical acuity and decision-making dynamics differ substantially. Addressing these knowledge gaps is crucial to ensuring equity and stewardship in pediatric infectious disease management.
Study Design
To examine the intersection of race/ethnicity, neighborhood opportunity, and inpatient antibiotic prescribing for pediatric pneumonia, Cotter and colleagues conducted a retrospective cohort study using the Pediatric Health Information System (PHIS) database. The analysis included 49,332 children aged 3 months to 18 years who were hospitalized with pneumonia between 2022 and 2024 at 43 U.S. children’s hospitals. The primary exposures were patient race/ethnicity (non-Hispanic White, Hispanic, non-Hispanic Black, Asian, and other) and Childhood Opportunity Index (COI) quintile, a composite measure reflecting educational, health, environmental, and socioeconomic neighborhood resources. Antibiotic prescribing patterns (any, broad-spectrum, intravenous vs. oral) were compared across groups, adjusting for potential confounders.
Key Findings
Overall, 81% of hospitalized children with pneumonia received antibiotics, with 48% receiving broad-spectrum agents and 75% intravenous therapy. The median patient age was 4 years, and the mean hospital stay was 1.8 days. The breakdown by race/ethnicity was 43% non-Hispanic White, 27% Hispanic, 17% non-Hispanic Black, and 5% Asian.
The analysis revealed several striking disparities:
- Asian and non-Hispanic Black children were more likely than non-Hispanic White children to receive any antibiotics: 86% (aOR 1.45) and 83% (aOR 1.59), respectively, versus 80% for non-Hispanic Whites.
- Hispanic children had higher odds of receiving broad-spectrum antibiotics than non-Hispanic Whites (52% vs. 46%; aOR 1.30).
- All minority groups were more likely than non-Hispanic Whites to receive intravenous (IV) antibiotics rather than oral formulations.
- Children from neighborhoods in the lowest COI quintile (least opportunity) had higher odds of receiving any antibiotics and higher odds of receiving broad-spectrum rather than narrow-spectrum agents compared to those from the highest COI quintile.
These differences persisted after adjustment for demographic and clinical variables. Notably, the direction of these disparities contrasts with the outpatient setting, where White and high-COI children are historically at greater risk for overtreatment with antibiotics.
Expert Commentary
Dr. Jillian Cotter, lead author and presenter at PHM 2025, highlighted the unexpected reversal in disparity patterns compared to outpatient care. “The outpatient literature has generally found that more antibiotics and more intense (broad-spectrum) antibiotics are more likely given to non-Hispanic White children and those residing in high opportunity neighborhoods. Our findings in the inpatient setting suggest the potential influence of different system-level factors and clinician implicit biases.”
Potential explanations for these findings include:
- Greater perceived or actual severity of illness among minority and low-COI children at the time of hospitalization, possibly due to delayed care access or social determinants.
- Lack of established doctor-patient relationships in inpatient settings, possibly amplifying risk-averse prescribing practices or bias.
- Systemic factors such as institutional protocols, resource constraints, or differential access to diagnostic tools that may influence clinical decision-making.
Cotter emphasized the need for clinicians to reflect on unconscious biases and how these may impact antibiotic utilization, especially in high-acuity settings.
Limitations
The authors acknowledged several limitations:
- Findings may not generalize to all hospitals, as the study population was limited to 43 large children’s hospitals contributing to PHIS.
- Use of ZIP code rather than census tract for COI assignment may have introduced misclassification.
- The observational design cannot establish causality, and residual confounding (e.g., illness severity, comorbidities, provider characteristics) may persist.
- Complex interactions between race, ethnicity, and neighborhood opportunity were not fully explored.
Clinical Implications and Research Gaps
This study calls for a nuanced approach to antibiotic stewardship that accounts for both patient- and system-level drivers of disparity. Key considerations include:
- Developing stewardship protocols that explicitly address equity and bias mitigation in inpatient pediatric care.
- Improving data granularity to better assess the role of neighborhood and social determinants in prescribing patterns.
- Extending research to clarify whether differences in illness severity, parental expectations, or care access contribute to observed disparities.
- Assessing the impact of educational interventions on clinician awareness of implicit bias and antibiotic stewardship.
Further research should also examine outcomes associated with differential antibiotic use—such as resistance patterns, adverse events, and readmission rates—across demographic and socioeconomic groups.
Conclusion
The PHIS study provides important new evidence that minority and socioeconomically disadvantaged children are at greater risk of overtreatment with antibiotics for pneumonia in the inpatient setting, reversing a well-documented trend from outpatient care. These disparities highlight the need for targeted stewardship, enhanced clinician education, and research into the underlying mechanisms driving inequitable care. As pediatric antibiotic stewardship evolves, integrating equity into both policy and practice will be essential to ensure optimal, safe, and just treatment for all children.
References
1. Cotter J, et al. Disparities in Inpatient Antibiotic Prescribing for Pediatric Pneumonia. Presented at Pediatric Hospital Medicine (PHM) 2025.
2. Hersh AL, et al. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053-1061.
3. Gerber JS, et al. Racial differences in antibiotic prescribing by primary care pediatricians. Pediatrics. 2013;131(4):677-684.
4. Beck AF, et al. The Child Opportunity Index: Improving Collaboration Between Health and Community Sectors to Improve Child Health. Health Aff (Millwood). 2020;39(10):1737-1745.
5. American Academy of Pediatrics. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Pediatric Community-Acquired Pneumonia. Pediatrics. 2011;128(5):e1385-e1403.
