Minority Children Receive More Antibiotics for Pneumonia

Children of minority populations living in lower socioeconomic neighborhoods received significantly more antibiotics when hospitalized for pneumonia than non-Hispanic White children, based on data from nearly 50,000 individuals.

The findings were presented at Pediatric Hospital Medicine (PHM) 2025.

Previous research showed that antibiotics are often overused in managing pediatric pneumonia, which may expose children to unnecessary risks, said Jillian Cotter, MD, of Children’s Hospital Colorado, Aurora, Colorado, in her presentation. Although disparities in outpatient antibiotic use in children are known, data on disparities for inpatient prescription of antibiotics, especially for pneumonia, are limited, she said.

To assess the associations of race/ethnicity and Childhood Opportunity Index (COI) with inpatient antibiotic prescribing trends, Cotter and colleagues reviewed data of 49,332 children aged 3 months to 18 years who were hospitalized with pneumonia between 2022 and 2024 across 43 hospitals in the Pediatric Health Information System.

The COI included education availability and quality, health and environmental factors (such as proximity to grocery stores), and social/economic factors (such as employment and single-headed households). The COI was divided into quintiles, with the highest representing areas with high resources. Median age of the children was 4 years, and the mean length of hospital stay was 1.8 days. The study population was 43% non-Hispanic White, 27% Hispanic, 17% non-Hispanic Black, and 5% Asian children.

Overall, 81% of the children received antibiotics; 48% received broad-spectrum antibiotics, and 75% received intravenous antibiotics. Asian or non-Hispanic Black children were significantly more likely than non-Hispanic White children to receive any antibiotics (Asian: 86% vs 80%; adjusted odds ratio [aOR], 1.45; non-Hispanic Black: 83% vs 80%; aOR, 1.59).

Hispanic children were significantly more likely to receive broad-spectrum antibiotics than non-Hispanic White children (52% vs 46%; aOR, 1.30). In addition, all other ethnic groups were more likely than non-Hispanic White children to receive intravenous antibiotics than oral antibiotics.

In a model, children in the lowest COI quintile had higher odds of any antibiotic prescribing vs no antibiotics and higher odds of broad-spectrum vs narrow-spectrum antibiotics than those in the highest quintile.

The findings may not be representative of all hospitals that care for children. Limitations included the effect of unmeasured confounding variables, the use of ZIP code rather than census tract data to determine COI, and the complex interactions among race, ethnicity, and COI that were beyond the scope of the study, Cotter noted in her presentation.

The researchers were surprised to find that the direction of antibiotic prescribing differences for inpatients was opposite to much of the outpatient antibiotic stewardship literature, Cotter told Medscape Medical News. “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,” she said. “Potential reasons for these differences include system-level factors and clinician implicit biases, which may be more pronounced in the inpatient vs outpatient settings due to higher severity of illness, or concern for higher illness severity, and absence of preexisting doctor-patient relationships,” Cotter noted.

Clinical Considerations and Research Gaps

“As healthcare providers, we need to carefully consider our unconscious implicit biases and how they may impact our utilization of antibiotics,” Cotter told Medscape Medical News. “Differing disparities in inpatient vs outpatient antibiotic prescribing emphasizes that findings in outpatient settings may not generalize to the inpatient setting,” she said.

Bias May Drive Decision-Making

“I think clinicians rightly or wrongly perceive patients from ethnic minority groups as more vulnerable and have a tendency to overtreat,” said Tim Joos, MD, a clinician with a combination internal medicine/pediatrics practice at Neighborcare Health in Seattle.

Minority patients often have a harder time engaging in healthcare initially, so clinicians may perceive them as late in presenting to care and feel less secure in their re-engaging in care for follow-up, said Joos, who was not involved in the current study.

In patient encounters where there are language or cultural barriers, clinicians may feel less comfortable and may be more likely to overtreat rather than observe and reassess, said Joos.

The current study reinforces the need for clinicians to examine potential biases in patient care for different ethnic and socioeconomic groups, Joos told Medscape Medical News. “Practices that were valid for a previous generation of clinicians may not be appropriate in an increasingly diverse American society,” he added.

The study received no outside funding. Cotter disclosed receiving funding from Pfizer for an unrelated study. Joos disclosed having no financial conflicts of interest.