Drivers of Non-First-Line Antibiotic Prescribing for Acute Respiratory Infections in Urgent Care

BACKGROUND/OBJECTIVE: National guidelines provide recommendations for first-line therapy (FLT) for acute respiratory infections (ARIs). Sociodemographic differences in FLT for ARIs have been described. This study identified and categorized reasons for non-FLT for ARIs in pediatric urgent care (PUC) and evaluated whether these reasons differ across sociodemographic groups. METHODS: We conducted a retrospective chart review of PUC encounters for patients ages 6 months to 19 years diagnosed with acute otitis media, pharyngitis, community-acquired pneumonia, or acute bacterial rhinosinusitis between April 2023 and March 2024 who received an oral antibiotic. We categorized reasons for non-FLT using predefined groups: penicillin allergy label (PAL), treatment failure, new adverse effect of FLT, recent antibiotic exposure, other clinical rationale such as additional diagnoses or concern for atypical infections, family request, or no documented reason. Sociodemographic characteristics were compared across categories. RESULTS: Among 18,507 ARI encounters, 1,506 (8.1%) received non-FLT. PALs accounted for 58.8% (n=886) of non-FLT prescribing. Recent antibiotic exposure was the second most common reason (n=265, 17.6%); however, only 9.8% of therapy escalations were guideline-concordant. Family requests accounted for 4.3% of non-FLT use. Non-FLT were more common in White children, those on Commercial insurance, and children who speak English as their primary language compared to their socioeconomic counterparts. No differences in reasons for non-FLT were observed by race, insurance type, or preferred language. Hispanic patients had a higher proportion of PAL-related non-FLT (71.4%) compared with non-Hispanic patients (58.3%). CONCLUSION: PALs and escalation of therapy were the predominant drivers of non-FLT prescribing in PUC. Family requests played a minimal role. Although we observed differences of non-FLT by race, language, and insurance as described previously, we did not observe differences in reasons for non-FLT between the different socioeconomic groups. Interventions aimed at improving PAL accuracy and guideline-concordant escalation practices may enhance appropriate FLT use.