Changing Empirical Antibiotic Prescribing Patterns Through a Clinical Decision Support System in Outpatient Paediatric Care in Italy: A Multicentre, Quality-Improvement Study

Background/Objectives: Respiratory tract infections (RTIs) represent one of the most frequent reasons for antibiotic prescribing in paediatric primary care. Clinical decision support systems (CDSS) offer a strategy to promote guideline-concordant prescribing, but evidence from real-world implementation remains limited. Methods: We conducted a cluster-level controlled before-and-after quality-improvement study among 15 family care paediatricians of an Italian paediatric primary care network. Antibiotic prescriptions for RTIs in children aged < 14 years were compared between November 2023–April 2024 and November 2024–April 2025 across three groups: CDSS only, CDSS plus multilingual caregiver leaflets, and no intervention. The CDSS, integrated into the software where health records were recorded, provided guideline-based treatment pathways and weight-based dosing. Episodes were identified via ICD-9-CM codes and validated free text in the Pedianet database; log-binomial regression estimated relative risk with 95% CI. Within-paediatrician correlation was accounted for in the analysis using a cluster-robust variance estimator. Results: A total of 7138 RTI episodes were included. The availability of a CDSS integrated into the electronic health record system was associated with an increased use of guideline-recommended first-line antibiotics for RTIs, although the increase in the use of amoxicillin reached statistical significance only for CAP in both intervention groups. Non-prescription rates remained unchanged across the intervention groups. The control group also showed temporal changes, including increased non-prescription for pharyngitis and reduced amoxicillin use for CAP. Conclusions: CDSS integration was associated with increased first-line antibiotic use for certain conditions. However, its limited effect on overall prescribing volume underscores the persistent role of diagnostic uncertainty. Future stewardship strategies may benefit from combining CDSSs with point-of-care testing and behavioural interventions.