Natasha Halasa, MD, on influenza antiviral use declining among hospitalized children after the COVID-19 pandemic

Influenza antiviral use declined significantly among children hospitalized with laboratory-confirmed influenza following the COVID-19 pandemic, according to a multicenter surveillance study conducted across US pediatric hospitals. Despite longstanding clinical guidelines recommending antiviral treatment for all hospitalized children with influenza, prescribing rates fell compared with prepandemic levels, highlighting persistent gaps in guideline-concordant care.

Investigators analyzed data from 1,560 children hospitalized with laboratory-confirmed influenza between December 2016 and June 2023 through the New Vaccine Surveillance Network, a multicenter surveillance system spanning 7 US pediatric hospitals. Antiviral use ranged from 48.3% to 56.8% during prepandemic seasons but declined to 38.1% in the 2021–2022 season and 46.1% in the 2022–2023 season. Overall, antiviral prescribing was estimated to be 23% lower during the late pandemic period compared with prepandemic levels.

These findings occurred despite consistent clinical recommendations from the American Academy of Pediatrics and the Infectious Diseases Society of America to treat all hospitalized children with suspected or confirmed influenza with antivirals, regardless of symptom duration or risk status.

Pandemic-era changes in clinical decision-making

Investigators noted that antiviral prescribing patterns did not improve despite increased diagnostic testing during and after the pandemic. Natasha Halasa, MD, MPH, professor of pediatric infectious diseases at Vanderbilt University Medical Center and study investigator, said the findings were unexpected given increased attention to respiratory viral testing during the COVID-19 pandemic.

“We actually thought there would be an increase in antiviral use during the COVID-19 pandemic, because we actually saw that not only were people testing more frequently because they're getting in the habit of testing for SARS-CoV-2 to see if they had COVID-19 disease. And so, we actually were a little surprised that it went down. Part of that is that they may be doing more testing, but the issue may be that they may not be getting the results back in time for them to make a decision. Also, the perception that if they've been in there greater than 48 hours, that it, quote, unquote, may not work.”

Although antiviral therapy has demonstrated clinical benefit even when initiated beyond 48 hours in hospitalized patients, investigators observed lower prescribing among children with longer symptom duration at presentation. Symptom duration of 2 or more days was associated with lower odds of antiviral treatment.

Halasa emphasized that misconceptions regarding timing may contribute to undertreatment.

“When it comes to hospitalization, I think the timing needs to go away,” she said. “The recommendations from the American Academy of Pediatrics, as well as the Infectious Diseases Society, are to start antiviral treatment as soon as possible, even if they've had symptoms longer.”

Clinical severity and diagnostic confirmation influenced treatment decisions

The study identified several clinical factors associated with a higher likelihood of antiviral prescribing during the late pandemic period. Children with underlying medical conditions were twice as likely to receive antiviral therapy, and those admitted to the intensive care unit (ICU) also had significantly higher treatment rates. Clinical influenza testing was similarly associated with increased antiviral use.

Halasa noted that clinicians may be more likely to initiate treatment when disease severity is more apparent.

“One of the things that I believe is happening is ICU doctors are actually seeing the complications associated with influenza. And when they start to see the cases, and with reports that are out there that it could reduce complications, I think they’re more likely to want to start an antiviral, because I feel like that’s something that they can actually do. They can obviously do the supportive care, but when it comes to a medication, being more aware that they can actually use the antiviral when they’re not in the ICU and they don’t have an underlying medical condition, perception by some hospitals may feel that it may not have a direct benefit.”

However, antiviral prescribing remained inconsistent even among children with confirmed influenza diagnoses. Among clinically tested children with positive influenza results during the late pandemic period, fewer than half received antiviral therapy.

Halasa also suggested multiple factors may contribute to this gap, including clinician awareness and parental acceptance of treatment.

Significant variation across hospitals highlights opportunity for intervention

Investigators also found substantial variation in antiviral prescribing between hospitals, with more than 5-fold differences in treatment rates across study sites.

This variability suggests that institutional protocols and clinical workflows may influence prescribing behavior. Halasa described how clinical decision support tools may help improve guideline adherence.

“An example of what we’ve done to improve this at Vanderbilt was through a hospital medicine fellow, that basically, when there was someone who was hospitalized, and they had a test that was positive for influenza, the orders for an antiviral treatment actually just popped up right away, so you had to actively decline it. Also, working with your antimicrobial stewardship program, even though it’s for antibiotics, they’re also the ones who could potentially notify the groups that flu has been detected, and then an antiviral would be beneficial.”

Persistent gap between recommendations and clinical practice

The observed decline in antiviral use occurred despite continued influenza circulation and increased severity during recent seasons. Investigators noted that pandemic-related changes in health care delivery, diagnostic workflows, and clinical perceptions may have influenced prescribing patterns.

These findings highlight a persistent gap between clinical guidelines and real-world treatment practices. Because antiviral therapy can reduce complications, intensive care admission, and hospital readmission, improving adherence to treatment recommendations remains a priority.

Investigators concluded that targeted interventions, including clinician education, standardized treatment protocols, and decision support systems, may help improve antiviral use among hospitalized children with influenza and ensure consistent delivery of guideline-recommended care.

Disclosure

Halasa reports no relevant disclosures

Reference

Hamdan O, Amarin JZ, Antoon JW, et al. Influenza antiviral use in hospitalized children before and during the COVID-19 pandemic. Pediatrics. 2026;157(2):e2025071898. doi:10.1542/peds.2025-071898