RSV rapid tests decrease inappropriate pediatric antibiotic prescriptions

Data published in JAMA Network Open indicate that respiratory syncytial virus (RSV) antigen rapid diagnostic tests (Ag-RDTs) are a useful tool for reducing inappropriate antibiotic prescriptions in children with viral lower respiratory tract infections (VLRTIs).¹

As one of the leading causes of VLRTIs, RSV has a significant burden toward pediatric health. Guidelines and antimicrobial stewardship efforts have been established, but antibiotics are still often prescribed to these patients. However, Ag-RDTs have spread in recent years because of the COVID-19 pandemic, advancing RSV diagnosis.²

“Although rapid tests are increasingly adopted in pediatric settings, evidence of their association with antibiotic prescribing for children in community settings remains scarce in the current literature,” wrote investigators.¹

Assessing antibiotic prescriptions

The cohort study was conducted to evaluate the link between RSV Ag-RDT implementation and antibiotic prescribing practices in pediatric primary care. Data was obtained from Pedianet, a network including more than 200 Italian family pediatricians. This covers approximately 4% of the pediatric population in Italy.

Participants included children aged 9 to 36 months with LRTIs between December 2023 and May 2024 with negative test results for RSV, influenza, and COVID-19 or a positive test result for RSV alone. VLRTIs were diagnosed based on International Classification of Diseases, Ninth Revision, Clinical Modification codes.

Cases underwent nasopharyngeal swab sampling followed by immediate Ag-RDT, which included a rapid antigen test. Exposures included the following:

• RSV-positive vs RSV-negative cases
• RSV-tested vs clinically diagnosed VLRTI cases
• RSV-positive vs clinically diagnosed VLRTI cases
• RSV-tested vs clinically diagnosed bronchiolitis cases in children aged less than 24 months
• RSV-positive vs clinically diagnosed bronchiolitis cases in children aged less than 24 months

Children were matched 1:1 in all scenarios but the first, with exposed children matched to unexposed children based on sex, age at diagnosis, and period of diagnosis. Prescriptions of an Anatomical Therapeutic Chemical dispensed within 14 days after the index date were defined as the primary outcome. The index date was defined as the day of diagnosis.

Demographics and prescription rates

There were 256 patients with VLRTIs aged a median 15.06 months included in the final analysis, 48.05% of whom were female and 51.95% were male. A positive RSV test was reported in 30.86% and a negative RSV test in 69.14%. A slight reduction in median age was reported among the latter group vs the former.

An average of 0.25 prescriptions per 10 person-days was reported in the overall population. This rate was slightly greater among RSV-negative cases vs positive cases, at 0.29 vs 0.18 per 10 person-days, respectively.

An antibiotic prescription was given to 20.25% of RSV-positive cases and 39.55% of RSV-negative cases. Additionally, the odds of receiving an antibiotic prescription within 14 days of the LRTI episode were reduced among RSV-positive cases, with a relative risk (RR) of 0.52.

The data indicated an overall reduction in antibiotic therapy risk from RSV Ag-RDT implementation among patients with any testing for VLRTIs vs those clinically diagnosed with VLRTIs, with an RR of 0.61 from 2023 to 2024 and 0.54 from 2022 to 2023. When focusing on RSV-confirmed VLRTIs, these RRs were 0.41 and 0.33, respectively.

Impact on infants and conclusion

An impact was also observed when the cohort was limited to infants younger than 24 months, though some comparisons had reduced statistical significance. For RSV Ag-RDT implementation vs clinically diagnosed bronchiolitis cases, the RRs in the 2022 to 2023 and 2023 to 2024 seasons were 0.56 and 0.75, respectively.

These results indicated RSV Ag-RDTs may be able to decrease the odds of pediatric patients being prescribed inappropriate antibiotics for LRTIs. Investigators recommended additional research to confirm their generalizability and evaluate their cost-effectiveness.

“By improving diagnostic accuracy at the point of care, Ag-RDTs can support more targeted treatment decisions and strengthen antimicrobial stewardship,” wrote investigators.

References

1. Boracchini R, Brigadoi G, Salvadori S, et al. RSV detection and antibiotic prescribing decisions for pediatric respiratory tract infections. JAMA Netw Open. 2026;9(3):e260409. doi:10.1001/jamanetworkopen.2026.0409
2. Mazur NI, Caballero MT, Nunes MC. Severe respiratory syncytial virus infection in children: burden, management, and emerging therapies.Lancet. 2024;404(10458):1143-1156. doi:10.1016/S0140-6736(24)01716-1