Antibiotic use in respiratory syncytial virus-positive children under two years: a prospective observational study at a tertiary hospital in Ghana

Introduction: Respiratory syncytial virus (RSV) is a major cause of lower respiratory tract infections in children, often leading to hospitalization in infants and vulnerable children. In low-resource settings where routine RSV diagnostics are unavailable, the overlap between clinical symptoms of RSV and those of bacterial pneumonia leads to unnecessary antibiotic use and contributes to the development of antimicrobial resistance. We conducted this study to evaluate the frequency and clinical determinants of antibiotic use among RSV-positive children under 2 years at a tertiary hospital in Ghana. Methods: We conducted a prospective observational sub-study nested within a longitudinal cohort of children at the Department of Child Health, Korle Bu Teaching Hospital, from June to November 2023. Eligible children aged <2 years with acute respiratory illness were enrolled and tested for RSV using molecular point-of-care testing. Antibiotic use and clinical characteristics were analyzed. Results: Of the 128 children enrolled, 72 (56.2%) tested positive for RSV. RSV-positive infants were significantly younger than RSV-negative infants (0-6 months vs. >6 months; p = 0.02). Among children with confirmed RSV infection, 48 (66.7%) received a total of 78 antibiotic prescriptions, although only 11 (23%) had clinically suspected bacterial co-infections. The most frequently prescribed antibiotic class was penicillins (38/78; 48.7%), followed by third-generation cephalosporins (17/78; 21.8%). Antibiotic use was significantly associated with indicators of disease severity, including hypoxia (p = 0.009), tachypnea (p = 0.015), dyspnea (p < 0.001), and hospital admission (p < 0.001). Independent predictors of antibiotic use were difficulty in breathing (OR 33.0, 95% CI 4.2-263.4; p = 0.001) and tachypnea (OR 9.3, 95% CI 1.4-60.9; p = 0.02). Discussion: Most RSV-positive children received antibiotics, often without confirmed bacterial co-infection. This highlights the need for antimicrobial stewardship, rapid diagnostics, and preventive strategies, such as maternal RSV vaccination, to reduce unnecessary antibiotic use and combat antimicrobial resistance in low-resource pediatric settings.