The scale of the problem is striking. Globally, studies consistently estimate that 30 to 40 percent of pediatric antibiotic use is unnecessary, much of it driven by the treatment of viral upper respiratory tract infections that derive no benefit from antibacterial drugs. In Oman, a national multicenter audit found that 37 percent of pediatric antimicrobial prescriptions were inappropriate, with a disproportionate reliance on broad-spectrum agents such as third-generation cephalosporins. These agents, which include combinations like amoxicillin–clavulanate and later-generation cephalosporins, act against a wide range of bacteria, and their overuse accelerates the selection of resistant organisms while exposing children to avoidable adverse effects and higher costs.

Why do frontline settings struggle so much with appropriate prescribing? The review points to a convergence of pressures that clinicians in emergency and primary care know intimately. Diagnostic uncertainty is particularly acute in infants and young children, who often present with non-specific symptoms that make it difficult to distinguish a self-limiting viral illness from a bacterial infection requiring treatment. Limited access to point-of-care diagnostics compounds the problem, pushing clinicians toward empirical prescribing as a safety measure. Parental expectations add another layer: parents who believe antibiotics will speed their child’s recovery frequently request them, and time-pressed clinicians may comply. In Oman specifically, the authors note additional structural challenges, including variable prescribing autonomy across facilities, limited local antibiogram data in community settings, and inconsistent training in stewardship principles.

The stakes of getting this right extend far beyond individual prescriptions. Primary care clinics and emergency departments together account for approximately two-thirds of all antibiotic prescriptions for children worldwide, making them the central arena in which resistant pathogens are either contained or allowed to circulate. Without consistent stewardship across both community and emergency sectors, the review warns, resistant bacteria move freely between hospitals and outpatient environments, undermining public health gains achieved in any single setting. This interconnectedness means that a stewardship program confined to a tertiary hospital, however successful, cannot protect a population if prescribing practices in the clinics and emergency rooms that feed into it remain unchecked.

International guidance offers a clear framework. The American Academy of Pediatrics and the World Health Organization emphasize prescribing antibiotics only when bacterial infection is strongly suspected, favoring narrow-spectrum agents such as amoxicillin over broad-spectrum alternatives, providing safety-net or delayed prescriptions for mild self-limiting infections like otitis media, adopting short-course therapy of five to seven days for uncomplicated bacterial infections, and engaging families in shared decision-making about watchful waiting. Crucially, the evidence suggests these conservative approaches carry little clinical penalty: short courses and delayed prescriptions do not increase treatment failure rates, yet they can reduce overall antibiotic use by 25 to 30 percent. The WHO’s AWaRe classification, which sorts antibiotics into Access, Watch, and Reserve categories, provides a practical tool for monitoring whether prescribing patterns shift toward narrower agents.

The review catalogs a suite of interventions with demonstrated effectiveness. Continuous professional education combined with audit-and-feedback cycles has been shown to reduce inappropriate prescribing by 20 to 30 percent, though the authors caution that sustained behavior change requires institutional support and leadership engagement rather than one-off training events. Clinical decision support tools embedded in electronic medical records can deliver real-time alerts, weight-based dose calculators, and culture review prompts, offering scalability at the cost of potential alert fatigue and high implementation expenses. Rapid antigen detection tests for streptococcal pharyngitis, influenza, and respiratory syncytial virus help clinicians rule out bacterial causes at the point of care, reducing empirical antibiotic use, though they require investment and training. Local antibiograms—summaries of which pathogens resist which drugs—allow empiric therapy to be tailored to actual resistance patterns, but in Oman these remain more available in hospitals than in community and emergency settings. Multidisciplinary collaboration involving pharmacists, microbiologists, nurses, and infection control specialists rounds out the toolkit, fostering a stewardship culture that bridges inpatient and outpatient care.

Oman’s own experience provides some of the most encouraging data in the review. The Royal Hospital’s antimicrobial stewardship program achieved a dramatic reduction in multidrug-resistant organisms, falling from 2.8 to 0.6 per 1,000 patient-days, while generating annual cost savings estimated at 70,000 to 80,000 US dollars. These results, drawn from a national multicenter initiative, demonstrate that stewardship in the region is not merely aspirational but deliverable with measurable clinical and financial returns. The challenge now, the authors argue, is extending these gains beyond hospital walls into the pediatric emergency departments and primary care clinics where most prescribing actually occurs—and where, notably, no published data yet exists on stewardship outcomes specific to pediatric emergency care in Oman.

The policy scaffolding for such an extension already exists. Oman’s National AMR Action Plan for 2017 to 2022 rests on five pillars: public awareness and education, surveillance and research, rational antimicrobial use, infection prevention and control, and sustainable governance and coordination. These align closely with Oman Vision 2040, the country’s national development blueprint, which prioritizes health system resilience and digital transformation. Yet the review identifies persistent obstacles, including workforce shortages, inconsistent antimicrobial formularies across regions, and limited integration of stewardship data into electronic medical records. Although Oman is classified as a high-income country by the World Bank, the authors observe that some of its healthcare challenges resemble those of upper-middle-income settings, particularly regarding workforce capacity and digital infrastructure—a reminder that income classification alone does not guarantee implementation readiness.

Public behavior emerges as a critical frontier in its own right. In many communities, leftover antibiotics are stored at home, shared among family members, or taken without prescriptions, while parental perceptions that antibiotics accelerate recovery drive demand in clinics and emergency departments. The review highlights educational initiatives that have proven effective at correcting these misconceptions, including school-based programs, pharmacist-led counseling, and national media campaigns. Looking forward, the authors see promise in emerging digital technologies: artificial intelligence-driven clinical decision support, mobile applications, and e-prescription surveillance systems could transform pediatric stewardship, while expanding pharmacists’ roles to include stewardship counseling in outpatient and emergency settings represents an underutilized but impactful strategy. Community engagement through educational posters, digital waiting-room displays, and interactive family tools can reinforce responsible use between clinical encounters.

The review’s ultimate message is one of pragmatic optimism. The evidence base for reducing unnecessary pediatric antibiotic use is mature, the interventions are known, and Oman has already demonstrated that stewardship programs can deliver dramatic reductions in resistance alongside real cost savings. What remains is the harder work of systems integration: embedding evidence-based strategies into the daily workflows of busy emergency departments and primary care clinics, equipping clinicians with diagnostics and decision support, training the workforce in pediatric-specific protocols, and engaging families as partners rather than obstacles. If Oman succeeds in aligning its national AMR policies, Vision 2040 goals, and global best practices across these frontline settings, the authors conclude, it can serve as a regional exemplar for context-sensitive stewardship—and offer a template for the many health systems worldwide grappling with the same quiet crisis in their own waiting rooms.

Subject of Research: Antibiotic stewardship practices in pediatric emergency and primary care settings in Oman

Article Title: Antibiotic stewardship in pediatric emergency and primary care: a narrative review from Oman’s perspective

Article References: Antibiotic stewardship in pediatric emergency and primary care: a narrative review from Oman’s perspective. (n.d.). https://doi.org/10.1007/s44467-025-00006-5

Image Credits: AI Generated

DOI: 10.1007/s44467-025-00006-5

Keywords: antimicrobial stewardship, antimicrobial resistance, pediatrics, emergency medicine, primary care, Oman, antibiotic prescribing, clinical decision support, WHO AWaRe classification, delayed prescriptions, point-of-care diagnostics, public health