Addressing the Silent Pandemic: The Role of Italian Primary Care Paediatrics in Combating Antimicrobial Resistance

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The discovery of penicillin by Alexander Fleming in 1928 marked the beginning of the antibiotic era [1]. Since then, the development of antimicrobial agents has transformed modern medicine, yet each new antibiotic has been accompanied by the inevitable emergence of bacterial resistance [1]. In response to this threat, the Infectious Diseases Society of America (IDSA) formally introduced in 2007 the concept of antimicrobial stewardship programs (ASPs), defined as a coordinated set of interventions aimed at optimising antimicrobial use—choosing the right agent, dose, route and duration—without compromising patient outcomes [1, 2]. The Italian Ministry of Health launched the first National Action Plan on Antimicrobial Resistance (PNCAR) in 2017, establishing a multisectoral task force that included family paediatricians, thereby recognising the key role of primary care in antimicrobial resistance (AMR) containment. In Italy, AMR is estimated to cause over 11 000 deaths each year—accounting for one-third of all AMR-related deaths in Europe, with a significant proportion occurring in younger individuals [2]. In this context, family paediatricians are pivotal. Their trusted relationships with families position them as central figures in promoting judicious antibiotic use and raising public awareness about infection prevention. The most recent AIFA National Report on Antibiotic Use in Italy (2023) underscores critical and persistent issues in paediatric prescribing, placing renewed responsibility on primary care paediatricians [3]. In 2023, 40.9% of children aged 0–13 years received at least one systemic antibiotic—up from 33.7% in 2022. Many of these prescriptions were deemed inappropriate, particularly among children aged 2–5 years, in whom viral infections are the most common cause of fever and respiratory symptoms [3]. There has also been a notable decline in adherence to clinical guidelines, coupled with increased use of broad-spectrum antibiotics. Only 54.4% of prescriptions were from the WHO ‘Access’ group, well below the EU's 65% target [2, 4]. Significant regional disparities persist; in Northern Italy, 37.7% of children receive antibiotics, compared to 44.1% in the South [4]. Moreover, broad-spectrum antibiotics such as macrolides and third-generation cephalosporins are heavily overused in southern regions, while narrower-spectrum penicillin remains more common in the North [4]. The amoxicillin/amoxicillin-clavulanate ratio—an established quality indicator—is 0.61 in the North but just 0.20 in the South [4]. Even more striking is the broad-to-narrow spectrum antibiotic ratio: 10.9 in the South versus 2.8 in the North, highlighting how Italy continues to lag behind European benchmarks [4]. These findings cast serious doubt on whether the PNCAR 2022–2025 target of a ≥ 20% reduction in this ratio can be met [4]. A prospective observational study in Italy (Picca et al.) between 2019 and 2021 examined antibiotic prescribing practices among family paediatricians for children with respiratory tract infections. Amoxicillin-clavulanate emerged as the most frequently prescribed agent, and bronchitis—typically viral—accounted for 73% of inappropriate prescriptions. Fever alone tripled the likelihood of antibiotic use, even in cases not requiring it [3]. These findings align with the 2023 AIFA report, which recorded a 5.4% increase in systemic antibiotic use compared to 2022, undermining the PNCAR goal of a 10% reduction by 2025 [4]. An emerging concern is the growing role of Service Pharmacies, introduced by Decree Law No. 73 (June 7, 2024). While they offer rapid diagnostic testing (e.g., SARS-CoV-2 and group A streptococcus antigen detection, CRP), the lack of physician oversight often leads to antibiotic prescriptions based solely on test results, bypassing essential clinical judgement. These interventions aim to align community prescribing practices with national and global AMR containment goals [4] and funds from the National Recovery and Resilience Plan (NRRP) were allocated—as established by Ministerial Decree No. 226 of 29 July 2022—to support the purchase of diagnostic equipment for General Practitioners (GPs) and Family Paediatricians. However, these funds have not yet been used. On March 27, 2025, the Italian Ministry of Health submitted for approval the draft agreement between the Government, Regions and Autonomous Provinces to allocate €120 million for the implementation of the PNCAR 2022–2025 (€40 million per year from 2023 to 2025). This investment will support surveillance, prevention and appropriate antibiotic use through a cross-sectoral approach aligned with the WHO's One Health framework, integrating human, veterinary and environmental health. The ECDC Annual Epidemiological Report 2023 provides a sobering overview of AMR in Europe, with Italy among the most affected nations. Southern and southeastern Europe report the highest incidence of bloodstream infections caused by multidrug-resistant organisms. In Italy, carbapenem-resistant Klebsiella pneumoniae, MRSA and vancomycin-resistant Enterococcus faecium (VREfm) are of particular concern, with VREfm prevalence exceeding 20%. Alarming levels of carbapenem resistance are also reported in Pseudomonas aeruginosa and Acinetobacter baumannii [2, 4]. Europe faces approximately 25 000 AMR-related deaths annually, with healthcare and productivity costs nearing €1.5 billion [4]. Meanwhile, in the United States, outpatient antibiotic prescribing remains widespread, particularly among young children, who receive over 65 million prescriptions annually—at least 29% of which are unnecessary [5]. To evaluate the appropriateness of antibiotic prescribing among family paediatricians in Italy, an online survey was conducted among 601 paediatricians [(601/6706 family paediatrician active in Italy; 9%) [6]] enrolled across regions of the country. All family paediatricians affiliated with FIMP (Italian Federation of Pediatricians) were recruited through an informative email regarding the study objectives and design. Each paediatrician could voluntarily and freely access the questionnaire, and answers were anonymously recorded. Participants were asked which antibiotic and treatment duration they would prescribe in three clinical scenarios: pharyngitis with a positive rapid antigen detection test (RADT) for group A Streptococcus (GABHS), acute otitis media (AOM) and community-acquired pneumonia (CAP). Data were subsequently entered into an electronic database and analysed. For GABHS pharyngitis, 81.9% of physicians prescribed amoxicillin, but 16.7% used amoxicillin-clavulanate (Figure 1). A 10-day course was most frequent (63.9%), although 31.8% opted for 6 days. In AOM, amoxicillin-clavulanate was the most prescribed antibiotic (49.9%), followed by amoxicillin (44.6%) (Figure 1); treatment lasted ≥ 6 days in over 90% of cases. For CAP, amoxicillin-clavulanate (33.1%), amoxicillin (30.1%) and macrolides (34.5%) were most frequently prescribed (Figure 1). Treatment was prolonged in most cases, with 62.1% prescribing 10 days and 15% up to 15 days. Our study reveals a persistently widespread use of amoxicillin-clavulanate for both GABHS pharyngitis and acute otitis media (Figure 1). A recent Italian intersociety consensus (2024) [7] recommended amoxicillin as the first-choice antibiotic for children with GABHS pharyngotonsillitis (Table 1). Given the lack of robust evidence, the recommendation for a 10-day course of therapy is conservatively maintained, particularly considering the increased risk of acute rheumatic fever in several Italian regions. Amoxicillin 50 mg/kg/day divided into two administrations may be recommended In patients with suspected penicillin allergy the alternative antibiotic regimen are third-generation cephalosporin or macrolides [7] 10 days 5 days with third-generation cephalosporin or macrolides 1st choice: Amoxicillin 80–90 mg/kg/day in three divided doses; 2nd choice: Amoxicillin +clavu

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