Comparative Effects of Antimicrobial Stewardship Interventions on Pediatric Antibiotic Prescribing: A Systematic Review of Randomized Controlled Trials.

Acute respiratory tract infections (ARTIs) are a major driver of antibiotic prescribing in pediatric outpatient care, much of which is inappropriate. Multiple randomized trials have evaluated antimicrobial stewardship interventions; however, the consistency of effects across different intervention mechanisms remains unclear. We conducted a systematic review of randomized and cluster-randomized controlled trials evaluating interventions aimed at reducing antibiotic prescribing for pediatric ARTIs in outpatient and primary care settings. Searches were performed in PubMed, Embase, the Cochrane Library, and Google Scholar from inception to January 2026. Due to substantial clinical and methodological heterogeneity, findings were synthesized narratively. Eight randomized controlled trials were included. Intervention effects were heterogeneous, with strategies incorporating accountability and performance feedback demonstrating more consistent directional effects toward reduced or more appropriate antibiotic use. In contrast, shared decision-making, communication-based, diagnostic-guided, and stand-alone digital interventions showed mixed or neutral effects. Where reported, reductions or neutral effects were not associated with increased reconsultation, hospital admission, or symptom deterioration. Interventions incorporating accountability mechanisms demonstrated more consistent influence on pediatric antibiotic prescribing than single-component strategies, supporting the use of multicomponent antimicrobial stewardship approaches in outpatient pediatric care.