Ocular Antibiotic Use in Young Danish Children From 2016 to 2024

Abstract

Ocular antibiotics are commonly prescribed to treat eye infections. Among young children, around half of acute conjunctivitis cases are bacterial, but distinguishing between viral and bacterial conjunctivitis can be challenging [1]. Most cases resolve spontaneously without treatment, although antibiotic treatment can modestly reduce symptom duration [1, 2]. Prescriptions may also be motivated by parental pressure and day care policies requiring treatment for re-entry, raising concerns about inappropriate use and antibiotic resistance [3]. To address such issues, Choosing Wisely programmes have been launched in over 30 countries. In Denmark, Choosing Wisely was established in 2020 as a collaboration between healthcare professionals and patient organisations [4]. The Danish initiative emphasizes consensus-based development of ‘do-not’ recommendations and local implementation. One of Choosing Wisely Denmark's key aims is to reduce unnecessary healthcare interventions, including antibiotic overuse. In support of a forthcoming Choosing Wisely recommendation in the autumn of 2025, this study analyses trends in ocular antibiotic use in Danish children from 2016 to 2024, extending previous work [5].

We conducted a nationwide descriptive drug utilization study using individual-level data on all redeemed prescriptions for ocular antibiotics in children under 6 years old, from 1 January 2016 to 31 December 2024.

From 2016 to 2024, 616 393 prescriptions for ocular antibiotics were issued to 343 096 children aged 0–5 years. In 2016, the prevalence was 322 per 1000 children aged 0–1 years and 128 per 1000 children aged 2–5 years (Figure 1a). Prevalence decreased sharply in 2020, coinciding with the onset of the COVID-19 pandemic, before gradually increasing in subsequent years, with a decrease again in 2024. By 2024, the prevalence was 172 per 1000 children aged 0–1 years and 70 per 1000 children aged 2–5 years, corresponding to prevalence ratios of 0.53 (95% confidence interval 0.53 to 0.54) and 0.55 (0.54 to 0.56) compared to the 2016 level.

Incidence trends mirrored prevalence, with a marked decline during the pandemic and a large rebound, particularly in 0- to 1-year-olds (Figure 1b). Peaks in the winter months were evident, and incidence was consistently higher among children aged 0–1 years. General practitioners issued 86% of treatment episodes.

The distribution of antibiotic types shifted over the study period (Figure 1c). Fusidic acid fell from 64% in 2016 to 34% by 2024. In contrast, chloramphenicol rose from 24% of prescriptions in 2016 to 74% in 2024. Tobramycin declined from 9.5% to 0%. Ciprofloxacin remained stable at around 5%.

In 2024, boys had higher IRs compared to girls across all age groups, although differences were attenuated with increasing child age (Figure 2a). The highest rate was observed in children aged 11–15 months with an IR of 310–351 per 1000 for boys and 260–297 per 1000 for girls. The IR decreased with age, reaching 53 per 1000 for boys and 48 per 1000 for girls by age 5. The number of antibiotic treatment episodes per child in 2024 also varied by age (Figure 2b). In the second year of life, 24% of children received at least one treatment episode, with 19% receiving only one, 3.8% receiving two and 0.9% having three or more treatment episodes. The fewest episodes were observed in 5-year-olds.

Regional variation was substantial. In 2024, the South, Zealand and North Regions had the highest IRs (137, 124 and 122 per 1000 children, respectively), while the Capital Region had the lowest (105 per 1000), corresponding to an incidence rate ratio of 1.30. Municipal rates ranged from below 80 to approximately 200 per 1000 (Figure 3).

This study highlights important trends in ocular antibiotic use among young Danish children from 2016 to 2024, supporting a Choosing Wisely Denmark recommendation. A steady decline in use from 2016 to 2019 was followed by a temporary reduction during the COVID-19 pandemic and a subsequent rebound, ending in a marked decline in 2024. We observed significant geographic variation, possibly linked to socioeconomic factors. These findings underscore the need for continued efforts to promote appropriate use. Addressing parental expectations, standardizing national guidelines, and reducing regional disparities could help optimize prescribing practices and limit unnecessary antibiotic use, thereby contributing to antimicrobial stewardship.

According to Danish law, studies based solely on register data do not require ethical approval.

The authors declare no conflicts of interest.