It's a Tuesday morning, and you're getting your toddler ready for daycare. But as you brush her hair into a ponytail, you notice that her cheeks are flushed, her nose is runny and her breathing is phlegmy. Instead of daycare, you head to your pediatrician, who offers a solution: a prescription for antibiotics.
That's why, in recent years, there's been a huge push in many countries to raise awareness of antibiotic misuse among doctors and to reduce the overprescription of these drugs. In Japan, the government noticed that the country's pediatricians were prescribing too many antibiotics, especially to young children, and offered them a financial incentive to break the habit.
Understanding why a fairly modest incentive of 800 yen (about $5) a visit is so effective requires unpacking why Japanese doctors overused antibiotics in the first place. If doctors face similar pressures stateside, maybe the same strategy could work here too.
I spoke with Fumie Kuchiba, a mother whose daughter can be seen here playing with a toy doctor's kit. Kuchiba and other Japanese parents told me about their views on antibiotics and pediatric care. (Image credit: Nicoletta Lanese)For decades, it was common in Japan to routinely prescribe antibiotics for sniffles and tummy bugs, Dr. Takemi Murai, deputy head of the Infectious Diseases Division at Nagano Children's Hospital in Azumino, told me. That's in part because medical education there didn't emphasize the risk of "superbugs," meaning bacteria that can withstand many antibiotics.
There also may be a generational divide, Dr. Tatsuki Ikuse, a pediatric infectious disease specialist at the National Center for Child Health and Development in Tokyo, told me. Ikuse, who finished medical school in 2013, suspects that older doctors "experienced many cases of bacterial infections when there was no vaccination."
Dr. Tatsuki Ikuse, a pediatric infectious disease specialist, said parents sometimes request antibiotics for their children when the drugs are not needed. "I try to convince them and try not to prescribe antibiotics as much as possible," he said, "but I think some doctors cannot convince them and end up prescribing antibiotics." (Image credit: Nicoletta Lanese)Surveys conducted in Japan suggest that doctors under 50 are more likely than doctors over 50 to see antimicrobial resistance as an urgent issue. Clinic doctors — those likeliest to see kids as outpatients for acute illnesses — also skew older than doctors in hospitals; in 2024, clinic doctors averaged about 60 years old, while those in academic and nonacademic hospitals averaged 40 and 48 years old, respectively.
Murai agreed with that sentiment. "If doctors saw a fever and a high CRP level [a sign of inflammation], they prescribed antibiotics," Murai said. "Doctors were following such a practice for a long time, so they didn't question it."
Is antibiotic misuse still a problem in the U.S.?
Young children in the U.S. were once the most likely group to receive unneeded antibiotics, but now, those unnecessary prescriptions have "dropped dramatically," Dr. Sarah Kabbani, director of the U.S. Centers for Disease Control and Prevention's (CDC) Office of Antibiotic Stewardship, told me in an email.
Japan has also decreased its overall antibiotic use in younger populations, halving its outpatient prescription rates for patients under 20 between 2011 and 2022, Dr. Yusuke Okubo, division chief of clinical epidemiology and health services research at the National Center for Child Health and Development in Tokyo, told me.
"I was taking antibiotics quite often" as a kid, Tatsuya Kanno, a software engineer and father of two in Tokyo, told me. "Nowadays, we don't get really prescribed those antibiotics easily."
Brown's pediatrician actually has an explicit policy on their website stating that they don't overprescribe antibiotics and instead follow evidence-based guidelines to determine when the drugs are truly necessary. I've found a number of other U.S. pediatric clinics that do the same.
Pediatricians in the U.S. have greatly improved their use of antibiotics over the years, but still, not all antibiotics that children get prescribed are actually needed. (Image credit: Halfpoint Images via Getty Images)
"Antibiotic stewardship was a core tenant of my residency training 20 years ago," Dr. Morgan Leafe, a U.S.-based pediatrician who worked in inpatient and outpatient settings for 11 years after residency, told me in a direct message. "So I would say it's not new in pediatrics."
Prescription rates vary widely among states and among different types of outpatient facilities, such as community practices versus those affiliated with academic medical centers. Rural communities often use antibiotics at higher rates and log more inappropriate use, compared with urban areas. These regional variations are "not explained by clinical factors," said Julia Szymczak, a medical sociologist and associate professor in the Division of Epidemiology at the University of Utah School of Medicine.
It may be that urgent cares are more likely to prescribe antibiotics for conditions that they're explicitly not recommended for. One national analysis found that urgent cares prescribed antibiotics for 20% of allergy cases, 42% of viral upper respiratory infections and 52% of uncomplicated ear infections, while doctor's offices wrote far fewer of these inappropriate prescriptions. Other studies highlight similar patterns.
Dr. Yusuke Shibata, who runs the clinic pictured above, notes that children's caregivers don't often understand that antibiotics are specifically used for bacterial infections. (Image credit: Nicoletta Lanese)
Japan's nationalized healthcare provides a staggering degree of choice, because insurance coverage doesn't tie you to specific clinics or require you to get referrals to access certain care. Young children's care is virtually free thanks to national and local subsidies. So on paper, parents can easily shop around for a pediatrician that best suits their family's needs, as well as pop into any healthcare facility with flexibility should the need arise.
"In the U.S. and in Switzerland, they try to get to know you and know your child," said Reid, a fundraiser and father of two based in Okinawa, who recently moved to Japan with his sons and husband. "They don't at all in Japan."
In some ways, pediatric clinics in Japan can be considered more analogous to urgent care in the U.S., in that they're intended to address acute cases of illness as they emerge. For more serious illnesses, caregivers bring their children to hospitals, parents in Japan told me.
Diagnostic uncertainty
The Karugamo Clinic in Tokyo (pictured here) is run by Dr. Atsushi Miyahara, a pediatrician who consistently uses the government incentive aimed at improving antibiotic use. (Image credit: Nicoletta Lanese)
The criteria enable doctors to "feel reassured" that they've correctly classified an infection as viral or bacterial, even in the absence of a highly sensitive diagnostic test, said Dr. Ilan Shapiro, a community pediatrician at AltaMed Health Services, a nonprofit health network in Southern California.
"For strep throat, we never treat [give antibiotics], now, without a positive test," said Dr. Jennifer Shu, a pediatrician with Children's Medical Group, a group of pediatric offices in the Atlanta metropolitan area. (That said, electronic medical records suggest that not all doctors' offices use these tests before prescribing antibiotics, despite these recommendations.)
Shu's practice also uses a 45-minute test that looks for multiple viruses and bacteria in the nose and throat, including the bacteria behind whooping cough and Mycoplasma, which causes "walking pneumonia." Not all clinics use this type of test, though, because they require a special certification and equipment to run on-site, Shu said.
The lack of quick, surefire diagnostic tests for bacterial infections can leave doctors with a degree of uncertainty, which can sometimes prompt unnecessary prescriptions, Szymczak said.
In both countries, doctors must make diagnoses and treatment plans in a limited amount of time. "Pediatric outpatients in Japan are very busy and can only secure a few minutes for each patient," Ikuse told me.
"I had a pediatrician who said they had — I can't remember the figure — but it was like 800 seconds for a sick visit," said Szymczak, who studies the factors that drive clinicians to misuse antibiotics. "They broke it down into seconds."
Doctor shopping and bad reviews
One factor driving antibiotic misuse that might be unique to Japan is the competition between clinics and the customer service culture it motivates.
But across all settings, families can still flexibly choose which clinic they go to. Meanwhile, pediatricians in Japan, who make less than their peers who care for adults, can worry about losing clients to nearby practices.
Dr. Yusuke Okubo of the National Center for Child Health and Development said that, historically, doctors were often wary of bad clinic reviews and also fearful of a patient's prognoses getting worse if they denied them antibiotics. (Image credit: Nicoletta Lanese)Parents frequently used to demand antibiotics from their children's pediatricians, Okubo added. "Ten years ago, it was a common situation," he told me.
"They'll say, 'Well, last time they took an antibiotic they got better faster, the next day,'" Shu said. Because mild viral infections often go away on their own in a few days, that timing could have just been a coincidence, but it leaves an impression on the caregiver nonetheless.
Tatsuya Kanno, a father of two in Tokyo, said he recently learned about antibiotic resistance through a television program. He said he'd learned that using too many antibiotics could cause bacteria to gain strength while the drugs become less effective. (Image credit: Nicoletta Lanese)Kanno once brought his daughter into a clinic after she developed a bad cough after catching the flu. Their doctor prescribed antibiotics, and the cough resolved within days. Later, Kanno's son had similar symptoms, but the doctor didn't recommend an antibiotic in his case. When his son's coughing and wheezing persisted, "I asked him to prescribe that antibiotic, the same one that my daughter took," Kanno said.
Szymczak's research has identified this "it-helped-last-time" bias as a common driver of patients' antibiotic requests that can be difficult for doctors to negotiate.
"I don't think parents generally understand that antibiotics don't work for colds, much less [understand] antibiotic resistance," said Dr. Yusuke Shibata of the Shibata Pediatric Clinic in Tokyo. "Explaining antibiotic resistance to parents is difficult," though he still tries to do so, he told me in an email after I visited his clinic.
Risa, a mother of two in Saku, generally prefers to limit her children's exposure to medications in the interest of strengthening their immunity. But if their symptoms seem serious or long-lasting, she brings them to a doctor to see if medicine is needed. (Image credit: Nicoletta Lanese)
Tomomi Sato*, a New York City-based teacher and mother of two who lived in Japan as a child, said she'd heard that taking antibiotics too often could make it so your body didn't respond to them well in the future. She likened it to an urban legend about roaches that she heard from her mother and others from her hometown of Tokyo.
Some parents are cautious about overusing medications in general but don't worry about antibiotic resistance, specifically.
Fumie Kuchiba and her three-year-old daughter play on the floor of their living room in Saitama. Kuchiba trained as a pharmaceutical salesperson and understands that antibiotics only treat bacterial infections. She said she doesn't think most parents consider the germ at play in a given infection. (Image credit: Nicoletta Lanese)
Risa told me she thinks antibiotics may be medically appropriate when an illness is particularly severe or prolonged. She doesn't weigh whether the cause is likely viral or bacterial, even though antibiotics don't treat viral illnesses.
Other parents have a clear sense of the threat resistance poses.
Difficult conversations
When parents seek an antibiotic that isn't medically needed, that can prompt difficult conversations with their children's doctors.
Some studies find that, when a pediatrician withholds antibiotics and a parent questions them, doctors can perceive that as negative pushback and give the drug against their initial judgment. But if a pediatrician denies antibiotics while also providing guidance for symptom relief, that conflict can be avoided and prescription becomes less likely.
These conversations take time, and they can stir up conflict, which Shapiro said he's grown more comfortable navigating over his career. Early on, "you don't want conflict; you feel that conflict is bad, and you want everybody to be happy," he said. But ultimately, "the objective is for them to be healthy."
Nicoletta LaneseNicoletta Lanese
Similarly, Japanese parents told me their doctors don't often say whether or why they suspect an infection is viral or bacterial — a clarification that might help caregivers feel more comfortable forgoing an antibiotic.
Some doctors in Japan who claim the incentive provide verbal explanations about resistance or give parents a slip of paper that explains the basics and includes links to further information. Dr. Atsushi Miyahara of the Karugamo Clinic in Tokyo told me that, over time, his clients have become more knowledgeable about antibiotics, and insurance data related to the incentive also hints that this learning takes place. But it's unclear if these interactions can always move the needle.
Parents I spoke to who understood that antibiotics only treat bacterial infections added that it can be frustrating that there aren't many medicines available for viral ailments. Waiting for an infection to clear up can be stressful because you don't want your child to suffer, parents said, and the sickness also disrupts the family's normal routine of work, school or daycare.
In both countries, pediatricians feel pressure to leave caregivers satisfied. While clinics in the U.S. aren't necessarily competing for patients in the same way Japanese clinics are, there is still a degree of customer service at play, Szymczak said. "That clinical encounter is very transactional, particularly in the United States," she said.
Could incentives motivate change?
Related storiesJapan's bold experiment to curb antibiotic misuse has been a huge success. Could it work in the US?'800 seconds for a sick visit': Some factors driving antibiotic resistance have nothing to do with biology, says medical sociologist Julia SzymczakHow fast can antibiotic resistance evolve?
Similar dynamics are at play in both countries, with parents and pediatricians in both places dealing with similar issues. But while these pressures are similar in the clinic, a key difference sets America's situation apart: Our complex healthcare system, funded through a patchwork of insurers, can be difficult for patients and doctors to fully trust.
Editor's note: The names of some parents quoted in this story have been abbreviated or changed to protect their privacy. Altered names are marked with asterisks (*).
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