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Previous studies showed variability in the use of diagnostic and therapeutic resources for children with febrile acute respiratory tract infections (ARTI), including antibiotics. Unnecessary antibiotic use has important public and individual health outcomes, but missed antibiotic prescribing also has important consequences. We sought to determine factors associated with antibiotic prescribing in pediatric ARTI, specifically those with pneumonia.We assessed national trends in the evaluation and treatment of ARTI for pediatric emergency department (ED) patients by analyzing the National Hospital Ambulatory Medical Care Survey from 2002 to 2013. We identified ED patients aged ≤ 18 with a reason for visit of ARTI, and created 4 diagnostic categories: pneumonia, ARTI where antibiotics are typically indicated, ARTI where antibiotics are typically not indicated, and “other” diagnoses. Our primary outcome was factors associated with the administration or prescription of antibiotics. A multivariate logistic regression model was fit to identify risk factors for underuse of antibiotics when they were indicated.We analyzed 6461 visits, of which 10.2% of the population had a final diagnosis of pneumonia and 86% received antibiotics. 41.5% of patients were diagnosed with an ARTI requiring antibiotics, of which 53.8% received antibiotics. 26.6% were diagnosed with ARTI not requiring antibiotics, of which 36.0% received antibiotics. Black race was a predictor for the underuse of antibiotics in ARTIs that require antibiotics (OR: 0.72; 95% CI: 0.58–0.90).For pediatric patients presenting to the ED with pneumonia and ARTI requiring antibiotics, we found that black race was an independent predictor of antibiotic underuse.