What are the causes of unnecessary antibiotic prescribing?

Why do parents seeking evaluation, reassurance and information about their child's cough end up with antibiotics from their GP? Research fellow Christie Cabral looks at the evidence.

GPs see a lot of children with respiratory tract infections (RTIs), usually presenting with a cough, high temperature or both. RTIs can be distressing and disruptive for children and parents but are mostly viral illnesses that will get better on their own: there is little that a GP can do to treat them.

However, many are prescribed unnecessary antibiotics that can lead to resistant bacteria. From our previous research, we know that parents often feel uncertain about the severity of an RTI and feel that it’s safer to consult a doctor.

They are usually seeking a medical evaluation, reassurance and information to help them understand and manage the illness. Parents often had a ‘no treatment’ preference, wanting to avoid giving their children unnecessary drugs.

Medical evaluation

Clinicians confirmed that overt pressure from parents for antibiotic treatment is rare. However, international studies of parents’ and clinicians’ communication within the primary care consultation have indicated that they may sometimes be talking at cross purposes about the seriousness of the illness.

This may lead clinicians to perceive that parents expect antibiotics, which in turn may influence clinicians to prescribe.

More recently, we videoed primary care consultations for children under 12 years with acute cough and RTI in six primary care practices selected to represent a range of neighbourhoods, both affluent and more deprived.

We then examined the interaction between parents and clinicians in 56 consultations, using the similar methods used in earlier studies, to see whether communication practices between parents and clinicians were related to decisions to prescribe antibiotics.

Communication with parents

We found no evidence of a link between parental communication practices and antibiotic prescribing. The most common pattern was for parents to give symptoms-based accounts of the illness and to accept the treatment recommendation given by the clinician.

The parental communication practices described by studies in the US, which imply lobbying for antibiotic treatment, were rare in this study. Prescribing rates for antibiotics are lower in the UK so this may be due to cultural differences in prescribing. Primary care patients in the UK have been shown to display an expectation of cautious prescribing for all types of treatment compared to the US.

When parents did suggest possible diagnoses or explanations up front, they may just be displaying their own expertise and justifying the need for a consultation. We know from our interview study that parents tried to create a shared understanding of the illness with the clinician, sometimes done by suggesting a serious diagnosis such as "chest infection" to ensure that this possibility was considered.

Parents sometimes asked questions about the illness or treatment towards the end of the consultation, when the clinician was trying to draw the interaction to a close.

This can be interpreted by clinicians as parents lobbying for antibiotics but from the nature of the questions observed and the interviews with parents, we can see that parents were seeking to understand more about the illness or suggested treatment. Pressure to explain may be experienced as pressure to prescribe, particularly in the time constrained context of UK primary care.

GP antibiotic prescribing

Where clinicians did prescribe antibiotics, they voiced concern about symptoms or signs, including chest pain, discoloured phlegm, prolonged fever, abnormal chest sounds, or pink or bulging ear drums, although few of these are good indicators of a bacterial infection.

This can influence parents to perceive these symptoms as indicative of a more severe illness that needed antibiotic treatment. Although parent communication practices may not have been associated with antibiotic prescribing in this UK study, clinician communication is an important influence on parent beliefs about RTI, which in turn drive high consulting rates for RTI in children.

Antibiotic prescribing for children with RTI in this UK study appears to be influenced mainly by clinicians’ reported interpretation of the symptoms and signs. However, there is clinical uncertainty about the prognosis for RTI in children and hanging over all clinicians is the dreadful prospect of missing a child who subsequently develops a serious or even fatal illness.

Clinicians feel it´s safer to prescribe antibiotics if there are any symptoms that might indicate a more serious infection.

This body of work enables us to see a well-intentioned but unfortunate positive feedback loop that contributes to high antibiotic prescribing rates for children with RTI. Uncertain parents bring their children for an evaluation.

Clinicians prescribe ´just in case´ and link this to common symptoms. Parents consult for similar symptoms in the future. Both are doing their best to ensure the health and safety of the child.

The over-prescription of antibiotics is a ‘wicked problem’ and will require a range of initiatives to tackle it.

What could help?

It may help if both parents and clinicians are better informed before the consultation. Information for parents can be limited or hard to find, so, in collaboration with parents, we compiled ‘Caring for children with coughs’ to address their key information needs.

We also created a short training video for clinicians to help them understand what parents are seeking from a consultation. A future intervention to improve communication within the consultation to try to weaken the feedback loop may also be needed.

Christie Cabral is a research fellow at the Centre for Academic Primary Care at the University of Bristol

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