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NIHR Signal Clinicians prescribe antibiotics for childhood respiratory tract infection based on assessment, rather than parental expectation

Published on 24 October 2019

doi: 10.3310/signal-000829

Implied parental expectation of antibiotic prescription does not appear to affect clinician prescribing for childhood respiratory tract infection in primary care. Parents typically accept clinicians’ treatment recommendations based on symptoms and signs, with a minority seeking further home care advice.

This NIHR-funded analysis of 56 videoed primary care consultations is the first such study to be carried out in the UK, covering diverse populations from both deprived and affluent neighbourhoods in England.

The study found that parents rarely use language that implies that they expect antibiotics to be prescribed. Parents mainly describe their child’s symptoms, suggesting that they are looking for a medical assessment rather than a pre-specified diagnosis or treatment.

Antibiotic prescribing was linked to the risk of serious illness based on clinician-observed symptoms and signs in this study. This suggests that interventions to improve prescribing for childhood respiratory tract infection in primary care will need to focus on tools that help rapidly determine which children will or will not benefit from antibiotics.

  •   Child Health, Infections, Medicines, Public and patient involvement, Respiratory disorders, Primary care
Clinicians prescribe antibiotics for childhood respiratory tract infection based on assessment, rather than parental expectation

Why was this study needed?

Estimates suggest that antibiotics are overprescribed in general practice compared with ideal levels based on guidelines and expert opinion. This overprescribing can contribute to increasing antibiotic resistance.

Data from English primary care settings suggest that overprescribing of antibiotics is particularly pronounced for respiratory tract conditions. For example, only about 25% of antibiotic prescriptions for acute cough in patients without comorbidities were considered necessary.

There have been concerns that perceived expectation from parents during consultations might influence clinicians’ decisions to prescribe antibiotics for children. While this possibility has been studied in other countries, it has not been explored in the UK.

This study aimed to fill this gap by exploring associations between parent-clinician communication and antibiotic prescribing for children with respiratory tract infection in primary care in England.

What did this study do?

This NIHR-funded mixed-methods study used conversation analysis and descriptive quantitative analysis of 56 video-recorded consultations in six general practices in the south-west of England. All consultations took place in 2013 and related to children aged under 12 years with acute cough and respiratory tract infection.

The practices selected were from a range of neighbourhoods, including deprived and affluent areas. Thirteen clinicians took part, including nine general practitioners, three nurse practitioners and one physician assistant.

Fifty-six parents accompanying 60 children aged three months to 12 years agreed to participate, representing a 72% response rate. Thirteen consultations included non-native English speakers. Just over a third (36%) of parents identified as non-white ethnicity.

The study design was guided by a Public and Patient Involvement Group of local parents.

What did it find?

  • Overall, the results did not suggest a link between parents’ communication behaviour and antibiotic prescribing.
  • Fifteen parents (27%) used language that implied a possible need for or expectation of antibiotic treatment. This included suggesting a possible diagnosis such as “chest infection”, or specifying symptoms such as being “phlegmy … right on the chest”. These cases were not associated with higher rates of antibiotic prescription (13% in these consultations compared with 24% in all other consultations).
  • No expectation of antibiotic treatment was apparent from the language used by 73% of parents (n=41). In these instances, parents described their child’s symptoms only (40%), suggested that the cause might be viral (20%) or gave possible explanations for symptoms (such as coughing so much that it caused vomiting, 13%).
  • Antibiotics were prescribed in 12 cases (21%). In 11 cases, this was linked to specific clinical observations. Eight (14%) antibiotic prescriptions were for immediate use linked to chest examination sounds, chest pain, yellow phlegm or ear infection. In four consultations (7%) delayed antibiotic prescriptions were given in case symptoms such as fever did not resolve.
  • In most cases, the parent either briefly acknowledged (77%) or actively agreed with the clinician’s treatment recommendation (5%). In six cases the parent responded to the treatment recommendation with a question, mainly to clarify home care advice. In one case of a “no antibiotic” recommendation, the parent questioned what to do after the recommended five-day “watch and wait” period, given that accessing same day appointments was problematic. In this case the clinician gave a delayed antibiotic prescription.

What does current guidance say on this issue?

NICE has produced a guideline on prescribing antibiotics for self-limiting respiratory tract infections (2008). It recommends that a no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for patients with conditions such as acute cough or bronchitis. The guideline gives advice on identifying those patients who are likely to be at risk of developing complications, and therefore need an immediate antibiotic prescription and/or further investigation and management.

NICE also has individual guidelines aiming to ensure appropriate antibiotic prescribing for cough, otitis media, sinusitis, and sore throat, as well as a quality standard on general antimicrobial stewardship.

What are the implications?

This study identified little evidence of parental demand for prescription of antibiotics for children with respiratory tract infection. Parents mainly appeared to be seeking the clinician’s assessment of their child’s condition rather than a prescription of specific drugs.

Although based on a small set of observations, the results support the continued efforts to find better ways to differentiate mild from serious illness.

Citation and Funding

Cabral C, Horwood J, Symonds J et al. Understanding the influence of parent-clinician communication on antibiotic prescribing for children with respiratory tract infections in primary care: a qualitative observational study using a conversation analysis approach. BMC Fam Pract. 2019;20(102).

This project was funded by the NIHR School for Primary Care Research Programme (project number SPCR204).

Bibliography

NHS website. Antibiotic resistance. London: NHS Digital; 2019.

NICE. Antibiotic stewardship. QS121. London: National Institute for Health and Care Excellence; 2016.

NICE. Respiratory tract infections (self-limiting): prescribing antibiotics. CG69. London: National Institute for Health and Care Excellence; 2008.

NICE. Otitis media (acute): antimicrobial prescribing. NG91. London: National Institute for Health and Care Excellence; 2018.

NICE. Sore throat (acute): antimicrobial prescribing. NG84. London: National Institute for Health and Care Excellence; 2018.

NICE. Cough (acute): antimicrobial prescribing. NG120. London: National Institute for Health and Care Excellence; 2019.

NICE. Sinusitis (acute): antimicrobial prescribing. NG79. London: National Institute for Health and Care Excellence; 2017, checked April 2019.

Expert commentary

Children with respiratory tract infections are often prescribed antibiotics. Doctors sometimes assume that parents, when they present with a child with an acute illness, attend with the expectation of receiving an antibiotic prescription.

This study showed that this was not generally the case, and in most consultations, there was no expectation from the parent of an antibiotic prescription for their child.

Doctors should continue to base decisions on whether to prescribe an antibiotic to children on the clinical presentation, in line with guidance that aims to improve the appropriateness of antibiotic prescribing.

Professor Azeem Majeed, Professor of Primary Care and Head of the Department of Primary Care & Public Health, Faculty of Medicine, School of Public Health, Imperial College London

The commentator declares no conflicting interests

Expert commentary

Although the data is six years old now, and much has changed in this time, these findings reflect my experience in practice.

Parents rarely ask for antibiotics and increasingly seem less concerned when they are not offered.

This research highlights the need to focus on the decision-making of clinicians, rather than the parents, in order to ensure antibiotics are only prescribed when needed.

Dr Samuel John Finnikin, Clinical Research Fellow, Institute of Applied Health Research, Birmingham; Salaried GP

The commentator declares no conflicting interests