NIHR Signal Education targeted at both parents and GPs reduces antibiotic prescribing for children

Published on 30 August 2016

Interventions aimed at improving communication between GPs and parents could reduce unnecessary antibiotic prescribing for childhood upper respiratory infections, such as the common cold.

Inappropriate use of antibiotics has contributed to antibiotic resistance, resulting in impossible or difficult to treat infections. Parents, as well as GPs, influence the decision to prescribe antibiotics. Educational interventions that target both groups appear to be more effective at reducing prescriptions than those focussing on either group on their own.

This information came from a systematic review of 12 studies conducted in high-income countries, one in the UK.  It could be used to improve the training and information provided to help tackle inappropriate antibiotic prescribing. Perhaps most importantly it highlights the need to ensure parental involvement in the process.

Education targeted at both parents and GPs reduces antibiotic prescribing for children

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Why was this study needed?

Upper respiratory infections include the common cold, tonsillitis and flu. Children tend to get these infections more often than adults because they have yet to build up immunity to them.

The majority of upper respiratory infections are caused by viruses. Although this means in most cases antibiotics will not be effective, prescriptions are still routinely made and this is contributing to the problem of antibiotic resistance. In England, overall antibiotic resistant infections increased through 2014. Although primary care prescriptions decreased in 2014, total antibiotic consumption increased suggesting longer courses or higher doses.

Shared decision making has been shown to have the potential to reduce antibiotic prescribing in adults in primary care. This review focuses on whether similar interventions can have the same effect on antibiotic prescribing rates for children with upper respiratory infections.

What did this study do?

This systematic review included 12 trials of educational interventions to reduce antibiotic prescribing for children with upper respiratory infections. These were two randomised controlled trials, seven large cluster randomised controlled trials (one UK and six US), and three non- randomised controlled trials.

The content and way interventions were delivered varied, often linked to whether the target audience were clinicians, parents or both. Most interventions included a training session, either face to face or online. Other interventions included prescribing feedback for clinicians, and leaflets and posters for parents.

This variation presents difficulties when combining study results and creates uncertainty as to the reliability of the findings. Many of the interventions had more than one part to them, and it is hard to know exactly what it was about the more successful interventions that worked. They were mostly judged to be at low risk of bias.

What did it find?

  • Interventions were associated with lower rates of antibiotic prescribing when compared to usual care (odds ratio [OR] 0.63, 95% confidence interval [CI] 0.50 to 0.81).
  • Interventions that targeted both clinicians and parents were the most effective, reducing prescribing by half (pooled OR 0.52, 95% CI 0.34 to 0.79).
  • The one UK based study successfully reduced antibiotic prescribing. It targeted both clinicians and parents through use of an interactive booklet during the consultation to improve communication by addressing concerns and discussing any symptoms that would require further medical attention. GPs had completed a 40 minute online training session. In the index consultation, antibiotics were prescribed 19.5% in the intervention group and 40.8% in the control group.

What does current guidance say on this issue?

The 2008 NICE guideline on self-limiting respiratory tract infections recommends that concerns and expectations be addressed. A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for children with the following conditions: acute otitis media, acute sore throat/acute pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis and acute cough/acute bronchitis.

Children with severe infections, and those who are systemically very unwell, or at risk of serious illness and/or complications can be considered for an immediate antibiotic prescribing strategy. Children in the following subgroups can also be considered for an immediate antibiotic prescribing strategy: bilateral acute otitis media in children younger than two years, acute otitis media with discharge from the ear and acute sore throat/acute pharyngitis/acute tonsillitis when three or more Centor criteria (see Definitions) are present.

What are the implications?

Despite the limitations in this review, improving parent-clinician communication is a relatively straightforward way to reduce unnecessary antibiotic prescribing in children with upper respiratory infections. The cost of interventions was not included, but given the seriousness of antibiotic resistance it would appear to be a strategy worth pursuing. Online options in particular could be a practical and cost effective method of delivery.

Citation and Funding

Hu Y, Walley J, Chou R, et al. Interventions to reduce childhood antibiotic prescribing for upper respiratory infections: systematic review and meta-analysis. J Epidemiol Community Health. 2016. [Epub ahead or print].

This work was supported by Medical Research Council, Global HealthTrials developmental grant—funding reference number: MR/M022161/1.

Bibliography

NHS Choices.The Antibiotic Awareness Campaign. London: Department of Health; 2015.

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

PHE. English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report. London: Public Health England; 2015.

Why was this study needed?

Upper respiratory infections include the common cold, tonsillitis and flu. Children tend to get these infections more often than adults because they have yet to build up immunity to them.

The majority of upper respiratory infections are caused by viruses. Although this means in most cases antibiotics will not be effective, prescriptions are still routinely made and this is contributing to the problem of antibiotic resistance. In England, overall antibiotic resistant infections increased through 2014. Although primary care prescriptions decreased in 2014, total antibiotic consumption increased suggesting longer courses or higher doses.

Shared decision making has been shown to have the potential to reduce antibiotic prescribing in adults in primary care. This review focuses on whether similar interventions can have the same effect on antibiotic prescribing rates for children with upper respiratory infections.

What did this study do?

This systematic review included 12 trials of educational interventions to reduce antibiotic prescribing for children with upper respiratory infections. These were two randomised controlled trials, seven large cluster randomised controlled trials (one UK and six US), and three non- randomised controlled trials.

The content and way interventions were delivered varied, often linked to whether the target audience were clinicians, parents or both. Most interventions included a training session, either face to face or online. Other interventions included prescribing feedback for clinicians, and leaflets and posters for parents.

This variation presents difficulties when combining study results and creates uncertainty as to the reliability of the findings. Many of the interventions had more than one part to them, and it is hard to know exactly what it was about the more successful interventions that worked. They were mostly judged to be at low risk of bias.

What did it find?

  • Interventions were associated with lower rates of antibiotic prescribing when compared to usual care (odds ratio [OR] 0.63, 95% confidence interval [CI] 0.50 to 0.81).
  • Interventions that targeted both clinicians and parents were the most effective, reducing prescribing by half (pooled OR 0.52, 95% CI 0.34 to 0.79).
  • The one UK based study successfully reduced antibiotic prescribing. It targeted both clinicians and parents through use of an interactive booklet during the consultation to improve communication by addressing concerns and discussing any symptoms that would require further medical attention. GPs had completed a 40 minute online training session. In the index consultation, antibiotics were prescribed 19.5% in the intervention group and 40.8% in the control group.

What does current guidance say on this issue?

The 2008 NICE guideline on self-limiting respiratory tract infections recommends that concerns and expectations be addressed. A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for children with the following conditions: acute otitis media, acute sore throat/acute pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis and acute cough/acute bronchitis.

Children with severe infections, and those who are systemically very unwell, or at risk of serious illness and/or complications can be considered for an immediate antibiotic prescribing strategy. Children in the following subgroups can also be considered for an immediate antibiotic prescribing strategy: bilateral acute otitis media in children younger than two years, acute otitis media with discharge from the ear and acute sore throat/acute pharyngitis/acute tonsillitis when three or more Centor criteria (see Definitions) are present.

What are the implications?

Despite the limitations in this review, improving parent-clinician communication is a relatively straightforward way to reduce unnecessary antibiotic prescribing in children with upper respiratory infections. The cost of interventions was not included, but given the seriousness of antibiotic resistance it would appear to be a strategy worth pursuing. Online options in particular could be a practical and cost effective method of delivery.

Citation and Funding

Hu Y, Walley J, Chou R, et al. Interventions to reduce childhood antibiotic prescribing for upper respiratory infections: systematic review and meta-analysis. J Epidemiol Community Health. 2016. [Epub ahead or print].

This work was supported by Medical Research Council, Global HealthTrials developmental grant—funding reference number: MR/M022161/1.

Bibliography

NHS Choices.The Antibiotic Awareness Campaign. London: Department of Health; 2015.

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

PHE. English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report. London: Public Health England; 2015.

Interventions to reduce childhood antibiotic prescribing for upper respiratory infections: systematic review and meta-analysis

Published on 22 June 2016

Hu, Y.,Walley, J.,Chou, R.,Tucker, J. D.,Harwell, J. I.,Wu, X.,Yin, J.,Zou, G.,Wei, X.

J Epidemiol Community Health , 2016

BACKGROUND: Antibiotics are overprescribed for children with upper respiratory infections (URIs), leading to unnecessary expenditures, adverse events and antibiotic resistance. This study assesses whether interventions antibiotic prescription rates (APR) for childhood URIs can be reduced and what factors impact intervention effectiveness. METHODS: MEDLINE, Embase, Google Scholar, Web of Science, Global Health, WHO website, United States CDC website and The Cochrane Central Register of Controlled Trials (CENTRAL) were searched by December 2015. Cluster or individual-patient randomised controlled trials (RCTs) and non-RCTs that examined interventions to change APR for children with URIs were selected for meta-analysis. Educational interventions for clinicians and/or parents were compared with usual care. RESULTS: Of 6074 studies identified, 13 were included. All were conducted in high-income countries. Interventions were associated with lower APR versus usual care (OR 0.63 (95% CI 0.50 to 0.81, p<0.001). A patient-clinician communication approach was the most effective type of intervention, with a pooled OR 0.41 (95% CI 0.20 to 0.83; p<0.001) for clinicians and 0.26 (95% CI 0.08 to 0.91; p=0.04) for parents. Interventions that targeted clinicians and parents were significant, with a pooled OR of 0.52 (95% CI 0.35 to 0.78; p=0.002). Insignificant effects were observed for targeting clinicians and parents alone, with a pooled OR of 0.88 (95% CI 0.67 to 1.16; p=0.37) and 0.50 (95% CI 0.10 to 2.51, p=0.40), respectively. CONCLUSIONS: Educational interventions are effective in reducing antibiotic prescribing for childhood URIs. Interventions targeting clinicians and parents are more effective than those for either group alone. The most effective interventions address patient-clinician communication. Studies in low-income to middle-income countries are needed.

Centor criteria are:

  • a grey or white coating on the tonsils
  • painful lymph nodes in the neck
  • a history of fever
  • no cough.

Expert commentary

Upper respiratory infections in children are common, and frequently the subject of inappropriate prescribing of antibiotics. This meta-analysis highlights the importance of communication between parents and clinicians as an effective means of reducing antibiotic prescribing for childhood upper respiratory infections. Doctors need to be aware of these findings, and to prioritise communication over other possible approaches to downward management of antibiotic prescribing in this clinical setting.

John L Campbell, Professor of General Practice and Primary Care, University of Exeter Medical School; Director, University of Exeter Collaboration for Academic Primary Care (APEx)