Physician behaviour for antimicrobial prescribing for paediatric upper respiratory tract infections: a survey in general practice in Trinidad, West Indies

Abstract

BackgroundUpper respiratory tract infections (URTIs) are among the most frequent reasons for physician office visits in paediatrics. Despite their predominant viral aetiology, URTIs continue to be treated with antimicrobials. We explored general practitioners' (GPs) prescribing behaviour for antimicrobials in children (≤ 16 years) with URTIs in Trinidad, using the guidelines from the Centers for Disease Control and Prevention (CDC) as a reference.MethodsA cross-sectional study was conducted on 92 consenting GPs from the 109 contacted in Central and East Trinidad, between January to June 2003. Using a pilot-tested questionnaire, GPs identified the 5 most frequent URTIs they see in office and reported on their antimicrobial prescribing practices for these URTIs to trained research students.ResultsThe 5 most frequent URTIs presenting in children in general practice, are the common cold, pharyngitis, tonsillitis, sinusitis and acute otitis media (AOM) in rank order. GPs prescribe at least 25 different antibiotics for these URTIs with significant associations for amoxicillin, co-amoxiclav, cefaclor, cefuroxime, erythromycin, clarithromycin and azithromycin (p < 0.001). Amoxicillin alone or with clavulanate was the most frequently prescribed antibiotic for all URTIs. Prescribing variations from the CDC recommendations were observed for all URTIs except for AOM (50%), the most common condition for antibiotics. Doctors practicing for >30 years were more likely to prescribe antibiotics for the common cold (p = 0.014). Severity (95.7%) and duration of illness (82.5%) influenced doctors' prescribing and over prescribing in general practice was attributed to parent demands (75%) and concern for secondary bacterial infections (70%). Physicians do not request laboratory investigations primarily because they are unnecessary (86%) and the waiting time for results is too long (51%).ConclusionsAntibiotics are over prescribed for paediatric URTIs in Trinidad and amoxicillin with co-amoxiclav were preferentially prescribed. Except for AOM, GPs' prescribing varied from the CDC guidelines for drug and duration. Physicians recognise antibiotics are overused and consider parents expecting antibiotics and a concern for secondary bacterial infections are prescribing pressures. Guidelines to manage URTIs, ongoing surveillance programs for antibiotic resistance, public health education on non-antibiotic strategies, and postgraduate education for rational pharmacotherapy in general practice would decrease inappropriate antibiotic use in URTIs.

Antibiotic prescribing for upper respiratory tract infections in children: The role of parental expectations

“…From their results, they suggest that (1) diagnostic uncertainty is the factor that most influences doctors' prescribing, and, (2) contrary to previously published literature, parental pressure is not associated with antibiotic prescribing. We would like to raise some questions and report our experience.…”

“…However, physicians in previous survey studies have acknowledged and admitted to bowing to parental pressure. 1,2,5 It is possible that physicians may admit to being influenced by parental pressure in general but do not always link this to their decision to prescribe in an individual situation. Thus the potential explanations for our failure to detect parental pressure as an important influence on antibiotic prescribing are likely manifold.…”

“…Physicians are not likely to disclose that sound clinical judgment has been influenced by social pressure, even in the particular case of parents caring for children. 2 We surveyed 4019 children with upper respiratory tract infections, out of whom 1521 had an antibiotic prescription. Parental expectation for an antibiotic, together with clinical variables such as fever >388 C (OR = 2.32; CI:1.97;2.74) and otorrhea (OR = 21.40; CI: 6.22;73.60 with only 67 cases), was unequivocally associated with antibiotic prescribing (OR = 12.78; CI: 10.48;15.58) in multivariate analysis.…”

A retrospective audit of antibiotic prescriptions in primary health-care facilities in Eastern Region, Ghana

“…A limitation however is whether prescribers would take advantage of available diagnostic services or tools. Studies have shown that this does not always happen ( Mohan et al . 2004 ; Polage et al .…”

Drugs in upper respiratory tract infections in paediatric patients in North Trinidad

“…Mohan et al in 2004 reported that the five most frequent URTIs presenting in children in Trinidad are the common cold, pharyngitis, tonsillitis, sinusitis and acute otitis media in rank order 3. Further only 12% of physicians would request laboratory tests before prescribing antimicrobials; 87.5% of physicians considered them unnecessary; 30% felt that a clinical diagnosis was sufficient; and 51.3% said the long waiting periods for results rendered laboratory impractical 3…”