Prescribing antibiotics to ‘at-risk’ children with influenza-like illness in primary care: qualitative study

Abstract

ObjectivesNational Institute for Health and Care Excellence guidelines recommend immediate antibiotic treatment of respiratory tract infections in ‘at-risk’ individuals with comorbidities. Observational evidence suggests that influenza particularly predisposes children to bacterial complications. This study investigates general practitioners’ (GPs’) accounts of factors influencing their decision-making about antibiotic prescribing in the management of at-risk children with influenza-like illness (ILI).DesignQualitative interview study using a maximum variation sample with thematic analysis through constant comparison.SettingSemistructured telephone interviews with UK GPs using a case vignette of a child with comorbidities presenting with ILI.ParticipantsThere were 41 GPs (41.5% men; 40 from England, 1 from Northern Ireland) with a range of characteristics including length of time in practice, paediatrics experience, practice setting and deprivation.ResultsThere was considerable uncertainty and variation in the way GPs responded to the case and difference of opinion about how long-term comorbidities should affect their antibiotic prescribing pattern. Factors influencing their decision included the child's case history and clinical examination; the GP's view of the parent's ability to self-manage; the GP's own confidence and experiences of managing sick children and assessment of individual versus abstract risk. GPs rarely mentioned potential influenza infection or asked about immunisation status. All said that they would want to see the child; views about delayed prescribing varied in relation to local health service provision including options for follow-up and paediatric services.ConclusionsThe study demonstrates diagnostic uncertainty and wide variation in GP decision-making about prescribing antibiotics to children with comorbidity. Future guidelines might encourage consideration of a specific diagnosis such as influenza, and risk assessment tools could be developed to allow clinicians to quantify the levels of risk associated with different types of comorbidity. However, the wide range of clinical and non-clinical factors involved in decision-making during these consultations should also be considered in future guidelines.

The Importance of Rapid Influenza Testing in Pediatric Primary Care: Experience During Three Consecutive Influenza Seasons (2016–2019) in Barcelona (Catalonia, Spain)

“…Unfortunately, the number of papers addressing prospectively the impact of influenza POCTs on antibiotic treatment in pediatric primary care were only two out of the 30 papers included in this systematic review ( 19 ). These papers confirm that decision-making process of an antibiotic prescription is vastly influenced by an accurate diagnosis ( 17 , 20 ).…”

Impact of point-of-care C reactive protein in ambulatory care: a systematic review and meta-analysis

“…Primary care is where the majority of antibiotics are prescribed, most of which are for respiratory infections. Children are a particularly high-risk group for unnecessary antibiotic prescribing 11. As well as the global threat of widespread antimicrobial resistance, individuals with resistant infections in primary care are more likely to have the clinical failure to subsequent antibiotic treatment 12.…”

Antibiotic prescribing for acute respiratory tract infections in primary care: an updated and expanded meta-ethnography

“…10,24,27,44,71,72 to PCPs' expertise or standing and many express fear of overlooking something, making a mistake, and being sued. Patients' increasing power in medical encounters and knowledge of the opportunity for legal action are commented as important factors influencing prescribing decisionsConfidence andConfidence and experience PCPs report increased confidence in more accurately differentiating[22][23][24]27,29,43,45,46,61,69 experience between patients who need treatment and those who can be safely monitored, as they see more patients over time with similar symptoms. On the other hand, they admit that previous bad experience of non-antibiotic management can have substantial impact on current prescribing practices The more insecure they feel about patients' ability to recognise a worsening illness and re-consult, the more inclined they become to an antibiotic prescription Patient pressure Pressure in the form of a clear demand or gesture, or of a patient's obvious10,24,27,30,39,55,62,[66][67][68]70,71 fear (for example, anxiety, repeated consultations for the same episode), is regarded as a main reason for unnecessary antibiotic prescribing.…”