Primary care clinician antibiotic prescribing decisions in consultations for children with RTIs: a qualitative interview study

Abstract

BackgroundRespiratory tract infections (RTIs) are a major primary care challenge in children because they are common and costly, there is uncertainty regarding their diagnosis, prognosis, and management, and the overuse of antibiotics leads to illness medicalisation and bacterial resistance.AimTo investigate healthcare professional (HCP) diagnostic and antibiotic prescribing decisions for children with RTIs.Design and settingSemi-structured interviews conducted with 22 GPs and six nurses. HCPs were recruited from six general practices and one walk-in centre, serving a mix of deprived and affluent areas.MethodInterviews were audiorecorded, transcribed, imported into NVivo 9, and analysed thematically.ResultsHCPs varied in the symptom and clinical examination findings used to identify children they thought might benefit from antibiotics. Their diagnostic reasoning and assessment of perceived clinical need for antibiotics used a dual process, combining an initial rapid assessment with subsequent detailed deductive reasoning. HCPs reported confidence diagnosing and managing most minor and severe RTIs. However, residual prognostic uncertainty, particularly for the intermediate illness severity group, frequently led to antibiotic prescribing to mitigate the perceived risk of subsequent illness deterioration. Some HCPs perceived a need for more paediatrics training to aid treatment decisions. The study also identified a number of non-clinical factors influencing prescribing.ConclusionPrognostic uncertainty remains an important driver of HCPs’ antibiotic prescribing. Experience and training in recognising severe RTIs, together with more evidence to help HCPs identify the children at risk of future illness deterioration, may support HCPs’ identification of the children most and least likely to benefit from antibiotics.

Development and internal validation of a clinical rule to improve antibiotic use in children presenting to primary care with acute respiratory tract infection and cough: a prognostic cohort study

“…Primary care clinicians acknowledge that they prescribe antibiotics for a range of medical and non-medical reasons, 10 particularly in children, who are seen as vulnerable 11 and whose clinical state can change rapidly. Many clinicians report that they prescribe antibiotics just in case, 12 to mitigate perceived risk of future hospital admission and complications,13, 14 and that failing to provide a prescription for a child who subsequently becomes seriously unwell is professionally unacceptable 11 . If primary care clinicians could identify children at low (or very low) risk of such future complications, the reduced clinical uncertainty could lead to a reduced use of antibiotics in these groups of patients.…”

Parents’ Expectations and Experiences of Antibiotics for Acute Respiratory Infections in Primary Care

“…[5][6][7][8] Common harms and the contribution to antibiotic resistance, 9 now a global public health crisis, 10,11 are rarely addressed. Primary care clinicians resort to antibiotics for many reasons, including diagnostic uncertainty 12,13 ; a desire to provide an unwell child with something to help 13,14 ; and an attempt to reduce visit length 12,13 and achieve parental satisfaction. 15 Interacting with many of these reasons is parental pressure for antibiotics, both articulated and perceived by clinicians.…”

Healthcare Providers’ Accounts of Influences of Antibiotic-Related Reforms on their Behavior with Respect to the Use of Antibiotics for Children: A Qualitative Study in China

“…In the studies of high income countries (HICs), the high workload and limited time have been identified as factors that influenced providers' antibiotic-related behavior for children in primary care [57,58]. These factors were also noted by providers in our study; however, they appeared to combine in different ways among providers working in different parts of China's healthcare system, pointing to the interactions between different healthcare institutions.…”