Perceived Parental Pressure May Result in Excessive Antibiotic Prescription

Laurie Barclay, MD

September 18, 2010

November 5, 2009 — Inadequate parental knowledge regarding the need for antibiotics and pressuring the clinician to prescribe them may result in antibiotic overuse, according to the results of a study reported online November 6 in BMC Pediatrics.

"Inappropriate use of antimicrobial agents for viral respiratory infections is common, leading to constant increase of bacterial respiratory pathogens," write Maria Luisa Moro, MD, from Agenzia Sanitaria e Sociale Regionale Emilia-Romagna, Area di Programma Rischio Infettivo in Bologna, Italy, and colleagues. "Several determinants of inappropriate prescribing have been reported, including diagnostic uncertainty, lack of knowledge, socio-cultural and economic pressures, fear of litigation, meeting parental expectations, but their importance varies in different environments."

The goal of this study was to evaluate determinants of antibiotic prescription in pediatric care as the first step of a multilevel intervention designed to improve prescribing for common respiratory tract infections (RTIs). The investigators performed a 2-step survey in Emilia-Romagna, a northern Italian region with a high antibiotic prescription rate.

In phase 1, family and hospital pediatricians and a sample of parents were surveyed regarding their knowledge of and attitudes concerning antibiotic prescription. During phase 2, the investigators explored patient care practices in a stratified random sample of hospital and family physician clinic visits. Parent expectations were also evaluated in a subsample of these visits.

An antibiotic was prescribed for suspected RTIs in 38% of 4352 pediatric visits. Pediatricians reported that perceived diagnostic uncertainty was the most common cause of inappropriate prescription (56% of 633 pediatricians interviewed). However, rapid antigen detection tests were used to evaluate pharyngitis or pharyngotonsillitis by only 36% of family pediatricians and by only 21% of family and hospital pediatricians.

For acute otitis, more than half of pediatricians reported not following a "wait and see" strategy. Otorrhea was the factor most strongly associated with antibiotic prescription (odds ratio, 12.8; 95% confidence interval, 10.4 – 15.8). Although pediatricians did not report that perceived parental expectation of antibiotics was a crucial determinant of prescription, it was actually the second-greatest determinant.

Parental factors potentially associated with overprescribing included lack of knowledge regarding RTIs and antibiotics, with 41% of 1029 parents indicating that bacteria could be a possible cause for the common cold. Another parental factor that could lead to antibiotic overprescription was the tendency to seek medical care for trivial infections, in that 48% of 4352 children seen in ambulatory care had only common cold symptoms.

"A wide gap between perceived and real determinants of antibiotic prescription exists," the study authors write. "This can promote antibiotic overuse. Inadequate parental knowledge can also induce inappropriate prescription."

Limitations of this study include the possible presence of the Hawthorne effect, incomplete control over potential selection of the children and parents population, and exclusion of parents not sufficiently proficient in Italian to complete the survey.

"The value of this study is that it simultaneously explored determinants of antimicrobial prescribing in an entire region involving both professionals and parents," the study authors conclude. "This study shows a complex situation that should be managed with multi-level interventions involving both parents and paediatricians. Use of rapid tests to reduce diagnostic uncertainty should be expanded; clear and feasible recommendations for the management of common RTIs in children should be implemented, information tools designed for parents should be developed and disseminated."

The study authors have disclosed no relevant financial relationships.

BMC Pediatr. Published online November 6, 2009.

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