Research News

Prognostic uncertainty drives GP antibiotic prescribing in children, study shows

BMJ 2016; 352 doi: (Published 26 February 2016) Cite this as: BMJ 2016;352:i1178
  1. Susan Mayor
  1. London

210.2.1, 210.2.3, 102.1, 102.2, 102.3, 102.4, 102.5, 102.6, 102.7, 102.8, 102.9, 102.10, 202.39.25 top

Uncertainty about prognosis is a major reason that GPs prescribe antibiotics for children with respiratory tract infections, a study of UK primary care has shown.1

Respiratory tract infection is the most common reason parents take their child to see a GP in the UK. Although antibiotics have only marginal benefits they are often prescribed—a situation that has previously been blamed on parental pressure.

“Consultations for respiratory tract infections are more complex than most guidelines assume,” said the authors of the new study, led by Jeremy Horwood, from the centre for academic primary care at the University of Bristol. “They require primary care doctors and nurses to manage clinical uncertainty regarding diagnosis, prognosis, and treatment.”

To investigate how GPs and practice nurses made prescribing decisions for children with respiratory tract infections the researchers carried out semistructured interviews with 22 GPs and six nurses from practices serving different socioeconomic areas. Their answers were analysed using the constant comparison technique which constantly compares newly collected data with previous data to confirm or discount emerging findings.

The results showed that primary healthcare professionals used a dual diagnostic process for identifying children that they thought might benefit from antibiotics. They rapidly assessed how a child looked, their energy levels, and how they interacted with the environment. They then went through the more formal assessment of taking a history and examining the child.

The GPs and practice nurses taking part in the study felt confident in diagnosing and managing most cases of minor and severe respiratory infections. But even where they thought that antibiotics were not indicated they prescribed them because of residual uncertainty about whether a child’s health might deteriorate.

“It was the children thought to be of intermediate illness severity that provoked the most uncertainty. Healthcare professionals often chose to prescribe antibiotics rather than risk a serious respiratory tract infection developing,” the research group said.

They said that more evidence was needed to support clinical decision making and reduce diagnostic uncertainty in antibiotic prescribing for children with respiratory tract infections. “Healthcare professionals need more detailed evidence about the prognosis of respiratory tract infections in children so that they can identify those children most and least likely to benefit from antibiotics,” the researchers suggested. Some of the study participants also said that additional training in paediatrics would be helpful.

Stephanie Smith of the Royal College of Paediatrics and Child Health said that the study highlighted some important drivers for the prevention of antimicrobial resistance, particularly the need for more effective education for GPs in treating unwell children.

“Healthcare professionals need to feel confident in their diagnosis and specialist child health training for GPs—who are the first point of call for unwell children—would help. Although this proposal has already gained support from all four governments in the UK, funding is still needed in order to make it a reality.

“Until then there are other tools available to support healthcare professionals in their diagnosis and treatment. The college has produced a number of e-learning resources and has just launched Paediatric Care Online—a decision support tool for health professionals treating children. We call on healthcare professionals to make use of­ these.”


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