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

BACKGROUND: Respiratory 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. AIM: To investigate healthcare professional (HCP) diagnostic and antibiotic prescribing decisions for children with RTIs. DESIGN AND SETTING: Semi-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. METHOD: Interviews were audiorecorded, transcribed, imported into NVivo 9, and analysed thematically. RESULTS: HCPs 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. CONCLUSION: Prognostic 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

Measuring the financial burden of acute cough in pre-school children: a cost of illness study

Abstract Background Context: Acute cough is a very common symptom presentation among children in primary care and is usually due to respiratory infection, yet its cost is unknown. An estimate of the cost to healthcare providers and parents would aid budgetary decision-making, and provide an insight into the need for interventions to reduce the burden. Purpose: To estimate the cost per child per episode, and the annual population cost in the UK, of acute cough in pre-school children presenting to primary care. Methods Design: Incidence and prevalence-based cost-of-illness study from the perspectives of the UK NHS and of parents and caregivers. Setting: 11 general practices in Bristol, UK. Subjects: 121 children without known asthma aged 3 to 59 months presenting for the first time with an acute (≤ 28 days) cough. Results Mean cost per episode to the NHS: £27.43 (95% CI: £24.38 – £30.49). Mean cost per episode to parents and carers: £14.77 (£4.90 – £24.65). Annual cost to the NHS in the UK: at least £31.5 m (95% CI: £28.0 m – £35.0 m). Conclusion The cost burden on the healthcare provider of acute cough in pre-school children is substantial; the majority of this cost arises from consultations with general practitioners. Parents experience some personal cost through travel and expenditure on over-the-counter preparations, and may suffer significantly if loss of earnings is experienced. There is scope for evaluating interventions designed to reduce this burden. </jats:sec

Parents’ information needs, self-efficacy and influences on consulting for childhood respiratory tract infections:a qualitative study

BACKGROUND: Acute respiratory tract infection (RTI) is the most common reason why parents consult primary care in the UK. Little is known about parents’ perceptions of what may help them to make an appropriate decision to consult when their child is ill and how to improve self-care. Using qualitative methods, this study aimed to explore parents’ views on support and information needs prior to consulting when children have RTIs with cough, and identify the triggers and barriers to consulting primary care. METHODS: 7 focus groups and 30 semi-structured interviews were held with 60 parents (with children aged 5 months - 17 years) from a range of socio-economic backgrounds. Topics discussed were informed by the Health Belief Model, and explored parents’ concerns and beliefs about susceptibility and severity of RTIs, beliefs about the triggers and barriers to consulting, and information and support seeking behaviour undertaken before consulting primary care. Discussions were audio-recorded, transcribed and analysed using thematic methods. RESULTS: Parents from all socio-economic backgrounds sought information from a wide range of sources about RTIs in children in order to identify which of their child’s symptoms should be of concern and trigger a visit to the doctor. The perception of threat to a child of RTI (with cough) was increased with more severe illness and by perceived susceptibility to illness of a particular child; whilst experience with other children increased parental efficacy to cope with childhood cough at home. Psychological models of health behaviour informed the understanding of cultural beliefs and attitudes that underpin health related behaviours. CONCLUSION: A wide range of perceptions influence the likelihood that parents will seek help from primary care for a child with cough; these perceptions are similar across socio-economic groups. Parents’ experience, confidence and efficacy influence the likelihood of consulting primary care for their child’s RTI. Parents would value consistent advice from a trusted source that addresses common concerns and supports home care and decision making about help seeking

The community paediatric respiratory infection surveillance study protocol:a feasibility, prospective inception cohort study

INTRODUCTION: Paediatric respiratory tract infections (RTIs) are common reasons for primary care consultations and antibiotic prescribing. Locally relevant syndromic and microbiological surveillance information has the potential to improve the care of children with RTIs by normalising illness (parents) and reducing uncertainty (clinicians). Currently, most RTI studies are conducted at the point of healthcare service consultation, leaving the community burden, microbiology, symptom duration and proportion consulting largely unknown. This study seeks to establish the feasibility of (mainly online) participant recruitment and retention, and the acceptability/comparability of parent versus nurse-collected microbiological sampling, to inform the design of a future surveillance intervention study. Evidence regarding consultation rates and symptom duration is also sought. METHODS AND ANALYSIS: A community-based, feasibility prospective inception cohort study, recruiting children aged ≥3 months and <16 years and their parents via general practitioner surgery invitation letter, aiming to collect data on 300 incident RTIs by July 2016. Following informed consent, parents provide baseline (demographic) data online, and respond to weekly emails to confirm the absence/presence of new RTI symptoms. Once symptomatic, parents provide daily data online (RTI symptoms, school/day-care attendance, time off work, health service use, medication), and a research nurse visits to collect clinical examination data and microbiological (nasal and saliva) swabs. Parents are invited to provide symptomatic (at nurse visit, but without nurse assistance) and asymptomatic (alone) swabs on recovery. A review of primary care medical notes will gather medical history, health service utilisation, referral and antibiotic prescribing rates. Feasibility will be assessed using recruitment and retention rates, data completeness; and acceptability by quantitative survey and qualitative interviews. Symptomatic parent and nurse swab pairs will be compared for microbe isolation

Global prevalence of antibiotic resistance in paediatric urinary tract infections caused by <i>Escherichia coli</i> and association with routine use of antibiotics in primary care:a systematic review and meta-analysis

Objectives To systematically review studies investigating the prevalence of antibiotic resistance in urinary tract infections caused by Escherichia coli in children and, when appropriate, to meta-analyse the relation between previous antibiotics prescribed in primary care and resistance. Design and data analysis Systematic review and meta-analysis. Pooled percentage prevalence of resistance to the most commonly used antibiotics in children in primary care, stratified by the OECD (Organisation for Economic Co-operation and Development) status of the study country. Random effects meta-analysis was used to quantify the association between previous exposure to antibiotics in primary care and resistance. Data sources Observational and experimental studies identified through Medline, Embase, Cochrane, and ISI Web of Knowledge databases, searched for articles published up to October 2015. Eligibility criteria for selecting studies Studies were eligible if they investigated and reported resistance in community acquired urinary tract infection in children and young people aged 0-17. Electronic searches with MeSH terms and text words identified 3115 papers. Two independent reviewers assessed study quality and performed data extraction. Results 58 observational studies investigated 77 783 E coli isolates in urine. In studies from OECD countries, the pooled prevalence of resistance was 53.4% (95% confidence interval 46.0% to 60.8%) for ampicillin, 23.6% (13.9% to 32.3%) for trimethoprim, 8.2% (7.9% to 9.6%) for co-amoxiclav, and 2.1% (0.8 to 4.4%) for ciprofloxacin; nitrofurantoin was the lowest at 1.3% (0.8% to 1.7%). Resistance in studies in countries outside the OECD was significantly higher: 79.8% (73.0% to 87.7%) for ampicillin, 60.3% (40.9% to 79.0%) for co-amoxiclav, 26.8% (11.1% to 43.0%) for ciprofloxacin, and 17.0% (9.8% to 24.2%) for nitrofurantoin. There was evidence that bacterial isolates from the urinary tract from individual children who had received previous prescriptions for antibiotics in primary care were more likely to be resistant to antibiotics, and this increased risk could persist for up to six months (odds ratio 13.23, 95% confidence interval 7.84 to 22.31). Conclusions Prevalence of resistance to commonly prescribed antibiotics in primary care in children with urinary tract infections caused by E coli is high, particularly in countries outside the OECD, where one possible explanation is the availability of antibiotics over the counter. This could render some antibiotics ineffective as first line treatments for urinary tract infection. Routine use of antibiotics in primary care contributes to antimicrobial resistance in children, which can persist for up to six months after treatment