Antimicrobial use for pediatric upper respiratory infections: reported practice, actual practice, and parent beliefs

In response to the dramatic emergence of resistant pneumococci, more judicious use of antibiotics has been advocated. Physician beliefs, their prescribing practices, and the attitudes of patients have been evaluated previously in separate studies.

This 3-part study included a statewide mailed survey, office chart reviews, and parent telephone interviews. We compared survey responses of 366 licensed pediatricians and family physicians in Georgia to recently published recommendations on diagnosis and treatment of upper respiratory infections (URIs). We further evaluated 25 randomly selected pediatricians from 119 surveyed in the Atlanta metropolitan area. For each, charts from the first 30 patients between the ages of 12 and 72 months seen on a randomly selected date were reviewed for encounters during the preceding year. A sample of parents from each practice were interviewed by telephone.

In the survey, physicians agreed that overuse of antibiotics is a major factor contributing to the development of antibiotic resistance (97%), and that they should consider selective pressure for resistance in their decisions on providing antibiotic treatment for URIs in children in their practices (83%). However, many reported practices do not conform to the recently published principles for judicious antibiotic use. For example, 69% of physicians considered purulent rhinitis a diagnostic finding for sinusitis; 86% prescribed antibiotics for bronchitis regardless of the duration of cough; and 42% prescribed antibiotics for the common cold. Reported practices by family physicians were more often at odds with the published principles: they were significantly more likely than pediatricians to omit pneumatic otoscopy (46% vs 25%); to omit the requirement for prolonged symptoms to diagnose sinusitis (median 4 vs 10 days); and to omit laboratory testing for pharyngitis (27% vs 14%). Of the 7531 encounters analyzed in the chart review, 43% resulted in an antibiotic prescription, including 11% of checkups, 18% of telephone calls, and 72% of visits for URIs. There was wide variability in the overall antibiotic use rates among the 25 physicians (1-10 courses per child per year). There was an even wider variability in some diagnosis-specific rates; bronchitis and sinusitis in particular. Those with the highest antibiotic prescribing rates had up to 30% more return office visits. Physicians who prescribed antibiotics for purulent rhinitis were more likely to see parents who believed that their children should be evaluated for cold symptoms.

Physicians recognize the problem of antibiotic resistance but their reported practices are not in line with recently published recommendations for most pediatric URIs. The actual prescribing practices of pediatricians are often considerably different from their close colleagues. Patient beliefs are correlated with their own physician's practices.