Prescribing antibiotics to 'at-risk' children with influenza-like illness in primary care: qualitative study
Helen F Ashdown1, Ulla Räisänen1, Kay Wang1
1Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
Insights
General practitioners (GPs) show significant uncertainty when deciding on antibiotic prescriptions for children with influenza-like illness and comorbidities. Guidelines should consider clinical and non-clinical factors influencing these complex prescribing decisions.
Area of Science:
- Pediatric infectious disease
- General practice and primary care
- Antibiotic stewardship
Background:
- National guidelines recommend prompt antibiotic treatment for respiratory infections in at-risk children with comorbidities.
- Influenza is known to increase the risk of secondary bacterial infections in children.
Purpose of the Study:
- To explore general practitioners' (GPs) decision-making processes regarding antibiotic prescribing for at-risk children presenting with influenza-like illness (ILI).
Main Methods:
- Qualitative study involving semistructured telephone interviews with 41 UK GPs.
- Thematic analysis using constant comparison was applied to interview data, which included a case vignette of a child with comorbidities and ILI.
Main Results:
- GPs exhibited considerable uncertainty and variation in their approach to antibiotic prescribing for children with comorbidities and ILI.
- Key influencing factors included clinical presentation, parental self-management capacity, GP confidence, and individual risk assessment, with less emphasis on influenza diagnosis or immunisation status.
- Decisions on delayed prescribing varied based on local healthcare service availability.
Conclusions:
- Diagnostic uncertainty and varied decision-making among GPs highlight the complexity of prescribing antibiotics for children with comorbidities.
- Future guidelines could benefit from incorporating specific diagnoses like influenza and utilizing risk assessment tools.
- Clinical and non-clinical factors influencing GP decisions require consideration in updated guidelines for managing pediatric respiratory infections.
Objectives:
National Institute for Health and Care Excellence guidelines recommend immediate antibiotic treatment of respiratory tract infections in 'at-risk' individuals with comorbidities. Observational evidence suggests that influenza particularly predisposes children to bacterial complications. This study investigates general practitioners' (GPs') accounts of factors influencing their decision-making about antibiotic prescribing in the management of at-risk children with influenza-like illness (ILI).
Design:
Qualitative interview study using a maximum variation sample with thematic analysis through constant comparison.
Setting:
Semistructured telephone interviews with UK GPs using a case vignette of a child with comorbidities presenting with ILI.
Participants:
There were 41 GPs (41.5% men; 40 from England, 1 from Northern Ireland) with a range of characteristics including length of time in practice, paediatrics experience, practice setting and deprivation.
Results:
There was considerable uncertainty and variation in the way GPs responded to the case and difference of opinion about how long-term comorbidities should affect their antibiotic prescribing pattern. Factors influencing their decision included the child's case history and clinical examination; the GP's view of the parent's ability to self-manage; the GP's own confidence and experiences of managing sick children and assessment of individual versus abstract risk. GPs rarely mentioned potential influenza infection or asked about immunisation status. All said that they would want to see the child; views about delayed prescribing varied in relation to local health service provision including options for follow-up and paediatric services.
Conclusions:
The study demonstrates diagnostic uncertainty and wide variation in GP decision-making about prescribing antibiotics to children with comorbidity. Future guidelines might encourage consideration of a specific diagnosis such as influenza, and risk assessment tools could be developed to allow clinicians to quantify the levels of risk associated with different types of comorbidity. However, the wide range of clinical and non-clinical factors involved in decision-making during these consultations should also be considered in future guidelines.
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