Interventions aimed at improving communication between GPs and parents could reduce unnecessary antibiotic prescribing for childhood upper respiratory infections, such as the common cold.
Inappropriate use of antibiotics has contributed to antibiotic resistance, resulting in impossible or difficult to treat infections. Parents, as well as GPs, influence the decision to prescribe antibiotics. Educational interventions that target both groups appear to be more effective at reducing prescriptions than those focussing on either group on their own.
This information came from a systematic review of 12 studies conducted in high-income countries, one in the UK. It could be used to improve the training and information provided to help tackle inappropriate antibiotic prescribing. Perhaps most importantly it highlights the need to ensure parental involvement in the process.
Why was this study needed?
Upper respiratory infections include the common cold, tonsillitis and flu. Children tend to get these infections more often than adults because they have yet to build up immunity to them.
The majority of upper respiratory infections are caused by viruses. Although this means in most cases antibiotics will not be effective, prescriptions are still routinely made and this is contributing to the problem of antibiotic resistance. In England, overall antibiotic resistant infections increased through 2014. Although primary care prescriptions decreased in 2014, total antibiotic consumption increased suggesting longer courses or higher doses.
Shared decision making has been shown to have the potential to reduce antibiotic prescribing in adults in primary care. This review focuses on whether similar interventions can have the same effect on antibiotic prescribing rates for children with upper respiratory infections.
What did this study do?
This systematic review included 12 trials of educational interventions to reduce antibiotic prescribing for children with upper respiratory infections. These were two randomised controlled trials, seven large cluster randomised controlled trials (one UK and six US), and three non- randomised controlled trials.
The content and way interventions were delivered varied, often linked to whether the target audience were clinicians, parents or both. Most interventions included a training session, either face to face or online. Other interventions included prescribing feedback for clinicians, and leaflets and posters for parents.
This variation presents difficulties when combining study results and creates uncertainty as to the reliability of the findings. Many of the interventions had more than one part to them, and it is hard to know exactly what it was about the more successful interventions that worked. They were mostly judged to be at low risk of bias.
What did it find?
- Interventions were associated with lower rates of antibiotic prescribing when compared to usual care (odds ratio [OR] 0.63, 95% confidence interval [CI] 0.50 to 0.81).
- Interventions that targeted both clinicians and parents were the most effective, reducing prescribing by half (pooled OR 0.52, 95% CI 0.34 to 0.79).
- The one UK based study successfully reduced antibiotic prescribing. It targeted both clinicians and parents through use of an interactive booklet during the consultation to improve communication by addressing concerns and discussing any symptoms that would require further medical attention. GPs had completed a 40 minute online training session. In the index consultation, antibiotics were prescribed 19.5% in the intervention group and 40.8% in the control group.
What does current guidance say on this issue?
The 2008 NICE guideline on self-limiting respiratory tract infections recommends that concerns and expectations be addressed. A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for children with the following conditions: acute otitis media, acute sore throat/acute pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis and acute cough/acute bronchitis.
Children with severe infections, and those who are systemically very unwell, or at risk of serious illness and/or complications can be considered for an immediate antibiotic prescribing strategy. Children in the following subgroups can also be considered for an immediate antibiotic prescribing strategy: bilateral acute otitis media in children younger than two years, acute otitis media with discharge from the ear and acute sore throat/acute pharyngitis/acute tonsillitis when three or more Centor criteria (see Definitions) are present.
What are the implications?
Despite the limitations in this review, improving parent-clinician communication is a relatively straightforward way to reduce unnecessary antibiotic prescribing in children with upper respiratory infections. The cost of interventions was not included, but given the seriousness of antibiotic resistance it would appear to be a strategy worth pursuing. Online options in particular could be a practical and cost effective method of delivery.
Citation and Funding
Hu Y, Walley J, Chou R, et al. Interventions to reduce childhood antibiotic prescribing for upper respiratory infections: systematic review and meta-analysis. J Epidemiol Community Health. 2016. [Epub ahead or print].
This work was supported by Medical Research Council, Global HealthTrials developmental grant—funding reference number: MR/M022161/1.
NHS Choices.The Antibiotic Awareness Campaign. London: Department of Health; 2015.
NICE. Respiratory tract infections (self-limiting): prescribing antibiotics . CG69. London: National Institute for Health and Care Excellence; 2008.
PHE. English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report. London: Public Health England; 2015.
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