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Parents' impact on antibiotic use
Howard Bauchner, MD
Division of General Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts,
USA
Mounting bacterial resistance to antibiotics represents
a global public health threat which is of particular concern in children because of frequent use of antibiotics
in the outpatient setting for the treatment of common childhood diseases, and in the inpatient setting for life-threatening
infections (1,3). Streptococcus pneumoniae, for instance, the most common bacterial causative agent for meningitis,
bacteremia, pneumonia, acute otitis media (AOM) and sinusitis (4), is increasingly reported around the world (5,6)
as being resistant to penicillins and cephalosporins. There are a number of well-known risk factors for penicillin-resistant
pneumococcal infections, including age, prior exposure to antibiotics, history of hospitalization, and day care
attendance (7-11).
The use of antibiotics is increasing. An estimated 110 million oral antimicrobial agents were prescribed by office-based
US physicians in 1992, of which 60 million were for children younger than 15 years of age (12). In 1980, 4,206,000
prescriptions were written for amoxicillin for the treatment of AOM. In 1992, that number had grown to 12,381,000-an
increase of 194%. In 1980, only 876,000 prescriptions for cephalosporins (broad-based antibiotics) were recorded
for the treatment of AOM, while in 1992, that number grew to 6, 892,000--an increase of 687%. It is estimated that
in 1997, 30,000,000 prescriptions will be written for the treatment of AOM, and at least 50% of those prescriptions
will be for broad-spectrum antimicrobials.
There are a number of explanations for the dramatic increase in outpatient antibiotic prescriptions, best exemplified
by AOM. First, there has been an increase in real disease. The number of young children attending day care has
risen significantly over the past decade and day care attendance is associated with the development of AOM (13,
14). Second, several studies
have shown that access to care for children has improved. Approximately 90% of parents indicate that their children
have a regular source of care (15,16). Improved access to care is accompanied by increased diagnoses of minor infections
and increased oral antibiotic use. Finally, unnecessary prescription of antibiotics also occurs. Time constraints
on practitioners and the need to promote consumer satisfaction (assuming parents want antibiotics) may be contributing
factors (17).
We recently published a study which determined parents' range of knowledge and understanding about antibiotics
(18). Three practices in the Boston area were studied. Two sites were private practices (PP) in the suburbs and
the other was an inner-city community health center (CHC). A research assistant in the waiting room asked parents
questions related to demographic information and their experiences with antibiotics. Four hundred parents were
interviewed, with a consent rate of 83%. The parents from the private practices were largely white (84%) and had
completed college (81%). They were older than the health center patients and had a higher family income. The parents
in the CHC were mostly black (80%) and had not completed college (91%) (Table 1).
The majority of parents (78%) had given their children oral antibiotics. Fifty-three percent had done so in the
past 6 months and 73% in the past year. Regarding the most recent antibiotic given, 89% were satisfied with the
ability of that drug to cure their child's illness, and 78% said they were able to give their child every single
dose. The response to these questions did not differ between parents from the PP and the CHC.
Overall, 29% of the parents were worried that their children were receiving too many antibiotics. Eighty-five percent
of parents believed that there could be problems with receiving too many antibiotics. In an open-ended question
in which parents were asked to list potential problems with receiving too many antibiotics, 55% mentioned "immunity"
or "resistance." Despite these concerns, 18% of parents said they had given an antibiotic at home before
consulting a physician.
Most parents answered that antibiotics were always or sometimes helpful in ear infections and throat infections,
but a large number also responded that antibiotics were useful in treating colds, coughs, and fever (Table 2),
a conception which is not generally valid. More parents in the PPs indicted that antibiotics were helpful for ear
infections (95%) and throat infections (87%) than parents in the CHC (88% and 71% respectively). More parents from
the CHC believed that antibiotics were useful in treating colds (59%) than did parents from the PPs (23%). Fifty-eight
percent of parents in both groups responded that antibiotics were useful for cough and fever.
When parents were asked, "Has your child ever needed an antibiotic when the doctor did not prescribe one?"
14% said "yes" (Table 3). Ear infections (32%) and colds (26%) were the most common reasons for parents
to believe that their child required an antibiotic. Significantly more parents from the private practice (12%)
believed that an unnecessary antibiotic had been prescribed in the past as compared to the CHC families (3%). Again,
the most common reasons were ear infections (50%) and colds (10%). Overall, thirty percent of parents had at some
time requested that their child's physician prescribe a specific antibiotic. Eighty-two percent of these parents
said that their doctor prescribed the drug requested.
Our survey suggests that parents have misconceptions about appropriate indications for antibiotics and sometimes
give antibiotics without physician knowledge. It is possible that parents misunderstood the questions about specific
signs of illness and indications for antibiotics. For example, if they had prior experience with a child having
a cold, had sought care, and
a physician had made the diagnosis of an ear infection, parents may have responded that antibiotics are indicated
in treating a cold. In some regards, this scenario illustrates the complexity in understanding what parents know
and believe about antibiotics.
Anecdotal information from colleagues and our own practices support our thesis that parents exert pressure on physicians
to dispense antibiotics. Many pediatricians have had the experience of parents "demanding" antibiotics
for illnesses such as coughs, colds, nonspecific diarrhea and sore throats for which they are generally not indicated.
Although we would like to believe otherwise, it is often less time-consuming for a physician to write a prescription
than it is to engage in a lengthy discussion with parents about the natural history of an infection, diarrhea,
or sore throat. Parental coercion, time constraints, and concerns of malpractice and litigation may all contribute
to physician prescribing practices.
Whether parent education alone will suffice to reduce the pressure to prescribe oral antibiotics inappropriately
is unclear. However, recent research does suggest that patients can change physician behavior. In an analysis of
99 randomized controlled trials of education strategies or interventions that objectively assessed physician performance
and/or health care outcomes, Davis and others found that four continuing medical education strategies were effective:
reminders, patient-mediated interventions, outreach visits, and opinion leaders (19). Davis, Pathman and others
indicate that parent preference impacts on physician behavior (20, 21). Pathman recently described an awareness-to-adherence
model of the steps to clinical guideline compliance. Immunizations were the basis for their model, with four aspects
of guideline implementation described, including: awareness, agreement, adoption, and adherence. In a survey of
2146 physicians, they found that physicians were much more likely to adopt the hepatitis B recommendation if they
believed parents knew about and/or requested the hepatitis vaccine. This belief on the part of physicians was the
most powerful predictor of adoption and agreement and could impact physician prescription of antibiotics.
Our study represents an initial step in understanding the complex relationship between parents and physicians as
it relates to antibiotics, though it is unclear if our results may be generally applied to all parents. Not only
may educational status be a critical variable, but ethnicity may also play a role. In addition, more information
is needed from the actual parent-clinician encounter. It is possible that the self-report is not accurate, and
that interviews before and after an encounter will be necessary. Nevertheless, we believe some parents are beginning
to question the use of antibiotics. Recent discussions in the media about bacterial resistance have acquainted
many parents with the concept. Ultimately, however, understanding parents' concerns and beliefs about antibiotics
is necessary before we can develop intervention strategies that reduce inappropriate antibiotic use.
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