Elsevier

Current Problems in Pediatric and Adolescent Health Care

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Judicious antibiotic prescribing in ambulatory pediatrics: Communication is key

Children in outpatient clinics are prescribed over 15 million courses of unnecessary antibiotics annually. Clinicians have identified parent pressure for antibiotics, parent satisfaction, and time constraints as the primary drivers of unnecessary antibiotic prescribing. Over the past decade, parents have become more aware that antibiotics only treat bacterial infections, yet continue to report an expectation for antibiotics in 50–65% of acute care visits. Parental expectations for antibiotics stem from parental concerns about symptom severity and a desire to alleviate symptoms. Clinicians can address parental concerns when they assess the severity of illness through a physical exam, provide a clear explanation for the symptoms, recommend ways to alleviate the symptoms, and provide council on when to be concerned. When clinicians fail to address parental concerns, parents are more likely to challenge the diagnosis or treatment recommendations, clinicians are more likely to perceive that parent as expecting an antibiotic, and antibiotics are significantly more likely to be prescribed. Parents that expect antibiotics are more likely to communicate using a 'candidate diagnosis' (e.g., "Johnny has strep throat.") and resist the diagnosis or treatment given. Clinicians can recognize these parental communication patterns and use specific communication practices shown to decrease unnecessary antibiotic prescribing. When parents expect antibiotics, clinicians should (1) review physical exam findings using 'no problem' commentary (e.g., "This ear is just a little red."), (2) deliver a specific diagnosis (e.g., avoid 'a virus'), (3) use a two-part negative/positive treatment recommendation (e.g., "On the one hand, antibiotics will not help. On the other hand, ibuprofen can help with pain."), and (4) provide a contingency plan. Clinicians should feel comfortable discussing the risks and benefits of antibiotics. Effective communication between parents and clinicians in outpatient clinics leads to more judicious antibiotic prescribing, higher parent satisfaction scores, and more efficient clinic visits.

Introduction

Of the more than 50 million outpatient courses of antibiotics prescribed annually to children, approximately 30% are unnecessary.1, 2, 3, 4 Although best practice guidelines to decrease inappropriate antibiotic use for common pediatric conditions have been available since 2007, antibiotic prescribing rates in outpatient settings have failed to decrease.5, 6, 7 The act of prescribing antibiotics involves medical need, clinician knowledge, social norms, and complex relationships.8, 9 A growing body of literature highlights the complexity and importance of parent-clinician relationships in prescribing antibiotics appropriately.9, 10, 11, 12

Clinicians consistently identify parent pressure for antibiotics, parent satisfaction, and time constraints as primary barriers to judicious antibiotic prescribing.8, 10, 13 Desire among clinicians to maintain a positive parent-clinician relationship and prescribe antibiotics appropriately can sometimes seem at odds.14 Communication between parents and clinicians is a critical component to delivering high quality care at outpatient clinic visits.15, 16 Research has shown that effective communication between parents and clinicians leads to more judicious antibiotic prescribing, higher parent satisfaction scores, and more efficient clinic visits.17, 18, 19

This article will provide ambulatory clinicians with information on common parent expectations at clinic visits, parent and clinician communication practices that lead to inappropriate antibiotic prescribing, and guidance on effective communication strategies for clinicians to use with parents in order to optimize antibiotic prescribing. This article will also share key messages and helpful resources for clinicians to use with parents to address antibiotic overuse.

The drivers behind parental expectations for antibiotics include misunderstandings about severity of illness in bacterial versus viral diagnoses, symptoms or diagnoses that warrant antibiotics, the therapeutic role of antibiotics, and symptoms that indicate complications.

Section snippets

Parent expectations at a clinic visit

Ambulatory clinicians describe working within a 'culture of expectation' for antibiotics by parents.13 A clinic visit can be tense and unsatisfactory for all parties involved if parental expectations for antibiotics are discordant with clinician prescribing decisions. Clinician attitudes of complacency towards parent pressure or demand for antibiotics lead to unnecessary antibiotic prescriptions.12, 20 Parents often expect antibiotics because of previous experience with antibiotics and past

Parental expectations for antibiotics and antibiotic prescribing

When clinicians fail to meet parental needs of a thorough evaluation, diagnosis explanation, symptom management, and return precautions, parents are more likely to challenge the diagnosis or treatment recommendations, and clinicians are more likely to perceive that parent as expecting antibiotics.35 Clinician perceptions of parental expectations for antibiotics drive inappropriate antibiotic prescribing.27 If a clinician perceives a parent expects antibiotics, antibiotics are prescribed

Clinician-parent misunderstandings are common

Clinicians correctly identify when parents expect antibiotics about 50% of the time.27 During clinic visits where clinicians incorrectly believe a parent desires an antibiotic, parents instead identify expectations for a diagnosis, reassurance that symptoms do not indicate a serious condition, or strategies for symptom resolution.24, 35 Clinician-parent misunderstandings about antibiotic expectations are common because clinicians avoid eliciting parent expectations in an attempt to avoid

Parent communication practices that drive inappropriate antibiotic prescribing

Although parents often expect antibiotics, they directly request antibiotics in just 1–3% of visits.29, 30,35, 36, 42 When parents expect antibiotics, they overtly pressure clinicians only 8% of the time, and instead express expectations for antibiotics implicitly 92% of the time.35 Parents that expect antibiotics more often communicate using a 'candidate diagnosis'. Clinicians perceive that parents expect antibiotics when parents resist the diagnosis or treatment given. Clinicians can recognize

Managing parental expectations for antibiotics

When parents expect antibiotics, several specific clinician communication behaviors have shown to decrease unnecessary antibiotic prescribing. During clinic visits where parents expect an antibiotic, clinicians should (1) review physical exam findings, (2) deliver a clear diagnosis, (3) use a two-part negative/positive treatment recommendation, and (4) provide a contingency plan (Table 2). These four communication practices are most effective when delivered sequentially as a communication

Time constraints

Clinicians report lack of time and high patient volumes as driving factors of unnecessary antibiotic prescribing when parents expect antibiotics.12, 13 The likelihood of prescribing unnecessary antibiotics has been shown to increase towards the end of a clinic day.52 However, studies have shown no difference in physician visit time when antibiotics are prescribed versus not prescribed in pediatric visits for respiratory tract infection.53, 54 Instead, effective communication has been shown to

Commitment poster

Clinicians prescribe more appropriately when they make a public commitment to avoid prescribing unnecessary antibiotics.76 A letter posted with a personal photograph and signature of the clinician, information about the risk of antibiotics, and a commitment to avoid antibiotics if they cause more harm than good has shown to decrease the rate of inappropriate antibiotic prescribing for acute respiratory infections by 20%.76 Patients that read the commitment poster may also become better informed

Helpful resources

Be antibiotics aware: smart use, best care: https://www.cdc.gov/antibiotic-use/: Centers for Disease Control and Prevention Outpatient Antibiotic Stewardship. Provides information and materials for clinicians and parents including a commitment poster, fact sheets on common pediatric illnesses, and parent education handouts about antibiotics.84

DART communication modules: http://www.seattlechildrens.org/research/child-health-behavior-and-development/mangione-smith-lab/dart-learning-modules/:

Financial disclosures

The author has no financial relationships relevant to this article to disclose.

Potential conflicts of interest

The author has no conflicts of interest relevant to this article to disclose.

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