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Am Fam Physician. 2007;75(6):895-899

Background: Inappropriately prescribing antibiotics is a common occurrence in the management of upper respiratory tract infections (URIs), many of which have a viral etiology. Previous studies show that 55 percent of the antibiotics prescribed for acute respiratory tract infections are considered unnecessary. Declines in antibiotic prescriptions for URIs have occurred recently; however, this may be because of a decrease in office visits for this type of infection. In children, acute respiratory illnesses account for approximately 75 percent of all antibiotic prescriptions, but most of these are viral infections. In addition, parents who bring their children to the office for URIs often expect to receive antibiotics. Mangione-Smith and colleagues questioned whether physicians were sending the right message about antibiotic treatment to parents, so they evaluated the relationship between physician-parent communication and the inappropriate use of antibiotics in children with URIs.

The Study: The cross-sectional study included pediatric visits to 38 subspecialists in 27 community practices. Parents were asked to participate if their child was between six months and 10 years of age, had symptoms of a respiratory tract infection, and had not taken antibiotics within the previous two weeks. Parents were given a questionnaire to complete before the visit. The office visit was videotaped, and the physician completed a survey after the appointment. This survey questioned whether the physician thought the parent was expecting antibiotic treatment, and the physician-patient communication was analyzed using a qualitative method of conversation analysis. The main outcomes measured included the physicians' perceptions of parental antibiotic expectations, inappropriate antibiotic prescribing, and whether the parent questioned the physician about not receiving an antibiotic prescription.

Results: There were 522 parents of children with URIs included in the study. Of the parents who did not receive antibiotic treatment for their children, 63.8 percent reported that they had expected an antibiotic prescription; however, physicians thought that this group expected antibiotics only 22 percent of the time. If the physicians thought that the parents expected antibiotics, they were significantly more likely (31.7 percent) to inappropriately prescribe them. If physicians exclusively decided against prescribing antibiotics after discussing the child's care with the parents or mentioned this option with other treatment recommendations or home remedies, parents were 24 percent more likely to question treatment. This was true even when the physician offered other treatment options.

Conclusion: The authors conclude that parental questioning of the treatment plan for children with URIs increases the physician's inappropriate use of antibiotics. They note that treatment plans that do not mention antibiotics, but focus on other, more positive treatment options, may help reduce the over-prescribing of antibiotics for viral illnesses.

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