Prescribing antibiotics to 'at-risk' children with influenza-like illness in primary care: Qualitative study
Ashdown HF., Räisänen U., Wang K., Ziebland S., Harnden A., Semple MG., Mallett S., Wolstenholme J., Perera-Salazar R., Yu LM., Hay A., Little P., Moore M., Butler C., Carver TT.
© Published by the BMJ Publishing Group Limited. 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 decisionmaking during these consultations should also beconsidered in future guidelines.