Parental pressure is frequently cited by pediatric practitioners as a primary reason for antibiotic overuse and inappropriate prescribing.1,2 However, a recent study published by Szymczak and colleagues in the Journal of the Pediatric Infectious Diseases Society brings these widely held beliefs into question. Their findings suggest pediatricians may overestimate the parental desire for antibiotics and that the “culture of expectation” is not as pervasive as some may think. This study, performed at four relatively diverse, hospital-affiliated practices in the Philadelphia area, explored parental perceptions about antibiotics and antimicrobial resistance. Parents accompanying their child to a sick visit for an acute respiratory tract infection (ARTI) were invited to participate in a semistructured interview prior to seeing the child’s physician. A total of 109 parents participated, with wide representation in parental age, race, and socioeconomic status.

Many important themes were revealed during this qualitative analysis. First, most parents were not necessarily expecting antibiotics at their visit. In fact, many parents were hoping their child would not need any antibiotics. Instead, they expected a clear diagnosis, reassurance that there wasn’t something more serious going on, and advice on how to mitigate symptoms. This is in line with previous studies in which a minority of parents expressed a preference for antibiotics or decreased satisfaction when antibiotics were not prescribed.1,3 Second, these parents were not planning to specifically request an antibiotic and conveyed high levels of trust in their child’s pediatrician. This is in contrast to previous studies in which clinicians believed a prescription for antibiotics would actually increase patient satisfaction and reinforce the doctor-patient relationship.1 Finally, although most parents had some knowledge of antibiotic resistance, the level of understanding varied and they were not concerned about antibiotic resistance in themselves or their child. Additionally, many parents recognized overuse of antibiotics as an important issue, but felt other parents were primarily responsible. Interestingly, this mirrors the beliefs of many pediatricians who perceive other providers as contributing to inappropriate prescribing more than themselves.

It’s important to recognize some of the potential limitations of the study. It was performed in a single area in the United States, which may limit generalizability. Additionally, as the authors point out, there may have been a selection bias since these parents generally had to arrive on time or early to their appointment in order to be included. There may also have been some social-desirability bias at play, with parents giving answers they thought would be more acceptable.

This study is a good wake-up call that when it comes to antibiotic overuse, though parental pressure and expectations are contributing factors they may not play as large of a role as some think. Instead, we all share the blame and must also share the responsibility for finding solutions. As the authors suggest, promoting ownership of the problem, with both parents and physicians, will be an important step in future efforts. Parents are key stakeholders in antimicrobial stewardship and need to be engaged in the discussion in order to make further progress, especially in the outpatient setting.

References

  1. Lucas PJ, Cabral C, Hay AD, Horwood J. A systematic review of parent and clinician views and perceptions that influence prescribing decisions in relation to acute childhood infections in primary care. Scandinavian journal of primary health care. Mar 2015;33(1):11-20.
  2. Szymczak JE, Feemster KA, Zaoutis TE, Gerber JS. Pediatrician perceptions of an outpatient antimicrobial stewardship intervention. Infection control and hospital epidemiology. Oct 2014;35 Suppl 3:S69-78.
  3. Vaz LE, Kleinman KP, Lakoma MD, et al. Prevalence of Parental Misconceptions About Antibiotic Use. Pediatrics. Aug 2015;136(2):221-231.
  4. Julia E Szymczak, Sarah B Klieger, Matthew Miller, Alexander G Fiks, Jeffrey S Gerber; What Parents Think About the Risks and Benefits of Antibiotics for Their Child’s Acute Respiratory Tract Infection, Journal of the Pediatric Infectious Diseases Society. 2017 Sept 14