An antibiotic stewardship gap? Exploring the views of A&E clinicians on antibiotic prescribing for children with fever.

Talk Code: 
EP3D.08
Presenter: 
Sarah Tonkin-Crine
Co-authors: 
Sarah Walker, Shelley Segal, Mike Sharland, Chris Butler.
Author institutions: 
University of Oxford, Oxford University Hospitals NHS Foundation Trust, St George's University Hospitals NHS Foundation Trust

Problem

Antibiotic resistance is a global threat and antibiotic stewardship across all healthcare contexts is key to containing antimicrobial resistance. The majority of outpatient antibiotic prescribing is for children with respiratory tract infections. Qualitative studies investigating clinicians’ views of antibiotic prescribing have mostly concentrated on general practitioners (GPs) as the usual first health care contact for patients. Whilst accident and emergency (A&E) is not recommended for initial consultations, children with acute infections do commonly attend. So far no research in the UK has explored the views of clinicians working in A&E about managing children with acute infections including antibiotic prescription.

Approach

Semi-structured interviews were carried out with doctors and nurses working in two A&E departments in South East England, which served contrasting patient populations. A mixture of purposive and opportunistic sampling was used to sample clinicians with variation in job role (doctor, nurse) and speciality (emergency medicine, paediatrics). Clinicians were asked about how they managed children (under 8 years) with fever and related infections and their views on antibiotic prescribing for such children. Interviews were audio-recorded, transcribed verbatim and analysed following thematic analysis.

Findings

In twenty five interviews, clinicians discussed the management of acutely unwell febrile children as routine in A&E. All clinicians felt there was a proportion of unnecessary attendance for such children as a result of both self-presenters and referral by NHS 111. High levels of parental anxiety about fever was stressed by all clinicians and seen as something which was increasing over time. Clinicians felt better parental education about fever was needed prior to attendance at A&E. Clinicians had mixed views on whether they felt parental pressure to prescribe antibiotics. Differences were seen between clinicians in the two emergency departments (EDs) regarding views on antibiotic prescribing. In one, clinicians were aware of antibiotic stewardship efforts and felt that prescribing could be improved in their ED. In the other, prudent prescribing was not commonly considered and antibiotic stewardship was seen as most relevant to general practice rather than the A&E department.

Consequences

Whilst clinicians working in A&E often manage similar patients to those seen in general practice, ED clinicians lack support and incentives to prescribe antibiotics more prudently. A&E may be a suitable target area for antibiotic stewardship interventions, which currently appear not to be making a specific impression. Identifying feasible and effective ways to promote prudent prescribing in A&E will support joined-up messages being delivered by general practice to patients and the public across all acute sectors.

Submitted by: 
Sarah Tonkin-Crine
Funding acknowledgement: 
Research was funded by the NIHR Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford.