Clinician views of antibiotic prescribing for children with respiratory tract infections (RTI) 2012 cf. 2015: Changing practice or public accounts?
Antimicrobial resistance (AMR) has become a high priority and high profile issue. Antibiotic prescribing in primary care is associated with higher rates of AMR in individuals. Antimicrobial stewardship is one of the key strategies for reducing AMR and targets for reduced antibiotic prescribing in primary care are being set by Public Health England. The context within which primary care clinicians make their antibiotic prescribing decisions has been transformed but the effect on antibiotic prescribing is unclear.
We interviewed 28 clinicians (GPs and nurse practitioners) in 2012 and another 28 clinicians in 2015 to investigate antibiotic prescribing views and practices for children with RTI. Interviews were audio recorded, transcribed and analysed thematically. The data from 2012 and from 2015 were analysed separately but by the same team. This paper presents a comparison between the 2012 and 2015 data.
In 2012, clinicians expressed uncertainty about antibiotic prescribing. They described ‘prescribing in isolation’ without knowing about other practitioners’ prescribing behaviours or the consequences of their prescribing decision (whether a child got better, re-consulted a different GP, attended ED), except in the rare cases when a child became very seriously ill. Some very low prescribers worried they were not prescribing enough and felt they might face censure from colleagues. Some clinicians acknowledged they over prescribed in order to make sure they didn’t miss any children who might become seriously ill and felt this was safe and acceptable practice. Clinicians’ main priority was ensuring the safety of the child and they developed their own symptoms and signs “rules of thumb” for which they prescribed. Antibiotic prescribing decisions were not of high enough priority to warrant practice level discussion of policy. In 2015, clinicians universally described themselves as low prescribers and identified that as the ‘correct’ position. All continued to describe a degree of clinical uncertainty and made use of different “rules of thumb” but felt these were appropriate and conservative with respect to prescribing, rather than (as in the earlier interviews) prescribing ’just in case’. Most described a sense of their prescribing practices being scrutinised, and some described practice level initiatives which entailed examining practitioners’ prescribing rates. Clinicians reported considerably more scrutiny and pressure and the need to protect themselves from accusations of inappropriate over-prescription.
Clinicians are experiencing considerable pressure to reduce their antibiotic prescribing. However, there is little new guidance on how to reduce prescribing rates safely, particularly for children. Clinicians are developing defensive accounts of their prescribing practices which may form a barrier to engaging with interventions to support reduced antibiotic prescribing, since it is no longer acceptable to admit that their prescribing practices are not as low as they could be.