Antibiotic prescribing in children in primary care: balancing interests of key ‘players’
Antibiotic use is particularly high for children in primary care. Concerns about antimicrobial resistance have led to increasing calls for reduction in prescribing, often targeting primary care. Research on prescribing for acute childhood illness has often failed to consider explicitly potential drivers for parents’ expectations and clinicians’ responses with regard to antibiotics.
This paper seeks to address this gap in the literature, illustrating the impact of external influences and internal beliefs as well as abstract concepts such as ethical rights and duties. Using a case scenario, we consider the prescription of antibiotics for a young child in terms of the interests of the ‘key players’ involved, the child’s mother and the consulting GP, as well as the broader healthcare system, and the general public.
Evidence suggests extremely limited clinical effectiveness of antibiotics in most acute childhood illness, with a very low risk-benefit ratio for treatment. However, numerous factors will influence parents in seeking antibiotics, and doctors in prescribing them. Demands of employment and child care, past experiences or media reports of severe or adverse consequences of illness, may support parents’ and doctors’ inclination towards antibiotic prescription, whilst awareness of side effects, scientific knowledge, guidelines, time pressure, and financial incentives may make prescription less attractive.Moral philosophy supports a duty to preserve the scarce resources and consider the risk of harm to future others, making avoidance of antibiotic resistance an important ethical course of action, with justification of some restriction of individual freedom of choice in doing this. However, doctors are thus placed in the difficult position of balancing the interests of the present patient and future individuals, conflicting with the focus of traditional doctor-patient interactions. Furthermore, apparently unilateral decisions about ‘appropriateness’ sit uncomfortably with current emphasis on self-determination of patients: different individuals involved in decisions about antibiotics may have very different standards of risk and benefit.
Evidence of clinical effectiveness is key in the consideration of antibiotic prescription for children with acute illness, but remains just part of the decision making process, with those involved subject to a wide variety of influences. Acknowledgement of this complexity is essential in approaching the problem of antibiotic resistance, with openness about competing interests, risk, and benefit crucial to a shared understanding between patients and clinicians. Nevertheless, whilst recognizing that factors other than clinical effectiveness are often important drivers of prescription, it must be stressed that antibiotics are not an acceptable solution to these problems; their purpose is to treat bacterial infection, and in the likely absence of this, other means should be found to address the concerns of parents and clinicians.