Elsevier

The Journal of Pediatrics

Volume 146, Issue 2, February 2005, Pages 222-226
The Journal of Pediatrics

Original Article
Antibiotic prescribing for upper respiratory tract infection: The importance of diagnostic uncertainty

https://doi.org/10.1016/j.jpeds.2004.09.020Get rights and content

Objectives

Antibiotic misuse for viral upper respiratory tract infections (URI) in children is a significant problem. We determined the influence on antibiotic prescribing of clinical features that may increase concern about possible bacterial infection (age, appearance, fever) in children with URI.

Study design

We created 16 scenarios of children with URI and distributed them by mail survey to 540 pediatricians and family practitioners in Ontario, Canada. The association of patient clinical features, parental pressure, and physician characteristics with antibiotic prescribing was determined through the use of logistic regression analysis.

Results

A total of 257 physicians responded (48%). Poor appearance (OR, 6.50; 95% CI, 5.06 to 3.84), fever above 38.5°C (OR, 1.48; 95% CI, 1.21 to 1.82), and age older than 2 years (OR, 2.27; 95% CI, 1.85 to 2.78) were associated with prescribing, whereas parental pressure was not. Physician characteristics associated with antibiotic use were family practitioner (OR, 1.54; 95% CI, 1.22 to 1.96), increasing number of patients seen per week (OR, 1.05; 95% CI, 1.01 to 1.08 for every 20-patient increase), and increasing physician age (OR, 1.17; 95% CI, 1.11 to 1.24, 5-year increments).

Conclusions

Clinical factors, which may lead physicians to be concerned about possible bacterial infection in children, are associated with antibiotic use for pediatric URI.

Section snippets

Participants

We distributed a self-administered mail survey to a quasi-randomized sample (obtained from a medical list provider, Southam Medical Lists) of English-speaking family physicians (n = 270) and pediatricians (n = 270) in Ontario, Canada. Pediatricians in Ontario consist of a mix of primary care physicians, consultant general pediatricians, and pediatric specialists. Most family practitioners provide primary care. The cover letter indicated that the survey was directed at physicians providing primary

Results

There were 257 completed surveys returned of 540 mailed, 47.6% from family practitioners and 52.4% from pediatricians. There were 419 simulations for which there was a missing value for either the response variable or a demographic variable, leaving 3693 cases of a potential 4112 (89.8%) for analysis.

Table I displays the categoric demographic characteristics of the survey respondents. In addition, pediatricians reported spending more hours on continuing medical education each year (80.0 vs

Discussion

The results of this study suggest that patient clinical characteristics, which may lead to diagnostic uncertainty, are a more important determinant of antibiotic overuse than parental pressure.7, 8, 9, 10 Physicians were more likely to prescribe antibiotics to a child with URI if the child had a temperature greater than 38.5°C or appeared unwell, regardless of age. This may be due to diagnostic uncertainty and resultant concern about missing an evolving or occult invasive bacterial infection.16

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  • Cited by (0)

    Supported by a research fellowship funded through the Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada (Dr Arnold) and by the Canadian Institutes of Health Research and the Ontario Ministry of Health and Long-Term Care through an Investigator Award (Dr To).

    The results and conclusions are those of the authors; no official endorsement by the Ministry is intended or should be inferred.

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