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    Parents overestimate benefits of antibiotics for acute respiratory infections

    Parents often carry misperceptions about the advantages and disadvantages of antibiotic use for pediatric acute respiratory infections, according to an Australian survey in the Annals of Family Medicine.1

    As a result, it is important that pediatricians convey honestly and frankly to parents the true benefits and harms of antibiotics, as most parents overestimate their value. Shared decision making is a good way of doing this.

    “Doctors need to be aware that most parents are coming in with massively optimistic expectations about the benefits of antibiotics,” says co-author Chris Del Mar, MD, a professor of public health and family physician at Bond University in Queensland, Australia. “The conversation needs to address that perception by providing accurate information.”

    In 2015, Del Mar and coauthor Tammy Hoffmann, PhD, a professor of Clinical Epidemiology at Bond University Centre for Research in Evidence-Based Practice, published in JAMA Internal Medicine a systematic review of patients’ expectations of the benefits and harms of treatments and tests for all indications.2

    “That study showed that across nearly every test and treatment studied, patients overestimate benefits and underestimate harm,” Hoffmann says.

    Through the years, the 2 authors have also researched antibiotics for acute respiratory infections, so after publication of their systematic review they knew there had not been any primary studies evaluating peoples’ expectations of antibiotic benefits.

    For the current study, the investigators interviewed 1 parent from 401 households across Australia (Table1).

     “We were surprised by how much benefit parents thought antibiotics delivered for their child’s acute otitis media, acute cough, or sore throat. On average, parents believed that antibiotics would shorten the duration of illness by 3 to 3.5 days, when the reality is less than 0.5 days,” Del Mar says. “The perceived benefit was up to 5 to 10 times greater than reality.”

    Another surprise was what parents nominated as the minimally important clinical difference. “In other words, how much difference would be worthwhile taking antibiotics for,” Del Mar says. “Parents thought it was only worthwhile using antibiotics if they produced a shortening of illness duration of 3 to 3.5 days,” he says.

    This information can be useful to clinicians because it means that if clinicians were to explain to patients the quantified benefits of antibiotics for acute respiratory infections, “many patients may then likely think it not worthwhile taking and have less predilection for assuming an antibiotic is needed,” Del Mar says.

    Besides overestimating the benefits of antibiotics, most parents felt not sufficiently involved in decision making about whether their child needed antibiotics in the first place. “Parents wanted to be more involved,” Hoffmann says. “Most were not told how much benefit antibiotics provide or the potential harms from antibiotics. Parents expressed a desire for a collaborative discussion about whether their child actually needed antibiotics or not, and the pros and cons of using or not using them.”

    By empowering parents and clinicians to engage in shared decision making,3 “we anticipate that this can help to reduce antibiotic use for acute respiratory infections in primary care,” Hoffmann says.

    This belief is supported by a systematic review of all primary-care trials that evaluated interventions that facilitated shared decision making for acute respiratory infections, published in 2015 in the Cochrane Database of Systematic Reviews.4 “This review shows that indeed shared decision making, if implemented, reduces the demand and the use of prescribed antibiotics,” says Del Mar, who along with Hoffmann was a co-author of the review.

    The review found that immediately after or within 6 weeks of consultation, 47% of patients in the control groups were given an antibiotic prescription, compared with 29% in the groups in which the doctors or patients had received the intervention to facilitate shared decision making (usually training or information).

    Another finding of the current study is that some parents mentioned resistance as a harm of antibiotics when asked about potential harms. “But a lot of people misunderstood what was meant by antibiotic resistance and interpreted it as their body becoming immune to the antibiotics,” Hoffmann says. “Therefore, physicians should explain to parents what antibiotic resistance is, and that every time you take antibiotics it increases the likelihood of resistance.”

    Del Mar adds that antibiotic resistance is not only a global threat to society, but a threat to the individual patient. “By taking antibiotics, resistance develops in the bacteria in the individual,” he says. “Then, if that individual becomes ill from a serious infection—mastoiditis, pneumonia meningitis, septicemia, and so on—this resistance can be transferred to a dangerous pathogen, which may mean it takes longer to find the right antibiotic, or maybe not at all for a tragic outcome.”

    A 2016 systematic review of 54 studies in the Journal of Antimicrobial Chemotherapy assessed the public’s knowledge and beliefs about antibiotic resistance.5 The investigators found that 70% of participants had heard of antibiotic resistance, but that 88% believed it referred to changes in the human body. As for what causes resistance, 70% of respondents believed it was excessive antibiotic use and 62% thought it was not completing antibiotic courses.

    “I would be surprised if antibiotic resistance was routinely communicated during consultation by a community pediatrician in the United States,” Del Mar says. “But it is important that the physician talks about the benefits and the harms of using and not using antibiotics in consultation with parents. It should also be an explicit discussion, including how the parent feels about the amount of benefit their child may receive, as well as how the parent feels about the harms and the risks of them. Afterward, the physician and parent can make a decision together about moving forward.”

    Although shared decision making is desired by patients and may be an effective strategy for managing expectations and reducing unnecessary antibiotic prescriptions, “doctors need awareness of what shared decision making is," Hoffman says. "They often need skill training and support tools.”

    Moreover, “there is some indication that doctors also overestimate the benefits of antibiotics,” says Hoffmann, who along with Del Mar co-authored a systematic review published in March this year in JAMA Internal Medicine that shows that physicians tend to overestimate the benefits and underestimate the harms of medical care in general.6 One of the included primary studies explored the expectations of antibiotics for acute respiratory infections held by European pediatricians.

    Del Mar says there are several factors fueling overinflated expectations of antibiotics. “Part of it is a human condition—that we are overoptimistic about lots of things, like not developing cancer or not getting into a motor accident or that our investments will return a good yield. It is a bias we all have,” he says.

     “It is a complicated issue, ranging from doctors’ being ill-informed to being in denial, to being in the habit of using antibiotics routinely,” Del Mar says. “Hence, we have an inflationary mixture in the consultation: patients who grossly overestimate the benefits of antibiotics and clinicians who also overestimate their benefits, and probably neither thinking about their harms much.”

    REFERENCES

    1. Coxeter PD, Del Mar C, Hoffmann TC. Parents’ expectations and experiences of antibiotics for acute respiratory infections in primary care. Ann Family Med. 2017;15(2):149-154.

    2. Hoffmann TC, Del Mar C. Patients' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2015;175(2):274-286.

    3. Hoffmann TC, Légaré F, Simmons MB, et al. Shared decision making: what do clinicians need to know and why should they bother? Med J Aust. 2014;201(1):35-39.

    4. Coxeter P, Del Mar CB, McGregor L, Beller EM, Hoffmann TC. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care. Cochrane Database Syst Rev. 2015;11:CD010907.

    5. McCullough AR, Parekh S, Rathbone J, Del Mar CB, Hoffmann TC. A systematic review of the public’s knowledge and beliefs about antibiotic resistance. J Antimicrob Chemother. 2016;71(1):27-33.

    6. Hoffmann TC, Del Mar C. Clinicians’ expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2017;177(3):407-419.

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