Risk Factors of Antibiotic Misuse for Upper Respiratory Tract Infections in Children: Results from a Cross-Sectional Knowledge-Attitude-Practice Study in Greece
Background. Upper respiratory tract infections (URTIs) are common in children. The cause of URTIs is usually viral, but parents’ attitudes often contribute to inappropriate prescription of antibiotics, promoting antibiotic resistance. The objective of this study was to identify possible risk factors associated with antibiotic misuse in Greece, a country with high levels of antibiotic use and antibiotic resistance. Methods. A knowledge-attitude-practice (KAP) questionnaire was developed and distributed to Greek parents caring for children who were 5-6 years old, between January and July of the same school year. Results. The sample of the study contained 5312 parents from all geographic areas of Greece. The risk factors of being a father, having low education, having immigrant status, being a single parent, having low income, having <2 or >3 children, living in the islands, and being without experience in recurrent URTIs were significantly associated to inadequate knowledge, inappropriate attitudes, and wrong practices. Conclusions. This study has identified the main groups of parents that should be targeted in future intervention programs. 1. Introduction Upper respiratory tract infections (URTIs) in children are mainly due to viral infections [1, 2]. Thus, the benefit from antimicrobial drugs is minimal. However, there is strong evidence that antibiotics are frequently administered to children suffering from URTIs [3, 4]. It appears that both pediatricians and parents are responsible for this antibiotic misuse [5–7] which is contributing to the development of resistant strains of bacterial pathogens [8–10] and placing a burden on the economy of the health care system. Amongst European countries, Greece presents the highest antibiotic consumption and antibiotic resistance [11]. In order to reveal the contributing factors of this phenomenon, a knowledge, attitude, and practice (KAP) study of Greek parents towards antibiotic use in children suffering from URTIs was performed. The objective of the current study was to identify possible risk factors associated with antibiotic misuse. This would enable the development of intervention strategies aiming to parental education. 2. Materials and Methods 2.1. Study Design and Settings The study sample comprised of parents from all geographic areas of Greece. A school-based stratified geographic clustering sampling was used to select a representative sample of students. Seven thousand seven hundred and four parents (7704) of children aged between 5 and 6 years old participated in the survey. Approval was given by
References
[1]
A. L. Nordlie and B. M. Andersen, “Parents' attitudes to the prescription of antibiotics to children,” Tidsskrift for den Norske Laegeforening, vol. 124, no. 17, pp. 2229–2231, 2004.
[2]
J. C. Bu？uel álvarez, E. Fortea Gimeno, R. B. Cortés Marina, C. Vila Pablos, F. Blanch Risec, and M. Estany Delgado, “Antibiotic use in primary care. Do we know what parents think?” Anales de Pediatria, vol. 61, no. 4, pp. 298–304, 2004.
[3]
E. Paluck, D. Katzenstein, C. J. Prankish et al., “Prescribing practices and attitudes toward giving children antibiotics,” Canadian Family Physician, vol. 47, pp. 521–527, 2001.
[4]
J. C. Pechère, “Patients' interviews and misuse of antibiotics,” Clinical Infectious Diseases, vol. 33, no. 3, pp. S170–S173, 2001.
[5]
R. Mangione-Smith, E. A. McGlynn, M. N. Elliott, L. McDonald, C. E. Franz, and R. L. Kravitz, “Parent expectations for antibiotics, physician-parent communication, and satisfaction,” Archives of Pediatrics and Adolescent Medicine, vol. 155, no. 7, pp. 800–806, 2001.
[6]
R. L. Watson, S. F. Dowell, M. Jayaraman, H. Keyserling, M. Kolczak, and B. Schwartz, “Antimicrobial use for pediatric upper respiratory infections: reported practice, actual practice, and parent beliefs,” Pediatrics, vol. 104, no. 6, pp. 1251–1257, 1999.
[7]
L. F. McCaig, R. E. Besser, and J. M. Hughes, “Trends in antimicrobial prescribing rates for children and adolescents,” Journal of the American Medical Association, vol. 287, no. 23, pp. 3096–3102, 2002.
[8]
A. Harnden, R. Perera, A. B. Brueggemann et al., “Respiratory infections for which general practitioners consider prescribing an antibiotic: a prospective study,” Archives of Disease in Childhood, vol. 92, no. 7, pp. 594–597, 2007.
[9]
R. Mangione-Smith, M. N. Elliott, T. Stivers, L. McDonald, J. Heritage, and E. A. McGlynn, “Racial/ethnic variation in parent expectations for antibiotics: implications for public health campaigns,” Pediatrics, vol. 113, no. 5, pp. e385–e394, 2004.
[10]
H. Bauchner, S. I. Pelton, and J. O. Klein, “Parents, physicians, and antibiotic use,” Pediatrics, vol. 103, no. 2, pp. 395–401, 1999.
[11]
Total Outpatient Antibiotic Use (ATC J01) in 27 European Countries, ECDC, 2006 http://www.ecdc.europa.eu/.
[12]
S. G. Panagakou, M. N. Theodoridou, V. Papaevangelou et al., “Development and assessment of a questionnaire for a descriptive cross-sectional study concerning parents' knowledge, attitudes and practices in antibiotic use in Greece,” BMC Infectious Diseases, vol. 9, article 52, 2009.
[13]
S. G. Panagakou, I. Spyridis, V. Papaevangelou et al., “Antibiotic use for upper respiratory tract infections in children: a cross-sectional survey of knowledge, attitudes, and practices (KAP) of parents in Greece,” BMC Pediatrics, vol. 11, article 60, 2011.
[14]
A. W. Sturm, R. Van Der Pol, A. J. Smits et al., “Over-the-counter availability of antimicrobial agents, self-medication and patterns of resistance in Karachi, Pakistan,” Journal of Antimicrobial Chemotherapy, vol. 39, no. 4, pp. 543–547, 1997.
[15]
N. Rosenstein, W. R. Phillips, M. A. Gerber, S. M. Marcy, B. Schwartz, and S. F. Dowell, “The common cold—principles of judicious use of antimicrobial agents,” Pediatrics, vol. 101, no. 1, supplement, pp. 181–184, 1998.
[16]
K. L. O'Brien, S. F. Dowell, B. Schwartz, S. M. Marcy, W. R. Phillips, and M. A. Gerber, “Cough illness/bronchitis—principles of judicious use of antimicrobial agents,” Pediatrics, vol. 101, no. 1, pp. 178–181, 1998.
[17]
S. F. Dowell, S. M. Marcy, W. R. Phillips, M. A. Gerber, and B. Schwartz, “Otitis media—principles of judicious use of antimicrobial agents,” Pediatrics, vol. 101, no. 1, pp. 165–171, 1998.
[18]
A. L. Kozyrskyj, G. E. Hildes-Ripstein, S. E. A. Longstaffe et al., “Treatment of acute otitis media with a shortened course of antibiotics: a meta-analysis,” Journal of the American Medical Association, vol. 279, no. 21, pp. 1736–1742, 1998.
[19]
R. Watson, “More than 15% of antibiotic sales in Greece are over the counter,” British Medical Journal, vol. 340, article c2143, 2010.
[20]
D. Plachouras, D. Kavatha, A. Antoniadou et al., “Dispensing of antibiotics without prescription in Greece, 2008: another link in the antibiotic resistance chain,” Eurosurveillance, vol. 15, no. 7, pp. 1–4, 2010.
[21]
A. Al Tenaiji, J. Al Mutawa, K. Al Redha, et al., “Knowledge, attitudes and behavior towards Antibiotic Use among Parents in Al Ain,” in Proceedings of the 1st Annual Student Research Symposium Faculty of Medicine and Health Sciences, U.A.E. University, 2006.
[22]
K. Kleinman, S. Rifas-Shiman, and J. A. Finkelstein, “Correlates of parental antibiotic knowledge, demand, and reported use,” Ambulatory Pediatrics, vol. 3, no. 4, pp. 203–210, 2003.
[23]
V. Shlomo, R. Adi, and K. Eliezer, “The knowledge and expectations of parents about the role of antibiotic treatment in upper respiratory tract infection—a survey among parents attending the primary physician with their sick child,” BMC Family Practice, vol. 4, article 20, 2003.
[24]
S. R. Arnold, T. To, W. J. McIsaac, and E. E. L. Wang, “Antibiotic prescribing for upper respiratory tract infection: the importance of diagnostic uncertainty,” Journal of Pediatrics, vol. 146, no. 2, pp. 222–226, 2005.
[25]
B. L. Braun and J. B. Fowles, “Characteristics and experiences of parents and adults who want antibiotics for cold symptoms,” Archives of Family Medicine, vol. 9, no. 7, pp. 589–595, 2000.
[26]
R. Mangione-Smith, M. N. Elliott, T. Stivers, L. McDonald, J. Heritage, and E. A. McGlynn, “Racial/ethnic variation in parent expectations for antibiotics: implications for public health campaigns,” Pediatrics, vol. 113, no. 5, pp. e385–e394, 2004.
[27]
E. Ladd, “The use of antibiotics for viral upper respiratory tract infections: an analysis of nurse practitioner and physician prescribing practices in ambulatory care, 1997–2001,” Journal of the American Academy of Nurse Practitioners., vol. 17, no. 10, pp. 416–424, 2005.
[28]
M. Kuzujanakis, K. Kleinman, S. Rifas-Shiman, and J. A. Finkelstein, “Correlates of parental antibiotic knowledge, demand, and reported use,” Ambulatory Pediatrics, vol. 3, no. 4, pp. 203–210, 2003.
[29]
C. Lewis, “Fathers and preschoolers,” in The Role of the Father in Child Development, M. E. Lamb, Ed., pp. 121–142, Wiley, New York, NY, USA, 3rd edition, 1997.
[30]
K. Maridaki-Kassotaki, “Understanding fatherhood in Greece: father's involvement in child care,” Psicologia: Teoria e Pesquisa, vol. 16, no. 3, pp. 213–219, 2000.
[31]
N. Thrane, C. Olesen, H. C. Sch？nheyder, and H. T. S？rensen, “Socioeconomic factors and prescription of antibiotics in 0- to 2-year-old Danish children,” Journal of Antimicrobial Chemotherapy, vol. 51, no. 3, pp. 683–689, 2003.
[32]
A. L. Kozyrskyj, M. E. Dahl, D. G. Chateau, G. B. Mazowita, T. P. Klassen, and B. J. Law, “Evidence-based prescribing of antibiotics for children: role of socioeconomic status and physician characteristics,” Canadian Medical Association Journal, vol. 171, no. 2, pp. 139–145, 2004.
[33]
V. Papaevangelou, A. Rousounides, A. Hadjipanagis, A. Katsioulis, M. Theodoridou, and C. Hadjichristodoulou, “Decrease of antibiotic consumption in children with upper respiratory tract infections after implementation of an intervention program in cyprus,” Antimicrobial Agents and Chemotherapy, vol. 56, no. 3, pp. 1658–1661, 2012.
