May 1998
ATLANTA - A recent survey of caregivers' knowledge, attitudes and practices regarding antibiotic use for children's upper respiratory infections found that most caregivers believe that the overuse of antibiotics can make them less effective. However, many have limited understanding of antibiotics and their appropriate use.
"In the United States, the overuse of antibiotics in the ambulatory setting is widespread. Antibiotic use has been associated with both colonization and invasive disease due to antibiotic-resistant bacteria," said Mary Jo Trepka, MD, here at the First International Conference on Emerging Infectious Diseases. "Children have the highest rates of antibiotic use, and many parents expect antibiotics for their children's upper respiratory infections. Physicians cite patient demand as a motivation for antibiotic prescription. Thus, interventions to decrease unnecessary antibiotic use among children should be focused not only on physicians and caregivers but on parents of pediatric patients, as well."
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Trepka and her colleagues conducted a cross-sectional telephone survey of primary adult caregivers of children younger than 4 years old. Those surveyed included eligible households in the Marshfield Epidemiologic Study Area, a rural area of 22 zip codes in north-central Wisconsin with a population of approximately 82,000.
"We used a 31-item questionnaire to assess demographic characteristics of the caregiver and child and knowledge, attitudes and practices of the primary caregiver," she said. "The sampling frame included the 3,612 households with one or more children younger than 4 years old identified from study area records. At least two daytime and two evening at tempts per household were made until a total of 430 respondents was achieved."
Of 763 randomly selected households, 3% were excluded because the child was 4 years old by the time the survey began, 4% refused and 36% were not reached prior to achieving the target number of respondents.
Of respondent primary caregivers, 2% were not parents, and these people were deleted from the subsequent analysis, leaving 422 participants. Among primary caregivers, 89% were mothers, 37% had no more than a high school education and the mean age was 30 years.
Seventy-two percent of the children in the survey had private insurance coverage, and 37% attended out-of-home child care. Thirty-five percent were the firstborn child in the household. Nearly all were white and non-Hispanic.
"We grouped selected responses into three categories: medication misclassification, belief that antibiotics are needed for viral infections and antibiotic resistance knowledge. Univariate analyses tested the association among each of these outcomes and the following variables: caregiver age, education, gender, source of medical information, child's insurance, child care attendance and birth order," Trepka said.
To assess potential misclassification medications, caregivers were asked to state if each of six medications was an antibiotic or not. Incorrect responses included misclassifying the medication or answering, "I don't know."
Twenty-four percent did not classify either penicillin, amoxicillin or erythromycin as an antibiotic, and most of these errors were due to erythromycin. Seven percent incorrectly classified aspirin, acetaminophen or cough syrup as an antibiotic. "In the multivariate model, including all of these variables, less education and no private insurance were associated with more misclassifications," she said.
For each of a series of scenarios, caregivers were asked if antibiotics are always, sometimes or never needed. Most (62%) of the caregivers thought that antibiotics are always or sometimes needed for influenza with cough and body aches; and 52% thought that antibiotics are needed for colds. Forty-five percent thought that they were needed for dry cough with no fever.
"In the multivariate model, education, gender of caregiver and caregiver age were independently associated with these beliefs. Compared to being a college graduate, having a high school education or less had an odds ratio of 2.1. The father as caregiver and age younger than 30 years had odds ratios of 3.1 and 2.2, respectively," she added.
Three questions assessed caregivers' understanding of antibiotic resistance. Most (89%) caregivers agreed that some germs are getting harder to treat with antibiotics, and 87% agreed that if antibiotics are overused, they will not work as well for treating infections. However, only 65% agreed that if antibiotics are used frequently in their own child, the child may be infected with bacteria that are hard to treat. Fifty-nine percent agreed with all three statements.
"In addition to knowledge and attitudes, we also assessed certain caregiver practices during the six months prior to the survey. Sixty percent of the caregivers reported having called their clinic for advice about upper respiratory symptoms, and 12% stated that they had not received an antibiotic when they felt that their child needed one. Four percent reported taking their child to a second clinician to obtain an antibiotic because the first clinician did not prescribe one," she said.
A small percentage reported inappropriate practices, such as stopping antibiotics prior to completing the course, being prescribed an antibiotic over the phone by a physician without the physician seeing the child, using a saved antibiotic in the index child for a later infection or saving an antibiotic from the index child and using it on another child for whom it was not prescribed.
However, there are some limitations with this survey. The study was done in a rural area that has a relatively homogeneous population; therefore, the results may not be generalized, she said.
Additionally, households without phones were not contacted, so some people with low socioeconomic status were probably excluded. All answers were self-reported, and actual antibiotic use was not assessed.
"Other factors such as pressure not to stay home from work to nurse a sick child may be more important than knowledge or attitudes. In addition, caregivers may have been hesitant to report practices such as using antibiotics on another child when they knew that this was not a good practice," Trepka said. "Based on these findings, we recommend that parents be educated that viral illnesses such as colds and flu do not need antibiotic treatment and overuse of antibiotics can be harmful to their own child, that efforts be especially focused on people with less education and lower socioeconomic status and that additional research be undertaken to determine which factors most greatly influence parents' and physicians' behavior regarding antibiotic use."
For more information:
- Trepka MJ. Knowledge, attitudes and practices of caregivers regarding antibiotic use for children's upper respiratory infections. Presented at the First International Conference on Emerging Infectious Diseases. March 8-11. Atlanta.
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