Trends in antibiotic prescribing in Dutch general practice and determinants of nonprudent antibiotic prescriptions.

BACKGROUND: Antibiotic resistance is mainly driven by (incorrect) use of antibiotics. Most antibiotics are prescribed in family medicine. Therefore, regularly monitoring of antibiotic prescriptions and evaluation of their (non-) prudent use in primary care is warranted. OBJECTIVES: The aim of this study was to determine time trends in antibiotic prescriptions by Dutch family physicians (FPs) and to identify determinants of nonprudent antibiotic prescriptions by Dutch FPs. METHODS: Retrospective study among 27 Dutch general practices from the Research Network Family Medicine Maastricht, from 2015 to 2019. RESULTS: In total 801,767 patient years were analysed. Antibiotic prescriptions mainly increased in patients aged 65+ while prescriptions mainly decreased in patients below 65 years. Nonprudent antibiotic prescriptions decreased from 2015 to 2019 with the highest percentage of decline found in skin infections (66.9% [2015] to 53.9% [2019]). Overall, higher likelihood of nonprudent antibiotic prescriptions was found among men (odds ratio [OR] 4.11, 95% confidence interval [CI]: 3.91-4.33), patients aged 80+ (OR 1.44, 95% CI: 1.03-2.01; reference category ≤17 years), patients with comedication (OR 1.24, 95% CI: 1.17-1.31), and patients in urban general practices (OR 1.47, 95% CI: 1.38-1.56). CONCLUSIONS: Antibiotic prescriptions increased over time in the elderly aged categories. Although an overall decrease in nonprudent antibiotic prescriptions was established from 2015 to 2019, percentages of nonprudent prescriptions remained high for skin infections and respiratory tract infections. Additionally, men, elderly aged patients (80+), patients with comedication and patients in urban general practices were more likely to receive nonprudent antibiotic prescriptions. Our results will help FPs to prioritize optimalization of antibiotic prescriptions in family medicine.

Detection and management of milk allergy: Delphi consensus study.

BACKGROUND: There is significant overdiagnosis of milk allergy in young children in some countries, leading to unnecessary use of specialized formula. This guidance, developed by experts without commercial ties to the formula industry, aims to reduce milk allergy overdiagnosis and support carers of children with suspected milk allergy. METHODS: Delphi study involving two rounds of anonymous consensus building and an open meeting between January and July 2021. Seventeen experts in general practice, nutrition, midwifery, health visiting, lactation support and relevant areas of paediatrics participated, located in Europe, North America, Middle East, Africa, Australia and Asia. Five authors of previous milk allergy guidelines and seven parents provided feedback. FINDINGS: Participants agreed on 38 essential recommendations through consensus. Recommendations highlighted the importance of reproducibility and specificity for diagnosing milk allergy in children with acute or delayed symptoms temporally related to milk protein ingestion; and distinguished between children directly consuming milk protein and exclusively breastfed infants. Consensus was reached that maternal dietary restriction is not usually necessary to manage milk allergy, and that for exclusively breastfed infants with chronic symptoms, milk allergy diagnosis should only be considered in specific, rare circumstances. Consensus was reached that milk allergy diagnosis does not need to be considered for stool changes, aversive feeding or occasional spots of blood in stool, if there is no temporal relationship with milk protein ingestion. When compared with previous guidelines, these consensus recommendations resulted in more restrictive criteria for detecting milk allergy and a more limited role for maternal dietary exclusions and specialized formula. INTERPRETATION: These new milk allergy recommendations from non-conflicted, multidisciplinary experts advise narrower criteria, more prominent support for breastfeeding and less use of specialized formula, compared with current guidelines.

Cross-sectional internet survey exploring women's knowledge, attitudes and practice regarding urinary tract infection-related symptoms in the Netherlands.

OBJECTIVES: Urinary tract infections (UTIs) are the most prevalent cause for women to consult a general practitioner (GP) and are commonly treated with (broad-spectrum) empirical antibiotics, even though 50% of UTIs are self-limiting. In this study, we aim to explore women's attitudes and experiences regarding UTIs, in order to determine patients' willingness to accept delayed antibiotic prescriptions. DESIGN: An internet-based cross-sectional survey SETTING: We recruited participants during 2 weeks of March and April in 2020 through several social media platforms. PARTICIPANTS: We obtained 1476 responses, of which 975 were eligible for analysis. RESULTS: We asked women about their knowledge, attitudes and practice regarding UTI-related symptoms. Participants ranked 'confirmation of diagnosis' (43.8%) as the most important reason to consult a GP with urinary symptoms, followed by 'pain relief' (32%), and 'antibiotic prescription' (14.3%). For treatment, 71% of participants reported that their GP prescribed immediate antibiotics, while only 3% received a delayed antibiotic prescription and 1% was advised pain medication. Furthermore, 50% of respondents were aware of the possible self-limiting course of UTIs and 70% would be willing to accept delayed antibiotic treatment, even if a certain diagnosis of UTI was established. Willingness to delay was lower in experienced patients compared to inexperienced patients. CONCLUSIONS: Women are quite receptive to delayed antibiotics as an alternative to immediate antibiotics for UTIs or urinary symptoms. GPs should consider discussing delayed antibiotic treatment more often with women presenting with urinary symptoms.

Workload, diagnostic work-up and treatment of urinary tract infections in adults during out-of-hours primary care: a retrospective cohort study.

BACKGROUND: Urinary tract infections (UTIs) are one of the most common infections in primary care. Previous research showed that GPs find it challenging to diagnose UTIs and frequently divert from guidelines leading to unwarranted antibiotic prescriptions and inefficient use of diagnostics such as urinary cultures. We hypothesise that management of UTIs during out-of-hours care may be extra challenging due to a higher workload and logistical issues regarding diagnostic work-up and obtaining results. We therefore aimed to study the workload, diagnostic work-up and treatment of UTIs during out-of-hours primary care. METHODS: We performed a retrospective observational cohort study in which we analysed a full year (2018) of electronic patient records of two large Dutch GP out-of-hours centres. All adult patients with UTI symptoms were included in this study. Descriptive statistics and multivariate regression were used to analyse diagnostics and subsequent management. RESULTS: A total of 5657 patients were included (78.9% female, mean age of 54 years), with an average of eight patients per day that contact a GP out-of-hours centre because of UTI symptoms. Urinary dipsticks were used in 87.5% of all patients visiting the out-of-hours centres with UTI symptoms. Strikingly, urinary cultures were only requested in 10.3% of patients in which urinary culture was indicated. Seventy-four percent of the patients received antibiotics. Seventy-nine percent of the patients with a negative nitrite test still received antibiotics. Remarkably, patients at risk of complications because of a UTI, such as men, received fewer antibiotic prescriptions. CONCLUSIONS: In total, 74% of the patients received antibiotics. 8 out of 10 patients still received an antibiotic prescription in case of a negative nitrite test, and 9 out of 10 patients with an indication did not receive a urine culture. In conclusion, we found that correctly diagnosing UTIs and prescribing antibiotics for UTIs is a challenge that needs major improvement, especially during out-of-hours GP care.

How well are sepsis and a sense of urgency documented throughout the acute care chain in the Netherlands? A prospective, observational study.

OBJECTIVE: To investigate the documentation of sepsis and a sense of urgency throughout the acute care chain. DESIGN: Prospective cohort study. SETTING: Emergency department (ED) in a large district hospital in Heerlen, The Netherlands. PARTICIPANTS: Participants included patients ≥18 years with suspected sepsis who visited the ED during out-of-hours between September 2017 and January 2018 (n=339) and had been referred by a general practitioner and/or transported by ambulance. We defined suspected sepsis as suspected or proven infection and the presence of ≥2 quick Sepsis-related Organ Failure Assessment and/or ≥2 Systemic Inflammatory Response Syndrome criteria. OUTCOME MEASURES: We analysed how often sepsis and a sense of urgency were documented in the prehospital and ED medical records. A sense of urgency was considered documented when a medical record suggested the need of immediate assessment by a physician in the ED. We described documentation patterns throughout the acute care chain and investigated whether documentation of sepsis or a sense of urgency is associated with adverse outcomes (intensive care admission/30-day all-cause mortality). RESULTS: Sepsis was documented in 16.8% of medical records and a sense of urgency in 22.4%. In 4.1% and 7.7%, respectively, sepsis and a sense of urgency were documented by all involved professionals. In patients with an adverse outcome, sepsis was documented more often in the ED than in patients without an adverse outcome (47.9% vs 13.7%, p<0.001). CONCLUSIONS: Our study shows that in prehospital and ED medical records, sepsis and a sense of urgency are documented in one out of five patients. In only 1 out of 20 patients sepsis or a sense of urgency is documented by all involved professionals. It is possible that poor documentation causes harm, due to delayed diagnosis or treatment. Hence, it could be important to raise awareness among professionals regarding the importance of their documentation.

Inappropriate Antibiotic Allergy Documentation in Health Records: A Qualitative Study on Family Physicians' and Pharmacists' Experiences.

PURPOSE: It is hypothesized that 90% of antibiotic allergies documented in patients' health records are not actual, potentially life threatening, type I allergies mediated by IgE. This distinction is important because such documentation increases antibiotic resistance, as more second-choice and broad-spectrum antibiotics are then used. Evidence is lacking regarding causes of this inappropriate documentation. To develop interventions aimed at improving documentation, we explored experiences of family physicians and pharmacists in this area. METHODS: We conducted a qualitative study among family physicians and pharmacists using focus group discussions, based on purposeful sampling and a naturalistic approach. Discussions were audio-recorded, transcribed verbatim, and analyzed in duplicate by means of constant comparative technique. RESULTS: We conducted 4 focus group discussions among 34 family physicians and 10 pharmacists, from which 3 main themes emerged: (1) magnitude and awareness of the problem of inappropriate antibiotic allergy documentation, (2) origin of the problem, and (3) approaches for addressing the problem. Participants noted that the magnitude of contamination of medical files with inappropriate documentation leads to skepticism about current documentation. Major hindering factors are electronic health record systems and electronic communication. In addition, family physicians and pharmacists believed they had insufficient knowledge about antibiotic allergies and called for tools to rectify inappropriate allergy documentation and facilitate proper documentation going forward. CONCLUSIONS: Family physicians and pharmacists perceive that few documented antibiotic allergies are in fact correct. Electronic health record barriers and communication barriers, as well as a lack of knowledge and facilitating tools, are main causes for numerous inappropriately documented antibiotic allergies and therefore targets for improving documentation in the future.

Childhood fever: Parental paracetamol administration after consulting out-of-hours general practice.

Background: Current guidelines emphasise prudent use of paracetamol in febrile children without pain. Little evidence is available on paracetamol administration by parents in general and post-GP-consultations.Objectives: To investigate if and how often parents of febrile children administer paracetamol to their child after consulting a GP during out-of-hours care. To explore if condition (painful or not), socio-economic status and age influenced this behaviour.Methods: This was a pre-planned secondary study, attached to an RCT (n = 25,355) that studied the effect of an illness-focused interactive booklet on antibiotic prescriptions in febrile children between three months and 12 years, at 20 GP out-of-hours centres across the Netherlands. Baseline data and ICPC codes were retrieved from the GP out-of-hours centre database. During a telephone survey two weeks after consulting a GP out-of-hours centre, a random sample of parents was asked if and how often they had given their child paracetamol.Results: Parents of 548 children participated. Most parents administrated paracetamol for two weeks after consulting (83.8%). Children received 11 doses on average during follow-up (maximum 72 doses). Paracetamol administration increased with age. Age three to six months received paracetamol in 68% (17/25) of the cases versus 89.6% (121/135) in children aged five to twelve years. Frequency of paracetamol administration was similar for most common infections, regardless of being painful or painless.Conclusion: Most children who consulted out-of-hours general practice for fever and common infections received paracetamol at home during their illness episode, regardless of a painful condition being present. Paracetamol administration increased with age.

Symptomatic Management of Febrile Illnesses in Children: A Systematic Review and Meta-Analysis of Parents' Knowledge and Behaviors and Their Evolution Over Time.

Recommendations to guide parents' symptomatic management of febrile illnesses in children have been published in many countries. The lack of systematic appraisal of parents' knowledge and behaviors and their evolution over time precludes an analysis of their impact and identification of targets for future educational messages. We systematically searched for studies published between 1980 and 2016 that reported a quantitative evaluation of knowledge and behaviors of >50 parents for managing fever in children. We used MEDLINE and tracked related articles, citations and co-authors personal files. Study selection and data extraction were independently performed by two reviewers. For each item of knowledge and behaviors, we calculated mean frequencies during the first and last quinquennials of the studied period and assessed temporal trends with inverse-variance weighted linear regression of frequencies over years. We observed substantial methodological heterogeneity among the 62 included articles (64 primary studies, 36,791 participants, 30 countries) that met inclusion criteria. Statistically significant changes over time were found in the use of rectal (98 to 4%) and axillary temperature measurement (1-19%), encouraging fluid intake (19-62%), and use of acetylsalicylic acid (60 to 1%). No statistically significant change was observed for the accurate definition of fever (38-55%), or the use of acetaminophen (91-92%) or ibuprofen (20-43%). Parents' knowledge and behaviors have changed over time but continue to show poor concordance with recommendations. Our study identified future targets for educational messages, including basic ones such as the definition of fever.

Booklet for Childhood Fever in Out-of-Hours Primary Care: A Cluster-Randomized Controlled Trial.

PURPOSE: Fever is the most common reason for a child to be taken to a physician, yet the level of unwarranted antibiotic prescribing remains high. We aimed to determine the effect on antibiotic prescribing of providing an illness-focused interactive booklet on fever in children to out-of-hours primary care clinicians. METHODS: We conducted a cluster-randomized controlled trial in 20 out-of-hours general practice centers in the Netherlands. Children aged younger than 12 years with fever were included. Family physicians at the 10 intervention sites had access to an illness-focused interactive booklet between November 2015 and June 2016. The primary outcome was antibiotic prescribing during the index consultation. Analysis was performed by fitting 2-level random intercept logistic regression models. RESULTS: The trial took place among 3,518 family physicians and 25,355 children. The booklet was used in 28.5% of 11,945 consultations in the intervention group. Compared with usual care, access to the booklet did not significantly alter antibiotic prescribing during the index consultation (odds ratio = 0.90; 95% CI, 0.79-1.02; prescription rate, 23.5% vs 25.2%; intracluster correlation coefficient = 0.005). In contrast, use of the booklet significantly reduced antibiotic prescribing (odds ratio = 0.83; 95% CI, 0.74-0.94; prescription rate, 21.9% vs 25.2%; intracluster correlation coefficient = 0.002). Children managed by family physicians with access to the booklet were less likely to receive any drug prescription, and parents in the booklet group showed a reduced intention to consult again for similar illnesses. CONCLUSIONS: Benefit of an illness-focused interactive booklet in improving outcomes of childhood fever in out-of-hours primary care was largely restricted to the cases in which family physicians actually used the booklet. Insight into reasons for use and nonuse may inform future interventions of this type.

Parental knowledge, attitudes and beliefs on fever: a cross-sectional study in Ireland.

OBJECTIVES: Fever is a common symptom of mostly benign illness in young children, yet concerning for parents. The aim of this study was to describe parental knowledge, attitudes and beliefs regarding fever in children aged ≤5 years of age. DESIGN: A cross-sectional study using a previously validated questionnaire. Results were analysed using descriptive statistics and multivariable logistic regression. SETTING: Purposively selected primary schools (n=8) in Cork, Ireland, using a paper-based questionnaire. Data were collected from a cross-sectional internet-based questionnaire with a convenience sample of parents via websites and web pages (n=10) previously identified in an interview study. PARTICIPANTS: Parents with at least one child aged ≤5 years were invited to participate in the study. MAIN OUTCOME MEASURES: Parental knowledge, attitudes and beliefs when managing fever in children. RESULTS: One thousand one hundred and four parents contributed to this research (121 parents from schools and 983 parents through an online questionnaire). Almost two-thirds of parents (63.1%) identified temperatures at which they define fever that were either below or above the recognised definition of temperature (38°C). Nearly two of every three parents (64.6%) alternate between two fever-reducing medications when managing a child's fever. Among parents, years of parenting experience, age, sex, educational status or marital status did not predict being able to correctly identify a fever, neither did they predict if the parent alternated between fever-reducing medications. CONCLUSIONS: Parental knowledge of fever and fever management was found to be deficient which concurs with existing literature. Parental experience and other sociodemographic factors were generally not helpful in identifying parents with high or low levels of knowledge. Resources to help parents when managing a febrile illness need to be introduced to help all parents provide effective care.

An illness-focused interactive booklet to optimise management and medication for childhood fever and infections in out-of-hours primary care: study protocol for a cluster randomised trial.

BACKGROUND: Fever is the most common reason for a child to be taken to a general practitioner (GP), especially during out-of-hours care. It is mostly caused by self-limiting infections. However, antibiotic prescription rates remain high, especially during out-of-hours care. Anxiety and lack of knowledge among parents, and perceived pressure to prescribe antibiotics amongst GPs, are important determinants of excessive antibiotic prescriptions. An illness-focused interactive booklet has the potential to improve this by providing parents with information about fever self-management strategies. The aim of this study is to develop and determine the effectiveness of an interactive booklet on management of children presenting with fever at Dutch GP out-of-hours cooperatives. METHODS/DESIGN: We are conducting a cluster randomised controlled trial (RCT) with 20 GP out-of-hours cooperatives randomised to 1 of 2 arms: GP access to the illness-focused interactive booklet or care as usual. GPs working at intervention sites will have access to the booklet, which was developed in a multistage process. It consists of a traffic light system for parents on how to respond to fever-related symptoms, as well as information on natural course of infections, benefits and harms of (antibiotic) medications, self-management strategies and 'safety net' instructions. Children < 12 years of age with parent-reported or physician-measured fever are eligible for inclusion. The primary outcome is antibiotic prescribing during the initial consultation. Secondary outcomes are (intention to) (re)consult, antibiotic prescriptions during re-consultations, referrals, parental satisfaction and reassurance. In 6 months, 20,000 children will be recruited to find a difference in antibiotic prescribing rates of 25% in the control group and 19% in the intervention group. Statistical analysis will be performed using descriptive statistics and by fitting two-level (GP out-of-hours cooperative and patient) random intercept logistic regression models. DISCUSSION: This will be the first and largest cluster RCT evaluating the effectiveness of an illness-focused interactive booklet during GP out-of-hours consultations with febrile children receiving antibiotic prescriptions. It is hypothesised that use of the booklet will result in a reduced number of antibiotic prescriptions, improved parental satisfaction and reduced intention to re-consult. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02594553 . Registered on 26 Oct 2015​, last updated 15 Sept 2016.

Medication management of febrile children: a qualitative study on pharmacy employees' experiences.

Background While fever is mostly self-limiting, antibiotic prescription rates for febrile children are high. Although every parent who receives a prescription visits a pharmacy, we have limited insight into pharmacy employees' experiences with these parents. Pharmacy employees do however exert an important role in ensuring children receive correct dosages and in advising parents on administration of antibiotics. Objective To describe pharmacists' and pharmacy assistants' experiences with parents contacting a pharmacy for their febrile child, and to identify ways of improving medication management of these children. Setting Community pharmacies in the Netherlands. Method A qualitative study including 24 Dutch pharmacy employees was conducted, performing four focus group discussions among pharmacy employees. Analysis was based on constant comparative technique using open and axial coding. Main outcome measure Pharmacy employees' experiences with parents contacting a pharmacy for their febrile child. Results Three categories were identified: (1) workload and general experience, (2) inconsistent information on antibiotic prescriptions, (3) improving communication and collaboration. Pharmacy employees experienced that dosing errors in antibiotic prescriptions occur frequently and doctors provide inconsistent information on prescriptions. Consequently, they have to contact doctors, resulting in a higher workload for both stakeholders. They believe this can be improved by providing the indication for antibiotics on prescriptions, especially when deviating from standard dosages. Conclusion Pharmacy employees experience a high amount of dosing errors in paediatric antibiotic prescriptions. Providing the indication for antibiotics in febrile children on prescriptions, especially when deviating from standard dosages, can potentially reduce dosage errors and miscommunication between doctors and pharmacy employees.

Childhood fever: a qualitative study on parents' expectations and experiences during general practice out-of-hours care consultations.

BACKGROUND: Fever in children is common and mostly caused by benign self-limiting infections. Yet consultation rates in primary care are high, especially during GP out-of-hours care. Therefore, we aimed to explore experiences of parents when having visited GP out-of-hours services with their febrile child. METHODS: We performed a qualitative study using 20 semi-structured interviews among parents from different backgrounds presenting to GP out-of-hours care with a febrile child <12 years. Questions were directed at parental motivations, expectations and experiences when visiting the GP out-of-hours centre with a febrile child. Interviews were audio-recorded, transcribed and analysed using constant comparison technique. RESULTS: We identified four main categories emerging from the data; (1) cautiously seeking care, (2) discrepancy between rationality and emotion, (3) expecting reassurance from a professional and (4) a need for consistent, reliable information. Not one symptom, but a combination of fever with other symptoms, made parents anxious and drove care seeking. Although parents carefully considered when to seek care, they experienced increased anxiety with increases in their child's temperature. Because parents work during the day and fever typically rises during the early evening, the decision to seek care was often made during out-of-hours care. When parents consulted a GP they did not have any set expectations other than seeking reassurance, however a proper physical examination diminished their anxiety. Parents did not demand antibiotics, but trusted on the expertise of the GP to assess necessity. Parents requested consistent, reliable information on fever and self-management strategies. CONCLUSIONS: Parents were inexperienced in self-management strategies and had a subsequent desire for reassurance; this played a pivotal role in out-of-hours help seeking for childhood fever. These factors provide clues to optimise information exchange between GPs and parents, by providing written, tailored, consistent information on self-management strategies for current and future fever episodes. GPs' had incorrect assumptions that parents expected antibiotic treatment.

Patient information leaflets to reduce antibiotic use and reconsultation rates in general practice: a systematic review.

OBJECTIVE: Patients' knowledge and expectations may influence prescription of antibiotics. Therefore, providing evidence-based information on cause of symptoms, self-management and treatment is essential. However, providing information during consultations is challenging. Patient information leaflets could facilitate consultations by increasing patients' knowledge, decrease unnecessary prescribing of antibiotics and decrease reconsultations for similar illnesses. Our objective was to systematically review effectiveness of information leaflets used for informing patients about common infections during consultations in general practice. DESIGN, SETTING AND PARTICIPANTS: We systematically searched PubMed/MEDLINE and EMBASE for studies evaluating information leaflets on common infections in general practice. Two reviewers extracted data and assessed article quality. PRIMARY AND SECONDARY OUTCOME MEASURES: Antibiotic use and reconsultation rates. RESULTS: Of 2512 unique records, eight studies were eligible (7 randomised, controlled trials, 1 non-randomised study) accounting for 3407 patients. Study quality varied from reasonable to good. Five studies investigated effects of leaflets during consultations for respiratory tract infections; one concerned conjunctivitis, one urinary tract infections and one gastroenteritis and tonsillitis. Three of four studies presented data on antibiotic use and showed significant reductions of prescriptions in leaflet groups with a relative risk (RR) varying from 0.53 (0.40 to 0.69) to 0.96 (0.83 to 1.11). Effects on reconsultation varied widely. One large study showed lower reconsultation rates (RR 0.70 (0.53 to 0.91), two studies showed no effect, and one study showed increased reconsultation rates (RR 1.53 (1.03 to 2.27)). Studies were too heterogenic to perform a meta-analysis. CONCLUSIONS: Patient information leaflets during general practitioners consultations for common infections are promising tools to reduce antibiotic prescriptions. Results on reconsultation rates for similar symptoms vary, with a tendency toward fewer reconsultations when patients are provided with a leaflet. Use of information leaflets in cases of common infections should be encouraged. Their contributing role in multifaceted interventions targeting management of common infections in primary care needs to further exploration.

Workload and management of childhood fever at general practice out-of-hours care: an observational cohort study.

OBJECTIVE: Even though childhood fever is mostly self-limiting, children with fever constitute a considerable workload in primary care. Little is known about the number of contacts and management during general practitioners' (GPs) out-of-hours care. We investigated all fever related telephone contacts, consultations, antibiotic prescriptions and paediatric referrals of children during GP out-of-hours care within 1 year. DESIGN: Observational cohort study. SETTING AND PATIENTS: We performed an observational cohort study at a large Dutch GP out-of-hours service. Children (<12 years) whose parents contacted the GP out-of-hours service for a fever related illness in 2012 were included. MAIN OUTCOME MEASURES: Number of contacts and consultations, antibiotic prescription rates and paediatric referral rates. RESULTS: We observed an average of 14.6 fever related contacts for children per day at GP out-of-hours services, with peaks during winter months. Of 17,170 contacts in 2012, 5343 (31.1%) were fever related and 70.0% resulted in a GP consultation. One in four consultations resulted in an antibiotic prescription. Prescriptions increased by age and referrals to secondary care decreased by age (p<0.001). The majority of parents (89.5%) contacted the out-of-hours service only once during a fever episode (89.5%) and 7.6% of children were referred to secondary care. CONCLUSIONS: This study shows that childhood fever does account for a large workload at GP out-of-hours services. One in three contacts is fever related and 70% of those febrile children are called in to be assessed by a GP. One in four consultations for childhood fever results in antibiotic prescribing and most consultations are managed in primary care without referral.

Childhood fever: a qualitative study on GPs' experiences during out-of-hours care.

BACKGROUND: Fever in children is common and mostly caused by self-limiting infections. However, parents of febrile children often consult in general practice, in particular during out-of-hours care. To improve management, it is important to understand experiences of GPs managing these consultations. OBJECTIVE: To describe GPs' experiences regarding management of childhood fever during out-of-hours care. METHODS: A descriptive qualitative study using purposeful sampling, five focus group discussions were held among 37 GPs. Analysis was based on constant comparative technique using open and axial coding. RESULTS: Main categories were: (i) Workload and general experience; (ii) GPs' perceptions of determinants of consulting behaviour; (iii) Parents' expectations from the GP's point of view; (iv) Antibiotic prescribing decisions; (v) Uncertainty of GPs versus uncertainty of parents and (vi) Information exchange during the consultation. GPs felt management of childhood fever imposes a considerable workload. They perceived a mismatch between parental concerns and their own impression of illness severity, which combined with time-pressure can lead to frustration. Diagnostic uncertainty is driven by low incidences of serious infections and dealing with parental demand for antibiotics is still challenging. CONCLUSION: Children with a fever account for a high workload during out-of-hours GP care which provides a diagnostic challenge due to the low incidence of serious illnesses and lacking long-term relationship. This can lead to frustration and drives antibiotics prescription rates. Improving information exchange during consultations and in the general public to young parents, could help provide a safety net thereby enhancing self-management, reducing consultations and workload, and subsequent antibiotic prescriptions.

[An individual 'traffic light system' for children with fever?]. / Voor elk kind met koorts een eigen 'stoplicht'?

Fever in children is very common, and is usually caused by self-limiting upper-respiratory-tract infections. The low incidence of serious infections makes it a challenge to identify children that do have a serious infection and need treatment or observation. The Dutch Society of Paediatrics (NVK) recently presented their guideline for febrile children in secondary care. This is an important, science-based guideline. However, the diagnostic schemes presented, which are based on tests that are not available in primary care, in combination with a different prior chance of serious infections between the primary and secondary care settings make it difficult to translate this guideline to primary care. Nevertheless, the 'traffic light system' presented is a promising potential safety net tool for providing advice for parents in the general practitioner's consultation room. A traffic light system especially developed for primary care should be considered.

[Risks and benefits of paracetamol in children with fever]. / Wel of geen paracetamol bij kinderen met koorts?

Worldwide, paracetamol is the most commonly used antipyretic for children and the drug of first choice for reducing fever named in the majority of practice guidelines. However, whether or not it is necessary or desirable to treat fever is questionable. The provision of accurate information on the causes and treatment of fever can decrease the help-seeking behaviour of parents. Paracetamol is both effective and advisable when there is a combination of fever and pain. Fever on its own does not require treatment and doctors should therefore show caution about advising paracetamol for children who have just this symptom. The effect of paracetamol on the general well-being of children with fever on its own has not been unequivocally proven. Treatment with paracetamol for the prevention of febrile convulsions has been proven ineffective. There are indications that inhibiting fever through paracetamol can adversely affect the immune response. The use of paracetamol can produce mild side effects and hepatotoxicity.

Enhanced communication skills and C-reactive protein point-of-care testing for respiratory tract infection: 3.5-year follow-up of a cluster randomized trial.

PURPOSE: The purpose of the study was to assess the long-term effect of family physicians' use of C-reactive protein (CRP) point-of-care testing and/or physician training in enhanced communication skills on office visit rates and antibiotic prescriptions for patients with respiratory tract infections. METHODS: We conducted a 3.5-year follow-up of a pragmatic, factorial, cluster-randomized controlled trial; 379 patients (20 family practices in the Netherlands) who visited their family physician for acute cough were enrolled in the trial and had follow-up data available (88% of original trial cohort). Main outcome measures were the average number of episodes of respiratory tract infections for which patients visited their family physician per patient per year (PPPY), and the percentage of the episodes for which patients were treated with antibiotics during follow-up. RESULTS: The mean number of episodes of respiratory tract infections during follow-up was 0.40 PPPY in the CRP test group and 0.56 PPPY in the no CRP test group (P = .12). In the communication skills training group, there was a mean of 0.36 PPPY episodes of respiratory tract infections, and in the no training group the mean was 0.57 PPPY (P = .09). During follow-up 30.7% of all episodes of respiratory tract infection were treated with antibiotics in the CRP test group compared with 35.7% in the no test group (P = .36). Family physicians trained in communication skills treated 26.3% of all episodes of respiratory tract infection with antibiotics compared with 39.1% treated by family physicians without training in communication skills (P = .02) CONCLUSIONS: Family physicians' use of CRP point-of-care testing and/or training in enhanced communication skills did not significantly affect office visit rates related to respiratory tract infections. Patients who saw a family physician trained in enhanced communication skills were prescribed significantly fewer antibiotics during episodes of respiratory tract infection in the subsequent 3.5 years.

"How Do You Feel about Antibiotics for This?" A Qualitative Study of Physician Attitudes towards a Context-Rich Communication Skills Method.

To explore experiences with and views of general practitioners (GPs) on a physician communication training method in primary care and its applicability and implementation in daily practice, we performed a semi-structured qualitative study of GPs' experience of training in and implementing a communication skills training program for managing lower respiratory tract infection (LRTI) which included a seminar, simulated patient consultation together with providing and receiving feedback on ones own transcript, and a seminar in a structured approach to the LRTI consultation. Seventeen out of 20 eligible GPs who had participated in the IMPAC³T trial and were allocated to receiving enhanced physician communication training for managing lower respiratory tract infection participated. GPs' experiences with the physician communication training method and its specific components were positive. The method gave GPs additional tools for managing LRTI consultations and increased their sense of providing evidence-based management. During the study, GPs reported using almost all communication items covered in the training, but some GPs stated that the communication skills diluted over time, and that they continued to use a selected set of the skills. The general communication items were most regularly used. Implementation of the method in daily practice helped GPs to prescribe fewer antibiotics in LRTI with the only perceived disadvantage being time-pressure. This study suggests that GPs felt positive about the physician communication training method for enhanced management of LRTI in primary care. GPs continued to use some of the communication items, of which general communication items were the most common. Furthermore, GPs believed that implementation of the communication skills in daily practice helped them to prescribe fewer antibiotics. The context-rich communication method could have wider application in common conditions in primary care.