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Peds ID Abx QOTW #8 Answer

d) Reassure mom that this is just a virus and recommend supportive care

f) Tell Mom this is probably viral, and give her a delayed prescription for 10 days of amoxicillin in case it is sinusitis

Patient’s & Parents’ Demanding Antibiotics

  • A problem of communication?
  • Prescribers and patients/parents often are having different conversations (ref 1, 2)

– Patient/parent comments about diagnosis or antibiotics are perceived by providers as an expectation of antibiotics

– Providers tend to minimize symptoms when diagnosis is viral, making patient/parent feel that their concerns are not being met

– Patient/parent comments about diagnosis or antibiotics may be related to statement of concern about the severity of diagnosis by patient/parent

  • Experience of patient/parent is that antibiotics are given when disease is severe
  • “It’s viral” often leaves parents concerned that the severity of the illness is not taken into consideration by provider
  • A combination of both positive and negative messaging leads to improved parent ratings and decreased Antibiotic Rx (ref 3)
  1. Positive – explanations of what parents can do to help their child’s symptoms
    • Humidifier, nasal sinus rinses, OTC medications
  2. Negative – explanations of the inappropriateness of antibiotics for their child’s infection
    • Antibiotics don’t treat viruses

Provider behavior

  • Study of children age 2-10 years with suspected viral URI: when providers thought parents wanted antibiotics, diagnosed acute otitis media 49% of the time (vs 13% when they did not), and sinusitis 38% of the time (vs 5%)
    • Mangione-Smith, R. et al. Pediatrics 103(4): 711-718
  • However, patient / parent satisfaction was unrelated to whether provider fulfilled expectations, and more related to whether concerns were addressed

When are antibiotics indicated for URI?

  • Sometimes: acute otitis media, sinusitis, community acquired pneumonia, streptococcal pharyngitis
  • Never: acute bronchitis, nonspecific upper respiratory infection, influenza (although oseltamavir may be indicated), and non-streptococcalpharyngitis

Persistent Symptoms of URI

  • Most commonly this is associated with intercurrent illness
  • Careful history can often find that the patient got better than worse again

– Likelihood of serious complications are low in these patient populations

  • And, oftentimes parents can be convinced that watchful waiting is the best approach
  • However, given the parents’ stance, giving the patient a delayed prescription (e.g. SNAP safety-net antibiotic prescription, or Wait and See Rx) is a reasonable option

– For AOM this led to 69% reduction in antibiotic Rx fills (ref 4)

Non-Infectious Causes

  • As was pointed out by one of our colleagues in the ED, a foreign body should be considered in this patient
  • Patient’s age puts her at risk for either her or other kids in the household/daycare inserting random objects in, e.g., her nose


1. Health Commun. 2002;14(3):299-338

2. J Fam Pract. 2003 Feb;52(2):140-8

3. Ann Fam Med 2015;13:221-227

4. Pediatrics. 2013 Mar;131(3):e964-99