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Antibiotics or not: a family service?

It's important to give evidence-based care that fits current guidelines,but that's not the whole story. Sometimes delivering a caring service means giving more than cold facts, and sometimes the human side of caring requires a different perspective

Janet Webb
BSc(Hons) RGN
DipN(Lond)
Practice Nurse
Lindum Medical Practice, London

Mrs M brought her four children to the minor illness clinic. Joanna, aged 6, skipped all the way from the waiting room to my room and said: "Hello, the others are just coming", before settling herself neatly on the footstool in front of my couch. Her mum was rounding up twins Harry and Georgina, aged four, having persuaded them to put all the toys away and settling Louisa, 14 months, into her pushchair. Eventually they were all present and correct - all the children sat attentively, Georgina beside Joanna, Harry cross-legged on the floor and Louisa now on her mum's knee. Mrs M got straight to the point: "I've brought them for antibiotics, and I didn't think you'd give them without seeing them first. Louisa's got a cold and I don't want them all to catch it." Precisely on cue Louisa sneezed.
I always feel as if I'm somehow letting people down in this situation; I don't want to disappoint them, but when patients ask for antibiotics and I can't justify giving them I expect they feel cheated. I wonder whether it's an indication of my insecurity that I need to feel I'm giving magic that will make everything better, but when I'm giving information and advice only I think they feel they're being fobbed off. My logical self tells me that they're getting the best care I can give, but I wonder whether my feeling of letting them down is obvious to the recipients of my "no prescription" advice, and if so, whether this makes my advice less credible. I consciously stop myself from saying: "I'm sorry....", in favour of a more positive note, but I can see they're not convinced.
I asked what prompted Mrs M's request. "Well, as I said, Louisa here has a cold. When Joanna was her age she had to be rushed into hospital with bronchiolitis. I'm determined that will never happen again with my children." I asked for history. Louisa had been feverish overnight with a temperature of 37.8oC. She had been given paracetamol, repeated that morning, which had made her less irritable. She had been coughing and sneezing, and had nasal congestion. The others were asymptomatic. Louisa was otherwise healthy, with no medical history apart from a chest infection earlier this year; her immunisations were up to date. She was alert and cooperative and her temperature was now 36.8oC.
Her ears and chest showed no abnormality. She smiled readily, told me her name and that she had had cereals for breakfast.
I started by saying colds are usually caused by viruses, are usually mild and self-limiting, and that antibiotics are generally not indicated. Confirming that Mrs M had acted wisely by giving timely doses of paracetamol in response to the pyrexia, I advised her to continue this as necessary. I advised that the other children might not catch the cold, and it would be ineffective to give antibiotics as prophylaxis. If symptoms developed, each child would need to be assessed individually. I went on to encourage observation, and the need for review with any concerns.
Mrs M replied that nevertheless she would still like the antibiotics. I discussed the possibility of antibiotic resistance from inappropriate usage and the possibility of side-effects, such as diarrhoea, being worse than the symptoms of a cold.(1,2) I described evidence suggesting antibiotics did not demonstrate any reduction in the duration of cold symptoms. I affirmed that I could not justify prescribing antibiotics now, but would be happy to review with any developments.(3) Mrs M was not impressed. She gathered the children together and swept out, only to go to reception and book the next available GP appointment.
 I later checked their notes to find prescriptions for antibiotics for them all. As soon as was feasible I went to talk to the GP. He explained that we are service providers not examination candidates, and need people to trust us. We can't hope to convince people of a new concept at a time when they are anxious or concerned; there would be time for that later. Although scientifically I was right, Mrs M needed to feel her children were safe, and because of that he had given each child a prescription, which he had advised was only to be used if Mrs M deemed it absolutely necessary. He said he had given guidance as to what was meant by absolutely necessary, and so devolved responsibility to her. He had left her to decide whether to generate antibiotic resistance in her children, whether to risk side-effects and subject their internal organs to inappropriate chemicals, or whether to "watch and wait" in the knowledge that she had treatment available if it was needed. 
I could see sense in his practice, and understood why the psychology of it made more sense than my flat refusal - evidence-based though it was.
Huang et al recommend the exploration of education and regulation and also training in communication skills, a combination of which might reduce the inappropriate prescribing of antibiotics for colds.(4) I accept that a more individualised, psychological approach might enhance my care provision. I could have handled things better.

References
1. Bennett J, St Geme JW. Bacterial resistance and antibiotic use in the emergency department. Pediatr Clin North Am 1999;46:1125-43.
2. Stone S, Gonzales R, Maselli J, Lowenstein SR. Antibiotics prescribing for patients with colds, upper respiratory tract infections, and bronchitis: A national study of hospital-based emergency departments. Ann Emerg Med 2000;36:320-7.
3. Clinical Knowledge Summaries. Available from: http://www.cks.library.nhs.uk
4. Huang N, Morlock L, Cheng-Hua Lee PH, Long-Shen, Yiing-Jenq Chou. Antibiotic prescribing for children with nasopharyngitis (common colds), upper respiratory infections, and bronchitis who have health-professional parents.  Pediatrics 2005;116:826-32.