Prescribing Antibiotics for Children with Acute Infections in Latvian Primary Care and Effects of Multifactorial Intervention. Summary of the Doctoral Thesis

Abstract

Antimicrobial resistance is one of the most significant causes of morbidity and mortality worldwide, including in the paediatric population. Its primary cause is the excessive and inappropriate use of antibacterial agents. In children, the most common reason for prescribing antibacterial therapy is upper and lower respiratory tract infections, which are most often self-limiting viral illnesses. However, up to 80% of these infections are treated with antibacterial therapy, although antibiotic treatment is generally not beneficial. The factors underlying extensive antibiotic prescribing are complex and multifactorial. The most significant problems are related to difficulties in differentiating viral and bacterial etiology based solely on clinical signs, as well as concerns about missing severe bacterial infections. The situation is worsened by physician workload, restricted consultation times, and parental or patient pressure to obtain antibacterial therapy. To reduce the prescription of antibacterial therapy, it is necessary to improve the diagnosis of acute illnesses and enhance physicians’ knowledge about prudent antibiotic use. The aim of the study was to investigate antibiotic prescribing habits and the use of diagnostic tests in children with acute infections in primary care in Latvia, and to evaluate the effect of multifactorial interventions (general practitioner education training and access to the use of C-reactive protein point-of-care testing (CRP POCT), as well as the long-term impact of the educational intervention on prescribing practices. Until now, there has been limited research on antibacterial prescribing and diagnostic practices in the paediatric population in Latvia, and no intervention studies focusing on education and diagnostic strategies to decrease antibiotic use in primary care for children have been carried out. A randomized controlled intervention study was carried out, during which 80 general practitioners from different regions of Latvia recorded data on paediatric patients with acute illnesses who attended in-person consultations. The study consisted of two phases, during which general practitioners were randomly divided into two groups. In the first phase, one group received a combined intervention—participation in an educational seminar and the introduction of CRP POCT into practice—while the other group continued routine practice without interventions and served as the control group. After three months, the groups were switched: the control group then received an equivalent combined intervention, while the other group continued routine practice without access to CRP POCT. Since the latter group had previously received the educational intervention, the long-term effect of education was assessed. A total of 3317 patients with a median age of 4.0 years were included in the study. The majority of patients (95.6%) presented with acute respiratory tract infections, most frequently acute upper respiratory tract infections. Antibacterial therapy was prescribed to 29.3% of patients, and in approximately one-third of cases broad-spectrum antibacterial agents were chosen. Therapy was often initiated within the first days of illness or for potentially self-limiting infections. The lowest frequency of antibacterial prescribing was observed in the long-term education group. In both intervention groups, there was a tendency to use delayed prescriptions more frequently compared to the control group. However, overall, the effect of combined and educational interventions on the frequency of antibacterial prescribing was not statistically significant. Decisions regarding the prescription of antibacterial therapy were predominantly based on clinical signs rather than objective test results when such tests were unavailable during the consultation. The availability of CRP POCT substantially increased the use of diagnostic testing in children with acute infections. In both intervention groups, the number of patients prescribed antibacterial therapy at low CRP values (<20 mg/L), which are rarely associated with severe bacterial infections, decreased. Although overall rates of antibacterial prescribing were relatively low, further improvements are necessary. The integration of POCT with clinical assessment has the potential to improve the diagnostic process and reduce inappropriate use of antibacterial therapy; however, the availability of CRP POCT alone is insufficient. Further research is required to develop standardized criteria for test interpretation and indications. While general practitioner education is essential in promoting prudent antibiotic use, a single passive educational session is insufficient and may need to be supplemented with interactive seminars, individualized practice improvement recommendations, or patient education to enhance its effectiveness.