Title: Improving the use of antibiotics for children with acute respiratory infections in primary care
Funder: Department of Health (England)

Abstract: The overall aim of the Programme is to improve the quality of care given to children presenting to primary care with respiratory tract infections (RTIs). Background: RTIs in children present a major problem to health care services internationally for three reasons. First, they are extremely common and costly to service providers, families, schools and parents’ employers. Second, there is clinical uncertainty in primary care regarding the diagnosis and best management of RTIs in children. Finally, the overuse of antibiotics leads to unnecessary antimicrobial resistance and re-enforces the belief that parents should consult for similar symptoms in the future. Research plans: We propose 4 integrated Workstreams (WS) that will utilise mixed methods, including existing data (WS1), the experiences of parents and clinicians (WS2) and a clinical prediction rule developed in WS3, to test an intervention to improve the targeting of antibiotics and parental health seeking behaviour for children with RTIs in WS4 (see Programme Flow Diagram, Annex 4). WS1 will consist of two systematic reviews. The first will identify the factors associated with frequent consultations for RTI and interventions to change parental consulting behaviours for RTIs. The second will describe the natural history (e.g. symptom duration, symptom severity, reconsultations and complications) of RTIs in children. This information is essential for parents and clinicians to facilitate evidence based ‘safety netting’ and more appropriate medical advice seeking. Results will inform the conduct of WS2 and design of WS3 and 4. WS2 will be a qualitative investigation with parents and health care professionals. First, parental focus groups will explore shared understandings and knowledge of RTIs, help seeking behaviours and information needs. Second, parent interviews for an in-depth exploration of parental consultation motivations and experiences. Health care professionals’ interviews will explore perceptions of parental views on presenting risk information when children have RTIs. Results will inform the design of WS4. WS3 will be a very large (n=8K), prospective cohort study to investigate (a) the clinical and (b) the microbiological factors influencing the prognosis of children presenting to primary care with RTI. Part (a) will use children’s socio-demographic characteristics and clinical symptoms and signs to derive and validate a clinical rule to predict, and quantify the risk of, hospitalisation. Part (b) will investigate the prognostic significance of respiratory bacteria and viruses detected in the upper respiratory tract. How part (a) is presented in WS4 will be refined by the results of WS2. WS4 will be a large (n=920) cluster randomised controlled trial (RCT) to test the clinical and cost effectiveness of the rule validated in WS3 (supplemented with other information found to be of importance in WS1 and WS2) on the consumption of antibiotics by children with RTIs (see RCT Flow Diagram, Annex 4). Research team: We are an internationally recognised, multidisciplinary (quantitative, qualitative, statistics, health psychology and health economics) group of applied researchers. Programme management: The Programme Management Group led by AH will take overall responsibility for the strategic planning and delivery of the programme. The PMG will meet monthly, with WS PIs and PMG members attending and contributing as appropriate. Delivery of individual WSs will be the responsibility of those WS PIs. We will appoint an independent Programme Steering Committee to oversee the Programme. Research environment: As demonstrated by the 2008 RAE, the contributing Universities and NHS Trusts have a track record of collaborating to deliver world leading and international level research. Anticipated outputs: The outputs (e.g. the written and website information from WS1 and WS2 and the clinical rule from WS3) will be available to the NHS via the National Library for Health within the lifetime of the Programme to improve the quality of millions of consultations annually. Patient and public involvement: Parent representatives have already been consulted and approved the Programme design. In-depth qualitative components will identify patients’ and professionals’ concerns and information needs. Parents will help manage the Programme and champion WS3 and WS4. Ethical implications: All Workstreams will be conducted according to the principles of the Research Governance Framework for Health and Social Care. The storage, analysis and disposal of upper respiratory (throat) swab samples will be conducted in accordance with the principles of the Human Tissue Act. Justification for resources: By using simple, proven recruitment techniques, the Programme will be able to deliver 4 Workstreams, including a very large prospective cohort study and a large community based cluster RCT.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: INFECTION