Dealing with aftermath of poor antibiotic prescribing
Annabelle is a five-year-old who has suffered a persistent cough at night for six weeks. She has seen another doctor at the practice on two occasions. Initially, the parents were advised it was a viral infection and would get better on its own. Subsequently, she was treated with antibiotics even though no abnormal examination findings were recorded. Her parents are upset because they are getting up to her each night and nothing seems to be working.
Dr Richard Stokell advises.
How does this presentation make you feel?
I would feel under pressure from the start. Tired, upset parents with an agenda that says 'something must be done' can press you to refer, investigate or initiate treatment at an earlier stage than you might normally. You might wonder why they have chosen you rather than go back to your colleague.
How can you respond?
There is no substitute for good consultation skills. 'When did the cough start?' followed by a few minutes of active listening with minimal interruption will provide a detailed history and present cues to parental frustrations such as 'I've had to take two weeks off work', 'she's waking her sister up every night'.
Ask general well-being questions about appetite, energy and behaviour as well as specific questions about wheeze, exertional dyspnoea and atopy in the family. A careful examination provides reassurance as well as excluding a significant illness. A chest X-ray can be a useful investigation at this stage to exclude infection or any signs of an inhaled foreign body.
What are the possible diagnoses?
The parents are likely to mention asthma at this stage. Other diagnoses to consider are gastro-oesophageal reflux, post-nasal drip problems, TB and cystic fibrosis. In many children none of these categories fit and chronic post-infectious cough is the likely cause.
What do we know about chronic
In children with previous wheezing and a family history of atopy, cough is a common symptom of poor control and increasing use of inhaled steroids is of proven benefit. However, isolated cough does not respond to inhaled steroids and is thought to be caused by a different pathway leading to cough reflex hypersensitivity. The diagnosis of cough-variant asthma has been largely discredited. Fortunately, chronic post-infectious cough usually gets better eventually without any long-term sequelae.
How can this consultation be brought to a successful conclusion?
If you have successfully gathered enough information to exclude a serious cause and the parents feel they have been listened to and the child examined carefully, a shared understanding of the problem can be reached. A chest X-ray and follow-up after two weeks may be all you have to offer, but together with a good overall prognosis and reassurance that nothing is being missed, it may work.
Some people advocate a three- to four-week trial of inhaled steroids, at a dose of 400-800µg of beclomethasone, and this option can be discussed with the parents as a way of excluding asthma.
But it is important not to label the child as asthmatic and escalate treatment when it doesn't work. Referral should also be discussed, and if the parents are not satisfied or you have doubts about the cause, this may be the best option.
What are the practice issues?
One of the contributory factors to the tension in this consultation is the previous visit to the surgery. Use of antibiotics as a placebo is bad practice because if the condition gets better it reinforces the patient's belief in them, and if it doesn't get better it casts doubt on the original diagnosis and turns the problem into a 'mystery illness'.
At the previous consultation, the parents should have been reassured that examination findings were okay and that sometimes prolonged cough can occur. As a registrar you are in a good position to ask members of the practice why they prescribed and discuss how it affected your surgery.