Clinical, social and relational determinants of paediatric ambulatory drug prescriptions due to respiratory tract infections in Italy

  • Marta Luisa Ciofi degli Atti
  • Marco Massari
  • Antonino Bella
  • Delia Boccia
  • Antonietta Filia
  • Stefania Salmaso
  • SPES study group
Pharmacoepidemiology and Prescription



Collecting information on patterns of drug prescriptions and on factors influencing prescribing decisions is fundamental for supporting the rational use of drugs. This study was aimed at investigating patterns of drug prescription in paediatric outpatients and at evaluating determinants of prescriptions for respiratory tract infections (RTIs).


We conducted a national cross-sectional survey involving primary care paediatricians and parents. Diagnoses and prescriptions made at each consultation were described. Poisson regression models were used to analyse determinants of drug and antibiotic prescriptions for visits due to RTIs.


A total of 4,302 physician and parent questionnaires were analysed. These corresponded to 2,151 visits, 792 of which were due to RTIs. Drugs were prescribed in 83.4% of RTI visits, while antibiotics were prescribed in 40.4%. According to paediatricians’ perceptions, 84.2% of parents of children with a RTI expected to receive a drug prescription. Paediatricians’ perception of parental expectations was the strongest determinant for prescription of drugs and specifically of antibiotics [adjusted relative risk (RR): 1.7 and 3.6, respectively; P < 0.001]. However, in 77.1% of RTI visits, paediatricians judged themselves as not being influenced at all by parents’ expectations in their decision to prescribe.


This study underscores that relational factors, in particular perceived parental expectations, are one of the leading factors of drug prescriptions in paediatric ambulatory care settings, reinforcing the opinion that communication between physicians and parents can affect prescription patterns.


Respiratory tract infections/diagnosis/drug therapy Child Parents Paediatrics Ambulatory care setting Physicians’ prescription practices Communication 


  1. 1.
    World Health Organization (2003) Introduction to drug utilization researchGoogle Scholar
  2. 2.
    Murray B (1994) Can antibiotic resistance be controlled? N Engl J Med 330:1229–1230PubMedCrossRefGoogle Scholar
  3. 3.
    Levin BR (2001) Minimizing potential resistance: a population dynamics view. Clin Infect Dis 33 (Suppl 3):S161–S169PubMedCrossRefGoogle Scholar
  4. 4.
    Goossens H, Ferech M, Vander Stichele R, Elseviers M (2005) Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 365:579–587PubMedGoogle Scholar
  5. 5.
    Cockburn J, Pitt S (1997) Prescribing behavior in clinical practice: patients’ expectations and doctors’ perceptions of patients’ expectations—a questionnaire study. BMJ 315:520–523PubMedGoogle Scholar
  6. 6.
    Britten N, Ukoumunne O (1997) The influence of patients’ hopes of receiving a prescription on doctors’ perceptions and the decision to prescribe: a questionnaire survey. BMJ 315:1506–1510PubMedGoogle Scholar
  7. 7.
    Himmel W, Lippert-Urbanke E, Kochen MM (1997) Are patients more satisfied when they receive a prescription? The effect of patient expectations in general practice. Scand J Prim Health Care 15:118–122PubMedCrossRefGoogle Scholar
  8. 8.
    Ramsden DJ, Quinn RF, Witham M (1998) Doctors are not pressured into giving prescriptions. BMJ 316:938PubMedGoogle Scholar
  9. 9.
    Webb S, Lloyd M (1994) Prescribing and referral in general practice: a study of patients’ expectations and doctors’ actions. Br J Gen Pract 44:165–169PubMedGoogle Scholar
  10. 10.
    Little P, Dorward M, Warner G, Stephens K, Senior J, Moore M (2004) Importance of patient pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study. BMJ 328:444–446PubMedCrossRefGoogle Scholar
  11. 11.
    Soumerai SB, Ross-Degnan DS (1990) Drug prescribing in pediatrics: challenges for quality improvement. Pediatrics 86:782–784PubMedGoogle Scholar
  12. 12.
    Otters HBM, van der Wouden JC, Schellevis FG, van Suijelekom-Smit LWA, Koes BW (2004) Trends in prescribing antibiotics for children in Dutch general practice. J Antimicrob Chemother 53(2):361–366PubMedCrossRefGoogle Scholar
  13. 13.
    Watson RL, Dowell SF, Jayaraman M, Keyserling H, Kolczak M, Schwartz B (1999) Antimicrobial use for pediatric upper respiratory infections: reported practice, actual practice, and parent beliefs. Pediatrics 104:1251–1257PubMedCrossRefGoogle Scholar
  14. 14.
    Finkelstein JA, Metlay JP, Davis RL, Rifas-Shiman SL, Dowell SF, Platt R (2000) Antimicrobial use in defined populations of infants and young children. Arch Pediatr Adolesc Med 154:395–400PubMedGoogle Scholar
  15. 15.
    Choonara I, Nunn AJ, Kearns G (eds) (2003) Introduction to pediatric and perinatal drug therapy. Nottingham University Press, NottinghamGoogle Scholar
  16. 16.
    del Torso S, Bussi R, DeWitt TG (1997) Primary care pediatrics in Italy: eighteen years of clinical care, research, and teaching under a national health service system. Pediatrics 99:E8PubMedCrossRefGoogle Scholar
  17. 17.
    Nyquist A, Gonzales R, Steiner JF, Sande MA (1998) Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 279:875–877PubMedCrossRefGoogle Scholar
  18. 18.
    Ciofi Degli Atti ML, Salmaso S, Bella A, Arigliani R, Gangemi M, Chiamenti G et al (2002) Pediatric sentinel surveillance of vaccine-preventable diseases in Italy. Pediatr Infect Dis J 21:763–768PubMedCrossRefGoogle Scholar
  19. 19.
    World Health Organization Collaborating Centre for Drug Statistic Methodology (1999) Guidelines for ATC classification and DDD assignment. Oslo, Norway, World Health Organization. Available at:
  20. 20.
    Greenland S (2004) Model-based estimation of relative risks and other epidemiologic measures in studies of common outcomes and in case-control studies. Am J Epidemiol 160:301–305PubMedCrossRefGoogle Scholar
  21. 21.
    Bronzwaer S, Cars O, Bucholz U, Molstad S et al (2002) A European study on the relationship between antimicrobial use and antimicrobial resistance. Emerg Infect Dis 8(3):278–282CrossRefGoogle Scholar
  22. 22.
    Boccia D, Spila Alegiani S, Pantosti A, Moro ML, Traversa G (2004) The geographic relationship between the use of antimicrobial drugs and the pattern of resistance for Streptococcus pneumoniae in Italy. Eur J Clin Pharmacol 60:115–119PubMedCrossRefGoogle Scholar
  23. 23.
    McCaig L, Besser RE, Hughes JM (2002) Trends in antimicrobial prescribing rates for children and adolescents. JAMA 287:3096–3102PubMedCrossRefGoogle Scholar
  24. 24.
    Bauchner H, Pelton SI, Klein JO (1999) Parents, physicians, and antibiotic use. Pediatrics 103:395–401PubMedCrossRefGoogle Scholar
  25. 25.
    Mangione-Smith R, McGlynn EA, Elliot MN, Krogstad P, Brook RH (1999) The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. Pediatrics 103:711–718PubMedCrossRefGoogle Scholar
  26. 26.
    Mangione Smith R, McGlynn EA, Elliot MN, McDonald L, Franz CE, Kravits RL (2001) Parent expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med 155:800–806PubMedGoogle Scholar
  27. 27.
    Thrane N, Olsen C, Schonheyder HC, Sorensen HT (2003) Socioeconomic factors and prescription of antibiotics in 0- to 2-year-old children. J Antimicrob Chemother 51:683–689PubMedCrossRefGoogle Scholar
  28. 28.
    Huang N, Morlock L, Lee C, Chen L, Chou Y (2005) Antibiotic prescribing for children with nasopharyngitis (common colds), upper respiratory infections, and bronchitis who have health-professional parents. Pediatrics 116:826–832PubMedCrossRefGoogle Scholar
  29. 29.
    Mangione-Smith R, Elliott MN, McDonald L, McGlynn EA (2002) An observational study on antibiotic prescribing behaviour and the Hawthorne effect. Health Serv Res 37:1603–1623PubMedCrossRefGoogle Scholar
  30. 30.
    Clavenna A, Bonati M, Rossi E, Berti A, De Rosa M (2004) Il profilo prescrittivo della popolazione pediatrica italiana nelle cure primarie. Ric Prat 20:224–244Google Scholar
  31. 31.
    Istituto Nazionale di Statistica (2003) Rapporto annuale; la situazione del Paese nel 2002. MaggioGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  • Marta Luisa Ciofi degli Atti
    • 1
  • Marco Massari
    • 1
  • Antonino Bella
    • 1
  • Delia Boccia
    • 2
  • Antonietta Filia
    • 1
  • Stefania Salmaso
    • 1
  • SPES study group
  1. 1.Reparto Malattie Infettive, Centro Nazionale di Epidemiologia, Sorveglianza e Promozione della SaluteIstituto Superiore di Sanita’RomeItaly
  2. 2.London School of Hygiene and Tropical Medicine, Department of Infectious and Tropical DiseasesClinical Research UnitLondonUK

Personalised recommendations