Communication Currents

We often hear the phrase, “Patience is a virtue,” but it turns out that practicing patience can be good for our health, too. According to a new study in NCA’s Journal of Applied Communication Research, parents who more closely adhere to the concept of “watchful waiting” before administering antibiotic drugs to their children with ear infections are also helping to prevent antibiotic-resistant infections.

“When we use antibiotics, the strongest bacteria still survive even though we feel well again,” says lead study author Erina L. MacGeorge of Pennsylvania State University. “Over time, these bacteria adapt to become resistant ‘superbugs’ that even very strong antibiotics with dangerous side effects cannot kill. Our best defense is to avoid antibiotics whenever possible, with guidance from health care professionals.”

Antibiotic-resistant infections are currently estimated to kill 50,000 people a year across the United States and Europe alone, and up to 700,000 worldwide. In response, government agencies and health organizations are increasingly investing in “antibiotic stewardship” programs. In outpatient healthcare, antibiotic stewardship emphasizes limiting antibiotics to necessary use, along with using vaccination and good hygiene to prevent infection from occurring in the first place.

Watchful waiting is an antibiotic stewardship strategy for outpatient conditions such as ear and respiratory tract infections. It is recommended for use when these infections are bacterial, but not severe, and therefore likely to resolve on their own without antibiotics. The strategy involves giving a prescription for antibiotics, but advising that it not be used unless symptoms persist or worsen over a period of time. Because many infections will resolve on their own, watchful waiting helps reduce unnecessary use of antibiotics.

The success and safety of the watchful waiting strategy depends on communication from health care providers about what to do, and why. MacGeorge and colleagues’ study indicates a need for improvement in this area. In their national sample of 134 parents who were advised to use watchful waiting for their children’s ear infections, only 4 percent recalled comprehensive advice, including information about the infection, the risks of antibiotics, and how to properly care for their children. Anyone who has walked away from a doctor’s office with more questions than when they arrived understands why such instruction is needed.

Importantly, the findings of this study also suggest that parents’ compliance with watchful waiting advice could be increased by enhancing delivery of physician instruction and parental recall. Parents who recalled receiving more detailed explanations from their health care providers were more likely to adhere to watchful waiting advice.

Per American Academy of Pediatrics guidelines, parents who are advised to undertake watchful waiting should receive information from health care providers on the nature of ear infections, adverse effects of antibiotics, how to monitor and manage symptoms such as pain, and when to seek follow-up care. In the study, researchers asked parents to recall the interaction with their child’s health care provider and report what they remembered being told to do. The responses were coded for the types of information noted in the AAP guidelines. Parents also reported whether they ever filled the antibiotic prescription; if so, how quickly; and if and when they administered it.

Only 10 percent of parents reported hearing about the adverse effects of antibiotics. And, while 75 percent reported direction to monitor symptoms, only 22 percent reported direction to medicate for pain management.

Responses also revealed that even when parents receive explanations about the risks of antibiotics, their recall and understanding of those explanations is not necessarily correct. One participant reported, “If children are given antibiotics when it is not necessary, they can build up an immunity to them.” However, it is bacteria, not children, that become immune to antibiotics, so the dangers of overuse extend beyond any individual child. This misunderstanding illustrates the challenge of understanding antibiotic resistance, and the need for health care providers to more clearly communicate the dangers of overuse.

The authors concluded that health care providers may not be fully adhering to the guidelines when communicating with parents and other caregivers. “Even the possibility of insufficient instruction creates concern about patient comfort and safety,” they write. They suggest training that emphasizes health care providers’ roles in educating parents who are uncertain about watchful waiting, and perhaps using a checklist or other prompt for comprehensive instruction.

Finally, the authors recommend further research aimed at designing messages that are “effective in changing key misconceptions about antibiotics and antibiotic resistance.”