This study showed that the majority of Lebanese pediatricians (97.4%) replied correctly on prescribing antibiotics for pneumonia (case 4) and avoiding antibiotics in cases of cough (86.3%), URI (74.4%), tympanic membrane dysfunction (64.1%) and prevention of secondary infection (63%). Eighty percent of physicians prescribed antibiotics for pharyngitis without requesting a throat culture. Practitioners stated that the following factors played a major role in increasing their prescription patterns: prevention of serious complications (65%), second visit for the same problem (50.4%), purulent discharge (37.6%), diagnostic (35%) or treatment uncertainty (26.5%). Most of the physicians considered that parents’ requests and expectations (81.2%), drug promotion (94%), parents’ satisfaction (87.2%) and fever (72.6%) did not change their practice. Treatment guidelines were considered to decrease antibiotics prescription by 55.6%. Concerning attitudes of physicians towards antibiotics prescribing the majority of physicians admitted that antibiotic use is notable in their community and that antibiotic resistance is a threat on the national and international level. Forty percent of pediatricians agreed and strongly agreed that advising parents reduces their antibiotic demand. The same percentage disapproved that antibiotics prescriptions might be made to gain parents’ trust.
In comparison to Canadians doctors, Lebanese colleagues used antibiotics more appropriately in both cases of tympanic membrane dysfunction and cough from sinusitis (first and last cases) (64.1% versus 43.5%, 79.5% versus 24.5% respectively). Answers to cases of URI, lobar pneumonia and pharyngitis (cases 3, 4 and 6) were almost identical. As for treating cough and prevention of secondary infections (cases 2 and 5), Lebanese pediatricians prescribed more inappropriate antibiotics in these cases (86.3% versus 94%, 62.4% versus 82% respectively) (20). These findings suggest that Lebanese pediatricians had an acceptable use of antibiotics but need more training to improve their practice especially regarding management of pharyngitis and antibiotic prophylaxis.
Several factors influence practitioners’ decisions in prescribing antibiotics, Lebanese physicians are in favor of prescribing antibiotics due to the presence of purulent discharge and fever, but less than their Indian colleagues as shown in previous studies (37.6% compared to 65%- 88.6% for discharge, 24.8% versus 40%-72.5% for fever) (26). Diagnostic or treatment uncertainty could increase antibiotic prescription for 35% and 26.5% of physicians respectively, compared to 59% and 53.3% Indian practitioners respectively (27). Our findings are in line with other studies proving that physicians prescribed antibiotics when they are not certain about the diagnosis (12). Developing clinical tools or laboratory tests can, therefore, aid physicians in making the correct diagnosis. Guidelines in Lebanon were found to decrease antibiotics prescription more than in India (55.6% compared to 40.6%). Preventing serious complications increased antibiotics prescription in 65% of Lebanese physicians versus 79% of Indians (27). Half of the Lebanese clinicians increased antimicrobials prescriptions if it is the second visit for the same problem confirming that this factor is related to overprescribing (19). Most Lebanese practitioners believed that parents’ requests and expectations, drug promotion and parent satisfaction did not change their practice more than Indians physicians (81.2%, 94%, 87.2% compared to 57.2%, 60.7% and 64.2% respectively) (27). Thankfully, pharmaceutical companies’ promotional campaigns did not have an influence on Lebanese pediatricians by a greater rate when compared to their Indians colleagues (94% and 57% respectively) (26). These findings contradict the studies conducted by Lucas at al. and Rezal et al. who found that clinicians reported prescribing antibiotics due to pressure exercised by drug companies (12, 13).
All in all, the percentage of Lebanese pediatricians who increased their antibiotic prescriptions due to several factors was lower than their international colleagues, which is promising and confirms once again that our physicians have a good level of practice.
When it comes to pediatricians’ opinions about antibiotics, most of them admitted that antibiotic use is a notable factor in their community but beyond what was found by in Canada (94% compared to 77%); maybe this problem is more critical in developing countries (20). Similarly, the majority stated that antibiotic resistance is a concern on the national and international level as stated by the MOPH (21) and WHO (8). Eighty-eight percent of Lebanese physicians are convinced that educating parents will control their demand for antibiotics compared to 93.5% of Canadian physicians (20). Lebanese doctors believed more than their Canadian colleagues that prior antibiotic use increases the risk of developing resistance (89.9% compared to 71.8%) (20). This confirms that physicians are aware of the principles of antibiotic resistance. Moreover, about three-quarters of Lebanese practitioners acknowledged that parents believe that they should prescribe antibiotics for flu and cold symptoms, which points out the public misconceptions about antibiotics that need to be corrected. Seven pediatricians out of 10 recognized that if a parent feels that his child needs antibiotics he would manage to obtain antimicrobials from a pharmacy without a prescription indicating OTC sale of antibiotics. Almost half of the pediatricians agreed that they would prescribe antibiotics if it were difficult to conduct a follow up echoing overprescribing due to non-clinical factors. This is not an indication by itself for antibiotics, and parents should be educated on how to observe the child and to recognize symptoms that need a follow up consultation. Amoxicillin/clavulanic acid is considered to be the first choice for most URI even more than amoxicillin; while guidelines agree that amoxicillin is the first line treatment (28). Six out of ten physicians were against prescribing wide spectrum antibiotics in case of doubt in diagnosis or etiology of URI, 88.5% disapproved that they might prescribe antibiotics so that parents continue to trust them. This emphasizes once again that Lebanese clinicians are cautious when prescribing antibiotics. The majority of pediatricians strongly disagreed on prescribing antibiotics if not indicated because of time pressure. This differs from other studies where lack of time during consultation was an incentive to prescribe antibiotics (19) and highlights judicious use of antibiotics in more than half of pediatricians.
4.1. Strengths and limitations:
Primarily the innovativeness of this study is a major strength. To the extent of our knowledge, this is the very first study about this subject in Lebanon and the Middle East region. Second, the study included physicians from different regions across the country, graduated from different universities and practicing in different settings and was not limited to one geographic area or to university hospitals. Moreover, administering the survey online has led to complete anonymity, which contributes to less information bias.
As for the study limitations, a selection bias may be present due to missing and non-accurate data in physicians’ contact list provided by the Order of Physicians. Furthermore, we didn’t find a previously validated questionnaire, but the questionnaire used was based on two previous studies. Third, the response rate was low making generalizability very difficult and the minimal sample size needed being not reached. Unfortunately, not all Lebanese physicians are interested in research participation. Finally, practices of physicians were evaluated based on self-reported practices to clinical scenarios instead of the actual practice; hence there will be an information bias. This might lead to an underestimation of the prevalence of inappropriate attitudes and prescribing behaviors. In fact, prescribing a medication is a multifaceted behavior and it is extremely difficult to measure in real practice unless we conduct a patient-simulated study and the latter might have some ethical considerations to take into account.