Video Abstract

Video Abstract

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OBJECTIVES

Preschool-aged children with mild community-acquired pneumonia (CAP) routinely receive antibiotics even though most infections are viral. We sought to identify barriers to the implementation of a “no antibiotic” strategy for mild CAP in young children.

METHODS

Qualitative study using semistructured interviews conducted in a large pediatric hospital in the United States from January 2021 to July 2021. Parents of young children diagnosed with mild CAP in the previous 3 years and clinicians practicing in outpatient settings (pediatric emergency department, community emergency department, general pediatrics offices) were included.

RESULTS

Interviews were conducted with 38 respondents (18 parents, 20 clinicians). No parent heard of the no antibiotic strategy, and parents varied in their support for the approach. Degree of support related to their desire to avoid unnecessary medications, trust in clinicians, the emotional difficulty of caring for a sick child, desire for relief of suffering, willingness to accept the risk of unnecessary antibiotics, and judgment about the child’s illness severity. Eleven (55%) clinicians were familiar with guidelines specifying a no antibiotic strategy. They identified challenges in not using antibiotics, including diagnostic uncertainty, consequences of undertreatment, parental expectations, follow-up concerns, and acceptance of the risks of unnecessary antibiotic treatment of many children if it means avoiding adverse outcomes for some children.

CONCLUSIONS

Although both parents and clinicians expressed broad support for the judicious use of antibiotics, pneumonia presents stewardship challenges. Interventions will need to consider the emotional, social, and logistical aspects of managing pneumonia, in addition to developing techniques to improve diagnosis.

What’s Known on This Subject:

Preschool-aged children with mild community-acquired pneumonia routinely receive antibiotics even though most infections are viral. The reasons why have not been assessed.

What This Study Adds:

Although interviews with parents and clinicians demonstrated broad support for the judicious use of antibiotics, pneumonia presents stewardship challenges in pediatrics. Interventions to improve prescribing must consider the emotional, social, and logistical aspects of managing pneumonia in the outpatient setting.

Community-acquired pneumonia (CAP) accounts for ∼1.8 million pediatric health care visits in the United States annually, and most children are well enough to be managed as outpatients.1 4  The 2011 Pediatric Infectious Diseases Society (PIDS)/Infectious Diseases Society of America (IDSA) CAP guidelines recommend against the routine use of antibiotics for preschool-aged children (<5 years old) in the outpatient setting, because most infections in this age group are viral.5 7  Since 2011, more evidence has amassed to support the idea that many young children with CAP can be treated without antibiotics, including no differences in treatment failure or relapse rates between those treated with and without antibiotics.8,9  However, preschool-aged children continue to routinely receive antibiotics for CAP.2,3  Antibiotics can expose children to harm, including side effects (eg, rash, diarrhea), mislabeled allergies, potentially severe complications, and promotion of antibiotic resistance.10 13  Nearly 70 000 emergency department (ED) visits occur each year by children for antibiotic adverse drug events.10  CAP leads to ∼1 million outpatient antibiotic courses annually.14  Limiting the use of antibiotics in young children with CAP is an important antibiotic stewardship target.15 

Changing clinical practice is challenging, especially the deimplementation of low-value care.16,17  There is a need to consider the acceptability and feasibility of a “no antibiotics” strategy in the management of young children with mild CAP.18  Key stakeholders include parents or guardians, ED clinicians, and general pediatricians (GPs). Eliciting their perspectives is critical to inform future antibiotic stewardship interventions for CAP. Our objective was to identify how parents and clinicians think about a no antibiotic strategy for CAP.

We conducted a qualitative study using semistructured interviews between January 2021 and July 2021. The study was conducted at Ann & Robert H. Lurie Children’s Hospital in Chicago, Illinois, by an interdisciplinary investigator group with expertise in CAP, pediatric emergency medicine, implementation science, qualitative methodology, pediatric infectious diseases, and sociology. Interviews were conducted with parents or legal guardians of children who were diagnosed with CAP in the ED or outpatient setting on or after January 1, 2018, and were 1 to 6 years old at the time of diagnosis. These criteria were selected to recruit an adequate number of respondents who would be representative of those for whom the IDSA/PIDS guideline recommends against routine antibiotic use. Children hospitalized for their CAP or who had underlying chronic medical conditions were excluded. Eligible respondents were identified retrospectively through the electronic health record on the basis of outpatient site of care and discharge diagnosis code. Interviews were conducted with clinicians who practice in pediatric EDs, general EDs, or general pediatric outpatient settings. Parents were recruited by telephone and clinicians by e-mail.

A trained researcher conducted all interviews via videoconference under the supervision of investigators with expertise in interview methodology using separate semistructured guides for parents and clinicians. We created the guides on the basis of literature review and our previous research.19 22  Each guide was piloted and amended for length and comprehensibility. We monitored for code saturation (ie, the point at which no new issues were identified) in our key domains.23  Parent respondents self-reported their race, ethnicity, education level, and employment status. These data were gathered to contextualize the social experience of parents as they navigated health care for their child. The protocol was approved by the Lurie institutional review board (#2020–3618). Informed consent was obtained from respondents before the start of each interview.

Interviews were transcribed and analyzed using the framework method.24  The analysis was overseen by the lead investigator, a sociologist with extensive experience using qualitative methods to understand antibiotic prescribing.19,20,25  Coding was performed by 4 study team members using Dedoose V. 9.0.17.26  The initial codebook was created on the basis of the interview guide domains and themes that emerged in the interviews.27  The codebook was applied to 4 interview transcripts, and its performance assessed for code clarity, comprehensiveness, and intercoder agreement. It was then refined, finalized, and applied line by line to each transcript, with intercoder agreement periodically evaluated. Once the data were coded, we created data digests identifying key findings by domain. Then, we used analytic matrices to examine variation in answers across respondents.28 

Interviews were conducted with 18 parents/caregivers and 20 clinicians. Of the 20 clinicians, 10 were pediatric ED physicians, 2 were general ED physicians and 8 were general pediatricians (Table 1). All parents reported that their child received antibiotics to treat their most recent episode of CAP.

TABLE 1

Characteristics of Respondents

Parent/Guardian Respondents, n = 18
Characteristicn (%)
Child age 
 Mean 5.1 y 
 Median 5 y 
 Range 2–11 ya 
Child sex 
 Female 12 (66.6) 
 Male 5 (27.7) 
 Nonbinary 1 (5.5) 
Parent race 
 African American/Black 4 (22.2) 
 Asian American 1 (5.5) 
 White 11 (61.1) 
 Another race 1 (5.5) 
 Prefer not to answer 1 (5.5) 
Parent ethnicity 
 Hispanic or Latino/a 6 (33.3) 
Child insurance coverage 
 Public insurance 6 (33.3) 
 Private insurance 12 (66.7) 
Highest education completed 
 High school diploma/GED 4 (22.3) 
 Some college 2 (11.1) 
 Bachelor’s degree 6 (33.4) 
 Master’s degree 6 (33.4) 
Employment status 
 Employed for wages 8 (44.5) 
 Self-employed 2 (11.1) 
 Out of work 1 (5.6) 
 Stay-at-home parent 6 (33.4) 
 Prefer not to answer 1 (5.6) 
Clinician respondents, n = 20 
Specialty 
 Pediatric emergency medicine 10 (50) 
 General emergency medicine 2 (10) 
 General pediatrics 8 (40) 
Primary practice setting 
 Academic 14 (70) 
 Community 6 (30) 
Y since completion of training 
 <5 5 (25) 
 5–10 4 (20) 
 11–15 5 (25) 
 16–20 1 (5) 
 >20 5 (25) 
Parent/Guardian Respondents, n = 18
Characteristicn (%)
Child age 
 Mean 5.1 y 
 Median 5 y 
 Range 2–11 ya 
Child sex 
 Female 12 (66.6) 
 Male 5 (27.7) 
 Nonbinary 1 (5.5) 
Parent race 
 African American/Black 4 (22.2) 
 Asian American 1 (5.5) 
 White 11 (61.1) 
 Another race 1 (5.5) 
 Prefer not to answer 1 (5.5) 
Parent ethnicity 
 Hispanic or Latino/a 6 (33.3) 
Child insurance coverage 
 Public insurance 6 (33.3) 
 Private insurance 12 (66.7) 
Highest education completed 
 High school diploma/GED 4 (22.3) 
 Some college 2 (11.1) 
 Bachelor’s degree 6 (33.4) 
 Master’s degree 6 (33.4) 
Employment status 
 Employed for wages 8 (44.5) 
 Self-employed 2 (11.1) 
 Out of work 1 (5.6) 
 Stay-at-home parent 6 (33.4) 
 Prefer not to answer 1 (5.6) 
Clinician respondents, n = 20 
Specialty 
 Pediatric emergency medicine 10 (50) 
 General emergency medicine 2 (10) 
 General pediatrics 8 (40) 
Primary practice setting 
 Academic 14 (70) 
 Community 6 (30) 
Y since completion of training 
 <5 5 (25) 
 5–10 4 (20) 
 11–15 5 (25) 
 16–20 1 (5) 
 >20 5 (25) 

GED, General Education Development.

a

Although our initial intent was to include children aged 1 to 6 years at the time of diagnosis, to obtain an adequate sample, we included 1 respondent whose child was older (11 years old) at the time of diagnosis.

None of the parents in our sample were familiar with the no antibiotic strategy to manage CAP. Their views varied but were distinctly clustered into 3 categories reflective of their feelings about the strategy, with most parents holding mixed sentiments.

Positive Sentiments

Parents who felt positively stated clear drawbacks to using medications when they are not necessary (quotation [Q] #1, Table 2). One parent expressed dismay that their child may have gotten unnecessary medication (Q #2). Supportive parents expressed trust in their child’s clinicians (Q #3) and described the ability to promptly seek care if their child’s condition worsened (Q #4).

TABLE 2

Exemplar Quotations from Parents

#1 If it’s proven that it’s not gonna work, that it’s not gonna do anything for them, then yeah, I don’t see why they should take the medicine. Really, I’m against medicine as it is, so if it’s unnecessary, I don’t think they should have to take it. (P #3006) 
#2 I think that is a good thing because, honestly, with 6-y-olds it was hard to get both of them to take the medicine, and outside of that…I feel like I gave them unnecessary medicine because if it was gonna run its course to be treated anyway, I guess maybe they didn’t need it. So, I feel that’s the first that I’ve heard of that, and so I think that’s a bit surprising, and I know that there’s forms of, like, bacterial pneumonia, but yeah. So, now I feel like I gave them medicine they didn’t need to have. (P #3011) 
#3 I would trust what the doctor is telling me. At that point, yeah, I think it would be more like the severity of it. If it’s mild, but mild like, “it’s going to get worse” or mild like “she can be treated with something else that she might not need the antibiotic; be treated with, like, Motrin or something that will make the fever go away” or something like that. But I would like to trust the doctors and trust that they are making the best decision for the patient. (P #3005) 
#4 I would believe him [the doctor, if the doctor said my child didn’t need antibiotics], but I would definitely keep an eye on the symptoms, and if I see that, let’s say, d are passing by, I see that there’s an increase of cough or they can’t sleep at night, they’re not eating, they’re not being themselves, I would definitely give the doctor a call and say, “Listen, what can we do? This is not working out. I don’t see any health coming back.” (P #3018) 
#5 I trust science and, like, I have trust in the process of clinical research that studies that, so it’s surprising maybe because, for me, sometimes it can feel like, when a little one gets sick, like, and is seeming more sick than at other times, like my daughter did when she had the pneumonia that, like, we need to treat it, you know, I need to give her something. It’s kind of, I feel like more of an emotional response than a scientific one; that, oh they’re sick, they must need something, let’s help make it better. But, you know, I think it’s important to get information like that from research and to kinda trust the scientific process of what it shows. (P #3016) 
#6 It depends, I guess, on what the other treatment options would be and how long it would take for them to feel better. Like, my daughter, she had a fever for a while, and I feel like the ibuprofen with the amoxicillin helped to get her fever down fairly quickly, like in a d or so. So, I would feel okay not giving them antibiotics as long as the alternative was a good option, because we weren’t given alternatives to antibiotics. It was just the treatment that was given. (P #3011) 
#7 I guess I would just want more information. To be honest actually, I have also had a personal experience where I got diagnosed with pneumonia and was given an antibiotic, and I have, I guess, a long-term injury from it. So, I’m not super excited about antibiotic treatment of pneumonia anyways. So, I would certainly be open to it, but I also recognize that something in the back of my mind says that’s the normal course of treatment, so it would just be like, well why? Why are you not using that and what can we use instead? (P #3004) 
#8 Initially, I think I would feel nervous because, again, like I feel like we’ve, I don’t know if it’s a parenting thing or a Western medicine thing, like if you have something you know it needs treatment. So that would be my initial gut reaction is, like, but what’s gonna help this go away? Like what do we give? But then, after, I think, hearing the explanation as to why, which I think is the really important piece that may or may not happen all the time, ya know? Just being explained that this is what the science tells us and this is what research has shown and these are additional things that you can do at home to care for your child and make them comfortable. Then, I would feel more comfortable not giving any medication. (P #3016) 
#9 Personally, I don’t agree that [most pneumonia is] viral. In my experience, most of the time, my boys or my son always had the bacterial one, and I’m not very much familiar with the viral pneumonia because I don’t think we experienced that part. The common one, I think, is mostly the bacterial, which requires the antibiotic. (P #3017) 
#10 In the condition that my son was in, I just wouldn’t have taken that [no antibiotics] for an answer, so I probably would have just taken my child somewhere else, because I already tried at home for several d and me seeing him not getting any better. You’re talking about fevers that can get so high and he had a febrile seizure, you know there’s other underlying things that can happen when a child is in that state. So, no. (P #3020) 
#11 This one’s tough because, again, I think it goes back to how was my child feeling at the moment? I know, for me, when we were in that office, she was just very much not herself and I think you know if their kid’s been sick a few times, sort of, what is a traditional symptom for them and what’s really extreme or intense. So, I think knowing now, based on what you just told me as opposed to your previous question, if I knew that the doctor could potentially be wrong or that an antibiotic, as long as the side effects were mild, something like a diaper rash or something more mild like that, to me, that wouldn’t outweigh the benefit of helping with the pneumonia symptoms. I’d rather take a diaper rash to labored breathing, so I guess I would be, perhaps I would push a little bit more on the doctor to see if we could try an antibiotic, a small dose infrequently to see what would happen and give it kind of a test period and then, if symptoms didn’t change, obviously, trying another method, whether it’s just not using an antibiotic, using a different one, something like that. But I suppose knowing that there’s a chance for error in that way by the doctor, I might push to still get it. (P #3015) 
#1 If it’s proven that it’s not gonna work, that it’s not gonna do anything for them, then yeah, I don’t see why they should take the medicine. Really, I’m against medicine as it is, so if it’s unnecessary, I don’t think they should have to take it. (P #3006) 
#2 I think that is a good thing because, honestly, with 6-y-olds it was hard to get both of them to take the medicine, and outside of that…I feel like I gave them unnecessary medicine because if it was gonna run its course to be treated anyway, I guess maybe they didn’t need it. So, I feel that’s the first that I’ve heard of that, and so I think that’s a bit surprising, and I know that there’s forms of, like, bacterial pneumonia, but yeah. So, now I feel like I gave them medicine they didn’t need to have. (P #3011) 
#3 I would trust what the doctor is telling me. At that point, yeah, I think it would be more like the severity of it. If it’s mild, but mild like, “it’s going to get worse” or mild like “she can be treated with something else that she might not need the antibiotic; be treated with, like, Motrin or something that will make the fever go away” or something like that. But I would like to trust the doctors and trust that they are making the best decision for the patient. (P #3005) 
#4 I would believe him [the doctor, if the doctor said my child didn’t need antibiotics], but I would definitely keep an eye on the symptoms, and if I see that, let’s say, d are passing by, I see that there’s an increase of cough or they can’t sleep at night, they’re not eating, they’re not being themselves, I would definitely give the doctor a call and say, “Listen, what can we do? This is not working out. I don’t see any health coming back.” (P #3018) 
#5 I trust science and, like, I have trust in the process of clinical research that studies that, so it’s surprising maybe because, for me, sometimes it can feel like, when a little one gets sick, like, and is seeming more sick than at other times, like my daughter did when she had the pneumonia that, like, we need to treat it, you know, I need to give her something. It’s kind of, I feel like more of an emotional response than a scientific one; that, oh they’re sick, they must need something, let’s help make it better. But, you know, I think it’s important to get information like that from research and to kinda trust the scientific process of what it shows. (P #3016) 
#6 It depends, I guess, on what the other treatment options would be and how long it would take for them to feel better. Like, my daughter, she had a fever for a while, and I feel like the ibuprofen with the amoxicillin helped to get her fever down fairly quickly, like in a d or so. So, I would feel okay not giving them antibiotics as long as the alternative was a good option, because we weren’t given alternatives to antibiotics. It was just the treatment that was given. (P #3011) 
#7 I guess I would just want more information. To be honest actually, I have also had a personal experience where I got diagnosed with pneumonia and was given an antibiotic, and I have, I guess, a long-term injury from it. So, I’m not super excited about antibiotic treatment of pneumonia anyways. So, I would certainly be open to it, but I also recognize that something in the back of my mind says that’s the normal course of treatment, so it would just be like, well why? Why are you not using that and what can we use instead? (P #3004) 
#8 Initially, I think I would feel nervous because, again, like I feel like we’ve, I don’t know if it’s a parenting thing or a Western medicine thing, like if you have something you know it needs treatment. So that would be my initial gut reaction is, like, but what’s gonna help this go away? Like what do we give? But then, after, I think, hearing the explanation as to why, which I think is the really important piece that may or may not happen all the time, ya know? Just being explained that this is what the science tells us and this is what research has shown and these are additional things that you can do at home to care for your child and make them comfortable. Then, I would feel more comfortable not giving any medication. (P #3016) 
#9 Personally, I don’t agree that [most pneumonia is] viral. In my experience, most of the time, my boys or my son always had the bacterial one, and I’m not very much familiar with the viral pneumonia because I don’t think we experienced that part. The common one, I think, is mostly the bacterial, which requires the antibiotic. (P #3017) 
#10 In the condition that my son was in, I just wouldn’t have taken that [no antibiotics] for an answer, so I probably would have just taken my child somewhere else, because I already tried at home for several d and me seeing him not getting any better. You’re talking about fevers that can get so high and he had a febrile seizure, you know there’s other underlying things that can happen when a child is in that state. So, no. (P #3020) 
#11 This one’s tough because, again, I think it goes back to how was my child feeling at the moment? I know, for me, when we were in that office, she was just very much not herself and I think you know if their kid’s been sick a few times, sort of, what is a traditional symptom for them and what’s really extreme or intense. So, I think knowing now, based on what you just told me as opposed to your previous question, if I knew that the doctor could potentially be wrong or that an antibiotic, as long as the side effects were mild, something like a diaper rash or something more mild like that, to me, that wouldn’t outweigh the benefit of helping with the pneumonia symptoms. I’d rather take a diaper rash to labored breathing, so I guess I would be, perhaps I would push a little bit more on the doctor to see if we could try an antibiotic, a small dose infrequently to see what would happen and give it kind of a test period and then, if symptoms didn’t change, obviously, trying another method, whether it’s just not using an antibiotic, using a different one, something like that. But I suppose knowing that there’s a chance for error in that way by the doctor, I might push to still get it. (P #3015) 

P, parent.

Mixed Sentiments

Parents expressing mixed feelings explained that, although they appreciated not using antibiotics in theory, accepting it in practice was difficult. One tension was between trust in scientific evidence and the emotional experience of caring for a suffering child (Q #5). Respondents suggested a willingness to accept a no antibiotic strategy contingent on being offered another treatment to facilitate speedy symptom resolution (Q #6). Because not using antibiotics was seen as so different from past experiences, our respondents stated it could feel like their child’s clinician was withholding needed treatment (Q #7). Respondents explained they could become comfortable with not receiving antibiotics if the rationale was clear and the clinician provided contingency plans (Q #8).

Negative Sentiments

Parents who felt negatively believed antibiotics are always needed for pneumonia on the basis of their previous experience (Q #9). These parents rejected the no antibiotic strategy on the basis of their assessment of the child’s course of illness, even if that assessment differed from the clinician’s (Q #10). Their own knowledge of what is a “traditional” symptom for their child versus one that is “really extreme or intense,” plays a role in their expectations (Q #11). For some parents, the perceived risks of unnecessary antibiotics are worth accepting; for example, “I’d rather take a diaper rash to labored breathing” (Q #11).

Although all clinicians acknowledged the importance of judicious antibiotic use, they varied in their awareness and opinions of the 2011 PIDS/IDSA pediatric CAP guidelines. Of 20 clinicians, 11 (55%) were familiar with the recommendation that antibiotics are not routinely required for preschool-aged children with mild CAP, most of whom were ED clinicians (n = 9, 81%). Those unaware accepted the idea that most mild CAP in this age group is viral; however, they exhibited a “trust but verify” approach before incorporating guidelines into practice (Table 3, Q #1). Those aware of the guidelines had mixed confidence about the evidence upon which they are based (Q #2). Clinicians identified 5 barriers to the implementation of this recommendation in real-world practice.

TABLE 3

Exemplar Quotations from Clinicians

#1 I’d read the guidelines myself and I’d look at the existing outcome data to convince myself that it is safe for some of these kids to not need antibiotics. If the rates of those kids being hospitalized are high after or they have complications, I’m less likely to not treat and, on the basis of the fact that those 2 societies came to the conclusion that it’s okay to not treat with antibiotics, I definitely trust those 2 societies. So, I would not expect to find any concerning information, but I would definitely do my own research on this before changing my practice. (GP) 
#2 I think you can give IDSA guidelines, but if IDSA guidelines are based on poor evidence, which you know (laughs) a lot of them are probably pretty poor, I think with the patient in front of you, it’s hard to apply those guidelines when you have a diagnosis of pneumonia. So, I don’t know. I think, yeah, I think it could be very challenging, especially in this d and age of, you know, families wanting to receive something and providers really worrying about misdiagnoses. (ED physician) 
#3 I think figuring out whether it’s bacterial or viral source is not always easy, and even with the tools that we have, it’s not necessarily 100%. You know we’re never, like, going into the lung to culture the organism or very rarely are we doing that, so you know there’s always a risk that you’re treating a viral illness with an antibiotic that’s not gonna necessarily improve that illness outcome and potentially could create harm with antibiotic resistance. (ED physician) 
#4 I tend to follow them [PIDS/IDSA guidelines] as much as possible, and so, the one thing that I think is a little bit different, is they recommend in outpatient settings, they don’t necessarily recommend routine use of chest x-ray in children who can be managed in an outpatient setting. I think the ED is a little bit of a gray area because we’re sort of sitting between the outpatient and the inpatient side. And so, even if I hear focal findings on exam, I find that a chest x-ray can help persuade me in 1 direction or another regarding antibiotics, because often times, when you are listening at a moment in time, a focal finding on auscultation is more likely to be atelectasis or positional than necessarily indicative of infiltrate, and looking at previous studies, clinicians often don’t even agree on their auscultation findings. And so, I think that that is the 1 time where I kind of deviate off of the guidelines and I’m more likely to get a chest x-ray in the ED than not if I hear something focal. (ED physician) 
#5 No [symptoms do not affect my decision to use or not use antibiotics in the treatment of children with mild CAP]. I mean, again, if I have an x-ray and, you know, if they call it pneumonia, I’m gonna treat it with antibiotics, unless the x-ray was obtained for a different reason and you know the kid’s had no fever or any respiratory symptoms whatsoever, then I would not give antibiotics. (ED physician) 
#6 Yeah, I think it would make me feel reassured if the procalcitonin level was very low. I think I would be probably maybe a little less comfortable if the procalcitonin was moderately elevated or significantly elevated, so I may be more hesitant to not use antibiotics in that case. But I think, if it was a case where I was feeling antibiotics are likely not indicated and then I received a procalcitonin that was very reassuring, I would kind of feel overall reassured that I’m making the correct decision. (ED physician) 
#7 I love using data to make decisions in my care, but I will say, in primary care, we work on a lot less objective data than many other places in medicine. Getting laboratories from kids can be really challenging in the outpatient setting. If they’re dehydrated, if they’re sick and depending on the skill of the MA or the nurse trying to draw laboratories in clinic, is often successful versus unsuccessful. If we’re not able to get the laboratories in clinic, then they have to go to an alternative site to get them, and that’s asking the family to do another visit somewhere else, which, for many of our families who have lower resources, that would be like 2 or 3 buses, or they don't have child care at home. And so, even though it seems kind of simple and it’s great to have a laboratory, the logistics of actually getting laboratories in the outpatient world is actually very challenging. (GP) 
#8 It makes me nervous honestly, because, even when I have a kid with mild pneumonia, I think my initial thought is, oh, like this kid looks now, but how are they gonna look in 24 h? So, again, I don’t just give an antibiotic if I don’t hear or see anything, but it honestly makes me nervous. Especially the kids that I see are pretty high risk. We have a predominantly underserved population, have lots of issues with transportation, and so I do worry, you know, when I’m seeing kids, if I just say, oh, there’s a pneumonia, it seems pretty mild, we’re just going to have you follow up and see how things go, I do worry about the parents’ ability to come back if there are issues…It would be, honestly, like, I would do that for ear infections. Like, oh, this looks pretty mild, let’s just, you know, if it gets worse, let us hear from you. But pneumonia is just one, I feel like those kids, they get sick really fast, you know, just kind of my experience. So, I’m always a little bit hesitant to watch and wait with those kids. (GP) 
#9 Also, [I would consider] what kind of follow-up they have, as well [when deciding to not use antibiotics to treat a child with mild CAP that I am discharging home from the ED]. If they have good follow-up, you know, if they’re gonna see their PCP in a d, I’d be more inclined to sort of do that. If I sort of feel that the parents, if I’m worried about the responsibility of the parents or maybe they live far away or if they are gonna, you know, they don’t have access to medical care, I may be more inclined to sort of treat. (ED physician) 
#10 I think, with all pneumonia, even when we are treating, but definitely if we’re not treating, the likelihood that, and I think the trust that I have in the family to follow up if things were getting worse, so, like, what barriers they have in terms of following up with me. And so, in my practice, we have a lot of English language learners, and access to the office might be complicated for them, and so I’d want to know for sure that they had a good understanding of what things they’re looking out for and reasons to come back or call us, and then that there wouldn’t be barriers to accessing care if things were to get worse. And yeah, I guess, just a family environment that allowed close supervision of the child. (GP) 
#11 If you can diagnose it when kids are on the healthier side outpatient, when there’s a consolidation just starting to form, you can decrease the chances that the child will become more sick or develop complications of it including, like, need for hospitalization because of dehydration or effusion or respiratory failure. So, we really want to try to catch these kids as early as possible and treat them in the earliest window to decrease their utilization, their hospital needs and their need for additional IV antibiotics and IV fluids and those kinds of treatments. (GP) 
#12 I always just worry, you know, the kids are at risk for complications for pneumonia, so the only other benefit I would say is I feel like it’s better health care utilization in general if you treat kids with appropriate antibiotics that they don’t end up with some of the more complications that require, you know, hospitalization and require a higher level of care. So, just trying to be respectful of, you know, trying to keep a kid out of the hospital so they’re not in the hospital utilizing medical resources that they otherwise wouldn’t have needed. (GP) 
#13 I think, for me, the main thing is, kids are just so unpredictable with respiratory stuff. I feel like I’ve seen so many kids where they look fine, fine, fine, fine, fine, and then, boom, they just get sick all the sudden, so I do worry about those kids. I’ve even seen a couple kids who I didn’t hear a pneumonia on and didn't get an x-ray because they look pretty good, and they come back the next d and just look horrible. The experience has unfortunately taught me probably to be a little bit more aggressive with pneumonia than the guidelines would suggest. (GP) 
#14 I feel like, when I was in residency and even now, like, I think a lot of the training is toward antibiotic use for pneumonia, especially pneumonia that, like I said, there’s other clinical features. So, they are having respiratory distress or breathing fast, they don't look well. Like, if they’re walking, running, playing, then you’re probably not gonna do antibiotics, but kids that come into your office that don’t look good or are having low desaturations, I don’t know many people that wouldn’t give antibiotics for that and just send them home and say you’re gonna be okay. So, I think the education tends to be when people come into your office and they don’t look well or they’re having difficulty breathing, that you do something about it. So, I think that is the training and that’s just the general human nature. You don’t want to send somebody out if they’re having difficulty breathing. (GP) 
#15 Well, I think, traditionally, even in the past few years with my practice, the guidelines for pneumonia have evolved to be less and less antibiotics it seems. So, when I was training, I’d feel like it was very much like a 7- to 10-d course, and now, it’s like a 5- to 7-d course, and then hearing things like that where, maybe at certain ages, antibiotics aren’t needed at all. So, I think it’s a cultural shift for people to readjust to the idea of not needing as much antibiotics, and I think it’s a cultural shift for the prescribers, as well as for the families who are worried. I think pneumonia has a connotation that feels scary to families. I’ve had many families who cry when I say the word pneumonia and, again, I’m talking about mild pneumonia being treated as an outpatient where my concern level is very low and then I’m sort of surprised at how upset the parents are about this diagnosis. So, I think a lot of times, providers feel pressured to do something and something feels like giving antibiotics, because families are so upset and worried about their child and it feels like you’re doing something to help cure their child, so there’s a lot of incentive to just give the antibiotic in those cases. (GP) 
#16 I think that it’s probably still difficult for a lot of community clinicians to adapt to those guidelines. To tell a family that they have a pneumonia that's possibly bacterial and we’re not going to be treating with antibiotics, I think it’s a difficult psychological sell for both clinicians and parents alike. (ED physician) 
#17 Also, you know it’s difficult for families sometimes to come to a place like the ED and go home with only symptomatic treatment. They feel like they came for, you know, something to treat the child, and if you tell them, well, they have a virus, we don’t have any treatments for this particular virus, and it just has to run its course, that can be frustrating for them. It can lead them to seek other opinions. So, you have to do the job of communicating that when you’re not treating with antibiotics. In a lot of ways, it may be easier to just give them an antibiotic and they feel like they got what they came for, but that’s not the right thing. (ED physician) 
#18 So, I would say, if we can get a child better faster with targeted treatment, if a parent can feel like they are doing something, they are proactively helping their child and they’re not powerless and part of that treatment is close follow-up, so making sure that there’s a primary care provider kind of a medical home for the child and I think that gives a parent a sense of calm and an understanding of, okay, my child is sick and is coughing and is febrile, but I’ve been educated what symptoms and how to treat the symptoms and how to get them better. So, I think there really is a sense of perhaps parental empowerment with an antibiotic prescription and maybe that alleviates some of their anxiety. (ED physician) 
#19 I think the benefits to the family are having an answer. I think it’s really stressful for parents when their kids are sick. They have to take time off of work. They’re already in your clinic, and so if you can get the right answer in the first clinic visit for an illness, that’s always gratifying because it takes a lot of stress off of the family, and the earlier we start the correct treatment, the faster the child recovers, which is good for the whole family in terms of just getting back to their normal and hopefully avoiding hospitalization. (ED physician) 
#20 I think we’re always under a lot of pressure for cases like this to treat with antibiotics and the treatments. I mean, the benefits to the provider are probably you can avoid a difficult conversation about, oh, I’m not treating with antibiotics because I don’t think you have bacterial pneumonia, and that conversation can sometimes go in unpleasant directions based on expectations from parents or the patient, I guess, in some situations. Because it feels like you’re withholding something they might benefit from and you’re a gatekeeper for that prescription, so you know when you’re in a busy ED shift and you don’t want to sit down and have a 40-min conversation about something that is in the big picture as small as antibiotics, that can really bog you down and kind of spoil your shift. (ED physician) 
#21 I think they’re [PIDS/IDSA guidelines] challenging to implement in practice because that differentiation between viral and bacterial disease is not always straightforward. You’re counting on patients and parents that can reliably follow up with their providers. In the ED, expectations are different and we lack the ability to follow up with patients longitudinally. So, it’s always our perspective to err on the side of caution and, although antibiotics are not risk free, those risks are generally low...I think, again, we’re talking about expectations on the parts of parents, having a good relationship with parents that is friendly, concerns about things like Press Ganey scores and the fact that it’s really easy to prescribe antibiotics. There’s no real gatekeeper involved. So, if it’s gonna make everybody happy, why not just do it? Also, the adverse effects of antibiotics are minimal enough that you’re not really causing any harm by overprescribing antibiotics. It’s not like giving opioids. (ED physician) 
#22 I think, in general, there’s a perception that amoxicillin is relatively harmless because we use it for so many things in pediatrics. You know if the first line treatment were a drug that had more complications or cost or side effects and concern associated with it that people might be more reluctant to give that to young children, but because it seems to [be] relatively benign, it isn’t something that I think we’re as cautious about using. (GP) 
#1 I’d read the guidelines myself and I’d look at the existing outcome data to convince myself that it is safe for some of these kids to not need antibiotics. If the rates of those kids being hospitalized are high after or they have complications, I’m less likely to not treat and, on the basis of the fact that those 2 societies came to the conclusion that it’s okay to not treat with antibiotics, I definitely trust those 2 societies. So, I would not expect to find any concerning information, but I would definitely do my own research on this before changing my practice. (GP) 
#2 I think you can give IDSA guidelines, but if IDSA guidelines are based on poor evidence, which you know (laughs) a lot of them are probably pretty poor, I think with the patient in front of you, it’s hard to apply those guidelines when you have a diagnosis of pneumonia. So, I don’t know. I think, yeah, I think it could be very challenging, especially in this d and age of, you know, families wanting to receive something and providers really worrying about misdiagnoses. (ED physician) 
#3 I think figuring out whether it’s bacterial or viral source is not always easy, and even with the tools that we have, it’s not necessarily 100%. You know we’re never, like, going into the lung to culture the organism or very rarely are we doing that, so you know there’s always a risk that you’re treating a viral illness with an antibiotic that’s not gonna necessarily improve that illness outcome and potentially could create harm with antibiotic resistance. (ED physician) 
#4 I tend to follow them [PIDS/IDSA guidelines] as much as possible, and so, the one thing that I think is a little bit different, is they recommend in outpatient settings, they don’t necessarily recommend routine use of chest x-ray in children who can be managed in an outpatient setting. I think the ED is a little bit of a gray area because we’re sort of sitting between the outpatient and the inpatient side. And so, even if I hear focal findings on exam, I find that a chest x-ray can help persuade me in 1 direction or another regarding antibiotics, because often times, when you are listening at a moment in time, a focal finding on auscultation is more likely to be atelectasis or positional than necessarily indicative of infiltrate, and looking at previous studies, clinicians often don’t even agree on their auscultation findings. And so, I think that that is the 1 time where I kind of deviate off of the guidelines and I’m more likely to get a chest x-ray in the ED than not if I hear something focal. (ED physician) 
#5 No [symptoms do not affect my decision to use or not use antibiotics in the treatment of children with mild CAP]. I mean, again, if I have an x-ray and, you know, if they call it pneumonia, I’m gonna treat it with antibiotics, unless the x-ray was obtained for a different reason and you know the kid’s had no fever or any respiratory symptoms whatsoever, then I would not give antibiotics. (ED physician) 
#6 Yeah, I think it would make me feel reassured if the procalcitonin level was very low. I think I would be probably maybe a little less comfortable if the procalcitonin was moderately elevated or significantly elevated, so I may be more hesitant to not use antibiotics in that case. But I think, if it was a case where I was feeling antibiotics are likely not indicated and then I received a procalcitonin that was very reassuring, I would kind of feel overall reassured that I’m making the correct decision. (ED physician) 
#7 I love using data to make decisions in my care, but I will say, in primary care, we work on a lot less objective data than many other places in medicine. Getting laboratories from kids can be really challenging in the outpatient setting. If they’re dehydrated, if they’re sick and depending on the skill of the MA or the nurse trying to draw laboratories in clinic, is often successful versus unsuccessful. If we’re not able to get the laboratories in clinic, then they have to go to an alternative site to get them, and that’s asking the family to do another visit somewhere else, which, for many of our families who have lower resources, that would be like 2 or 3 buses, or they don't have child care at home. And so, even though it seems kind of simple and it’s great to have a laboratory, the logistics of actually getting laboratories in the outpatient world is actually very challenging. (GP) 
#8 It makes me nervous honestly, because, even when I have a kid with mild pneumonia, I think my initial thought is, oh, like this kid looks now, but how are they gonna look in 24 h? So, again, I don’t just give an antibiotic if I don’t hear or see anything, but it honestly makes me nervous. Especially the kids that I see are pretty high risk. We have a predominantly underserved population, have lots of issues with transportation, and so I do worry, you know, when I’m seeing kids, if I just say, oh, there’s a pneumonia, it seems pretty mild, we’re just going to have you follow up and see how things go, I do worry about the parents’ ability to come back if there are issues…It would be, honestly, like, I would do that for ear infections. Like, oh, this looks pretty mild, let’s just, you know, if it gets worse, let us hear from you. But pneumonia is just one, I feel like those kids, they get sick really fast, you know, just kind of my experience. So, I’m always a little bit hesitant to watch and wait with those kids. (GP) 
#9 Also, [I would consider] what kind of follow-up they have, as well [when deciding to not use antibiotics to treat a child with mild CAP that I am discharging home from the ED]. If they have good follow-up, you know, if they’re gonna see their PCP in a d, I’d be more inclined to sort of do that. If I sort of feel that the parents, if I’m worried about the responsibility of the parents or maybe they live far away or if they are gonna, you know, they don’t have access to medical care, I may be more inclined to sort of treat. (ED physician) 
#10 I think, with all pneumonia, even when we are treating, but definitely if we’re not treating, the likelihood that, and I think the trust that I have in the family to follow up if things were getting worse, so, like, what barriers they have in terms of following up with me. And so, in my practice, we have a lot of English language learners, and access to the office might be complicated for them, and so I’d want to know for sure that they had a good understanding of what things they’re looking out for and reasons to come back or call us, and then that there wouldn’t be barriers to accessing care if things were to get worse. And yeah, I guess, just a family environment that allowed close supervision of the child. (GP) 
#11 If you can diagnose it when kids are on the healthier side outpatient, when there’s a consolidation just starting to form, you can decrease the chances that the child will become more sick or develop complications of it including, like, need for hospitalization because of dehydration or effusion or respiratory failure. So, we really want to try to catch these kids as early as possible and treat them in the earliest window to decrease their utilization, their hospital needs and their need for additional IV antibiotics and IV fluids and those kinds of treatments. (GP) 
#12 I always just worry, you know, the kids are at risk for complications for pneumonia, so the only other benefit I would say is I feel like it’s better health care utilization in general if you treat kids with appropriate antibiotics that they don’t end up with some of the more complications that require, you know, hospitalization and require a higher level of care. So, just trying to be respectful of, you know, trying to keep a kid out of the hospital so they’re not in the hospital utilizing medical resources that they otherwise wouldn’t have needed. (GP) 
#13 I think, for me, the main thing is, kids are just so unpredictable with respiratory stuff. I feel like I’ve seen so many kids where they look fine, fine, fine, fine, fine, and then, boom, they just get sick all the sudden, so I do worry about those kids. I’ve even seen a couple kids who I didn’t hear a pneumonia on and didn't get an x-ray because they look pretty good, and they come back the next d and just look horrible. The experience has unfortunately taught me probably to be a little bit more aggressive with pneumonia than the guidelines would suggest. (GP) 
#14 I feel like, when I was in residency and even now, like, I think a lot of the training is toward antibiotic use for pneumonia, especially pneumonia that, like I said, there’s other clinical features. So, they are having respiratory distress or breathing fast, they don't look well. Like, if they’re walking, running, playing, then you’re probably not gonna do antibiotics, but kids that come into your office that don’t look good or are having low desaturations, I don’t know many people that wouldn’t give antibiotics for that and just send them home and say you’re gonna be okay. So, I think the education tends to be when people come into your office and they don’t look well or they’re having difficulty breathing, that you do something about it. So, I think that is the training and that’s just the general human nature. You don’t want to send somebody out if they’re having difficulty breathing. (GP) 
#15 Well, I think, traditionally, even in the past few years with my practice, the guidelines for pneumonia have evolved to be less and less antibiotics it seems. So, when I was training, I’d feel like it was very much like a 7- to 10-d course, and now, it’s like a 5- to 7-d course, and then hearing things like that where, maybe at certain ages, antibiotics aren’t needed at all. So, I think it’s a cultural shift for people to readjust to the idea of not needing as much antibiotics, and I think it’s a cultural shift for the prescribers, as well as for the families who are worried. I think pneumonia has a connotation that feels scary to families. I’ve had many families who cry when I say the word pneumonia and, again, I’m talking about mild pneumonia being treated as an outpatient where my concern level is very low and then I’m sort of surprised at how upset the parents are about this diagnosis. So, I think a lot of times, providers feel pressured to do something and something feels like giving antibiotics, because families are so upset and worried about their child and it feels like you’re doing something to help cure their child, so there’s a lot of incentive to just give the antibiotic in those cases. (GP) 
#16 I think that it’s probably still difficult for a lot of community clinicians to adapt to those guidelines. To tell a family that they have a pneumonia that's possibly bacterial and we’re not going to be treating with antibiotics, I think it’s a difficult psychological sell for both clinicians and parents alike. (ED physician) 
#17 Also, you know it’s difficult for families sometimes to come to a place like the ED and go home with only symptomatic treatment. They feel like they came for, you know, something to treat the child, and if you tell them, well, they have a virus, we don’t have any treatments for this particular virus, and it just has to run its course, that can be frustrating for them. It can lead them to seek other opinions. So, you have to do the job of communicating that when you’re not treating with antibiotics. In a lot of ways, it may be easier to just give them an antibiotic and they feel like they got what they came for, but that’s not the right thing. (ED physician) 
#18 So, I would say, if we can get a child better faster with targeted treatment, if a parent can feel like they are doing something, they are proactively helping their child and they’re not powerless and part of that treatment is close follow-up, so making sure that there’s a primary care provider kind of a medical home for the child and I think that gives a parent a sense of calm and an understanding of, okay, my child is sick and is coughing and is febrile, but I’ve been educated what symptoms and how to treat the symptoms and how to get them better. So, I think there really is a sense of perhaps parental empowerment with an antibiotic prescription and maybe that alleviates some of their anxiety. (ED physician) 
#19 I think the benefits to the family are having an answer. I think it’s really stressful for parents when their kids are sick. They have to take time off of work. They’re already in your clinic, and so if you can get the right answer in the first clinic visit for an illness, that’s always gratifying because it takes a lot of stress off of the family, and the earlier we start the correct treatment, the faster the child recovers, which is good for the whole family in terms of just getting back to their normal and hopefully avoiding hospitalization. (ED physician) 
#20 I think we’re always under a lot of pressure for cases like this to treat with antibiotics and the treatments. I mean, the benefits to the provider are probably you can avoid a difficult conversation about, oh, I’m not treating with antibiotics because I don’t think you have bacterial pneumonia, and that conversation can sometimes go in unpleasant directions based on expectations from parents or the patient, I guess, in some situations. Because it feels like you’re withholding something they might benefit from and you’re a gatekeeper for that prescription, so you know when you’re in a busy ED shift and you don’t want to sit down and have a 40-min conversation about something that is in the big picture as small as antibiotics, that can really bog you down and kind of spoil your shift. (ED physician) 
#21 I think they’re [PIDS/IDSA guidelines] challenging to implement in practice because that differentiation between viral and bacterial disease is not always straightforward. You’re counting on patients and parents that can reliably follow up with their providers. In the ED, expectations are different and we lack the ability to follow up with patients longitudinally. So, it’s always our perspective to err on the side of caution and, although antibiotics are not risk free, those risks are generally low...I think, again, we’re talking about expectations on the parts of parents, having a good relationship with parents that is friendly, concerns about things like Press Ganey scores and the fact that it’s really easy to prescribe antibiotics. There’s no real gatekeeper involved. So, if it’s gonna make everybody happy, why not just do it? Also, the adverse effects of antibiotics are minimal enough that you’re not really causing any harm by overprescribing antibiotics. It’s not like giving opioids. (ED physician) 
#22 I think, in general, there’s a perception that amoxicillin is relatively harmless because we use it for so many things in pediatrics. You know if the first line treatment were a drug that had more complications or cost or side effects and concern associated with it that people might be more reluctant to give that to young children, but because it seems to [be] relatively benign, it isn’t something that I think we’re as cautious about using. (GP) 

IV, intravenous; MA, medical assistant; PCP, primary care provider.

Diagnostic Uncertainty

Respondents suggested that CAP is a challenging diagnosis to make. Once confirmed, differentiating viral from bacterial CAP is similarly difficult (Q #3). Clinicians in our sample talked about diagnostic uncertainty in relation to the lack of options for testing to inform their decision-making. Although guidelines state that chest radiography (CXR) is not necessary to confirm the diagnosis, nor differentiate etiology, many respondents mentioned it (Q #4). ED clinicians emphasized relying on CXR findings to determine how to manage CAP (Q #5). In contrast, GPs reported rarely using CXR. Although respondents expressed enthusiasm for procalcitonin to support decision-making, there was uncertainty about how to interpret procalcitonin values other than very low levels (Q #6). Clinicians felt that obtaining blood from a sick child always involves considerations of time, patient discomfort, communication delays, and family burden (Q #7).

The Consequences of Delaying Treatment

Against the backdrop of diagnostic uncertainty, clinicians reported that a major barrier to not using antibiotics is their concern for misidentifying children who have bacterial infections and the consequences of delayed treatment. Both ED clinicians and GPs perceived that children with CAP can unexpectedly take a turn for the worse (Q #8). Thus, obtaining timely follow-up care was a key factor in decision-making (Q #9). Our respondents considered the social context of families, access to transportation, parent work schedules, degree of available supervision of the sick child, when deciding about antibiotics. Clinicians also described evaluating how responsible a parent seemed, their degree of trust in the parent to follow up, and whether they felt a sense of shared understanding with the parent about the child’s condition (Q #10).

Our respondents were motivated to avoid children getting worse and requiring hospitalization, which was seen as harmful to the individual child (Q #11) and to others who could benefit from limited resources (Q #12). ED clinicians explained that they were especially motivated to prevent return visits for undertreated CAP because their institution tracked “bounce backs,” which could lead to a “ding on your record.” Respondents across clinical areas emphasized that they felt a higher degree of concern about undertreating an infection than the harms from unnecessary antibiotics; as 1 ED clinician reported: “I’m not going to lie awake at night worrying about the antibiotic. I’m going to worry about the kid I sent home that’s going to come back the next day sicker.”

Cultural Norms and the Management of CAP

Clinicians explained that the meaning attributed to CAP as a diagnosis broadly, both in medicine and lay society, contributes to the challenges of not using antibiotics. Respondents explained that respiratory difficulty in children is accompanied by a higher degree of concern than other symptoms (Q #13). Three clinicians contrasted CAP to otitis media in terms of their degree of comfort in not using antibiotics (Q #8). Both ED clinicians and GPs describe a “longstanding culture of giving antibiotics for pneumonia.” Norms learned through training, “human nature” to want to actively intervene to do something about labored breathing, and previous experiences caring for children with respiratory conditions lead many to see antibiotics as the normal management approach (Q #14). Changing the care of children with CAP would require a “cultural shift” for both clinicians and families (Q #15).

Navigating Parent Interactions

Clinicians across settings stated that a primary reason to prescribe antibiotics for mild CAP is because they believed parents expected them (Q #16). In talking about parent expectations, respondents acknowledged the “difficult psychological sell” of no antibiotics, especially in the ED setting (Q #17). Clinicians explained that an antibiotic prescription can make a parent feel empowered (Q #18) and create a sense of relief because it minimizes uncertainty, even if the diagnosis is incorrect (Q #19). In addition to the positive feelings generated through providing parents with a “solution” to a problem, an antibiotic prescription also protects the clinician from having a potentially uncomfortable and time-intensive conversation with families (Q #20).

Weighing the Risks of Antibiotics

Although our respondents believed that antibiotics could cause adverse effects in individual patients, they generally believed that these risks were minimal and adverse outcomes well managed. The contextual challenges in the ED (lack of ability to follow up with patients, parent expectations, incentives tied to patient satisfaction metrics, time pressures) combined with diagnostic uncertainty and the perception that antibiotics are low risk make prescribing the easiest course of action (Q #21). Multiple respondents compared the risk of antibiotics to other classes of medication (eg, opioids), and described variation in caution around prescribing (Q #22).

In this qualitative study, parents and clinicians reported the social, emotional, and logistical factors that make the no antibiotic strategy for mild CAP in preschool-aged children difficult to implement. Although all respondents acknowledged the importance of only using antibiotics when necessary, navigating the diagnosis and care of a young child with respiratory illness made it difficult to prioritize judicious antibiotic use. The cultural meaning of CAP as a serious illness, diagnostic uncertainty, fear of respiratory symptoms in young children, contextual factors surrounding the clinical encounter, and consequences of undertreating a bacterial infection contribute to a willingness to accept the risks of antibiotics even if there is a low likelihood they are needed.

No parent in our sample was familiar with this approach to CAP and they varied in their degree of support for the idea. Consistent with previous research, those supportive of the no antibiotic strategy felt strongly about avoiding unnecessary medication.19  Parents who were mixed in their support described the emotional challenges of caring for a child with respiratory illness and the desire to do something “active” to intervene.29  Importantly, parents explained they could be open to not receiving antibiotics for their child on the basis of their degree of trust in the clinician, communication of a clear rationale for the approach, and description of a contingency plan. This underscores the influence of clinician–parent communication on antibiotic prescribing.30 32 

Although some parents may be open to the no antibiotic strategy, this will require time on the part of treating clinicians to establish rapport with parents. In busy, high-acuity clinical environments where clinicians have no previous relationship with a patient or ability to follow-up after the visit, this may be challenging.33 35  The parents in our sample most adamant against the idea of the no antibiotic approach drew on their previous experiences caring for children with CAP, their willingness to accept the risk of unnecessary antibiotics, and their own judgment about the degree to which their child is sick. Research demonstrates discordance between parent-reported and clinician-confirmed assessment of symptom severity, including the assessment of respiratory symptoms.36  In a situation where a parent does not agree with the assessment of mild CAP, perceiving their child to be more ill than the clinician does, it may be difficult for parents to accept not receiving antibiotics.37 

Clinicians described the meaning of CAP in both lay and medical culture as a generally serious illness, contrasting it to other targets of antibiotic stewardship like otitis media. They emphasized norms learned in training, memories of previous severe cases, and a sense that children with CAP could get sick very quickly with little warning. Although communication training has been demonstrated to improve antibiotic prescribing for common acute respiratory tract infections (eg, sinusitis, pharyngitis, acute otitis media), pneumonia has typically been excluded.38 40  Our findings suggest that communication-based antibiotic stewardship interventions for CAP should consider the social meanings of illness, because these shape emotions which, in turn, shape interactions and decisions.41  These interventions should also consider the context in which clinicians work by, for example, modifying incentives around satisfaction scores or bounce backs to align with stewardship goals.

Both parents and clinicians emphasized the role of fear in caring for children with respiratory symptoms as a driver of antibiotic use even if there is awareness of population-level data suggesting that most mild CAP in young children are caused by viruses. The desire to act in the form of an antibiotic prescription to reduce risk, manage diagnostic uncertainty, and achieve safety has been reported as a barrier to judicious antibiotic use for acute respiratory tract infections across settings.35,42 44  Approaches to reduce unnecessary antibiotic prescribing for mild CAP could be informed by initiatives to minimize unnecessary interventions for infants with bronchiolitis, a viral lower respiratory infection where treatment is largely supportive.45,46  Feelings of fear about respiratory symptoms, coupled with parental expectations for interventions, have been reported as barriers to evidence-based bronchiolitis care.47  Theory-informed interventions that address multilevel sociobehavioral drivers of overuse, plus the engagement of clinicians and institutions in quality improvement collaboratives, have demonstrated success at improving the care of infants with bronchiolitis and could be a model for future stewardship interventions for children with mild CAP.45,48,49 

Our findings also have important implications for health equity. The clinicians in our sample highlighted the importance of the social context of the patient and their family when making decisions about treatment, especially the ability of families to access follow-up care. The parents in our sample expressed the importance of communication with and trust in their child’s clinician when considering the acceptability of a no antibiotics strategy for mild CAP. These findings must be considered against a backdrop of documented disparities in high-quality pediatric care delivery by child and family race, ethnicity, and language preference in the ED and primary care settings.50 58  As antibiotic stewardship interventions are developed and implemented to increase guideline adherence for the care of children with mild CAP, concurrent equity evaluations are needed to ensure that certain groups of patients are not disproportionately harmed by these efforts.59,60  The social interactions between clinicians and parents from marginalized backgrounds are of particular importance in light of our finding that some parents see a no antibiotic strategy as withholding necessary treatment.

This study has several strengths, including the combination of parent and clinician perspectives on the same phenomenon, purposive sampling of parents whose children experienced CAP allowing for more in-depth answers, and inclusion of clinicians working in diverse settings where children with mild CAP receive care. Because the timing of our study (January 2021–July 2021) was during the coronavirus disease 2019 pandemic, some limitations were introduced. Parent respondents were eligible if their child had received care for CAP from December 2018 onward. In addition to recall bias, the recollection of their experiences and feelings toward antibiotic therapy may have been influenced by knowledge gained about infectious diseases and respiratory illness in the subsequent years. Additionally, this study was conducted in 1 health system, which limits the generalizability of our findings.

Although clinicians and parents are supportive of reducing unnecessary antibiotic use, implementation of the no antibiotic strategy for mild CAP in children might be difficult in practice. Our findings suggest that, although advances in diagnostic testing and increasing evidence for the safety of the no antibiotics strategy will likely improve clinician’s confidence in avoiding antibiotics in young children with mild CAP, it will not be sufficient to change current practice because of the social, emotional, and logistical challenges. Future work should consider these challenges, along with attention to health equity implications, in the design and implementation of stewardship interventions.

We thank the parents and clinicians who participated in this study by sharing their experiences honestly.

Dr Szymczak conceptualized and designed the study, developed the interview guides, supervised the data collection and qualitative data analyses, drafted the initial manuscript, and critically reviewed and revised the manuscript; Ms Hayes and Ms Labellarte conducted all the qualitative interviews, performed the qualitative data analysis, and critically reviewed the manuscript; Dr Becker contributed to the development of the interview guides, supervised the qualitative data analyses, and critically reviewed the manuscript; Dr Toor performed the qualitative data analyses and critically reviewed the manuscript; Mr Zighelboim contributed to the literature review and critically reviewed the manuscript; Drs Gerber and Kuppermann contributed to the design of the project and critically reviewed and revised the manuscript; Dr Florin contributed to the conceptualization and design of the project and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Supported by National Heart Lung and Blood Institute grant R34HL153474 to Dr Florin. During the project period, Drs Szymczak and Gerber received support from a Centers for Disease Control and Prevention Cooperative Agreement #FOA#CK16-004-Epicenters for the Prevention of Healthcare Associated Infections. The funder had no role in the design or conduct of this study.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.

CAP

community-acquired pneumonia

CXR

chest radiography

ED

emergency department

GP

general pediatrician

IDSA

Infectious Diseases Society of America

PIDS

Pediatric Infectious Diseases Society

Q

quotation

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