A targeted online training program for general practitioners, combined with an information booklet for parents, led to fewer antibiotic prescriptions for children with respiratory tract infections.

This way, unnecessary use of antibiotics can be reduced relatively easily. The benefits are a lower risk of antibiotic resistance, fewer adverse effects and lower health costs. These conclusions are drawn by Anne Dekker, who took her PhD on this research in Utrecht on September 27, 2018.

Of all antibiotics, about eighty percent are prescribed by general practitioners, mainly for respiratory infections and ear infections. Such infections are often viral, usually mild and often go away spontaneously. An antibiotic treatment is unnecessary in that case because it does not reduce the severity or the duration of the symptoms. Unnecessary antibiotic use increases the risk of antibiotic resistance, leads to excessive use of medication and exposes patients to unnecessary adverse effects. This thesis shows that in one third of the cases in Dutch general practice where an antibiotic is prescribed for children, this is not indicated according to the guidelines.

Antibiotic use in children

Dekker's research also shows from the records of 45 Dutch general practices that general practitioners are consulted 1029 times a year for an infectious disease and prescribe 262 antibiotic treatments per 1,000 children. The highest number of prescriptions was for one-year-old children (714 prescriptions per 1,000 child years). The most common reason to visit a general practitioner was an acute respiratory tract infection and this was, after ear infection, the second most common reason to prescribe antibiotics. 

Influencing prescription behavior

General practitioners tend to prescribe antibiotics more often for children when they feel insecure about the severity of the symptoms. In addition, the uncertainties, beliefs and expectations of parents play an important role in the physician's decision as to whether or not to prescribe antibiotics.

Anne Dekker explains: "In my thesis I describe the effect of the RAAK intervention (this stands for Rational Antibiotics Use Children). This online training for general practitioners, combined with information booklets for parents, reduces the number of antibiotic prescriptions for children with respiratory tract infections. About 21 percent of children with respiratory tract infection symptoms in practices that followed the online training received an antibiotic, compared to 33 percent of children in the control practices. It therefore seems that even in a country where relatively few antibiotics are used, we can still further improve prescription behavior." The study also showed that the RAAK intervention in children with respiratory tract infections was cost-effective from a health perspective at a relatively low investment.

Information booklet

From interviews with parents after they had read the information booklet, it became clear that they were reassured, that they had gained more knowledge (for example, some parents did not know that antibiotics do not work against viral respiratory tract infections), and that they saw the reservations they already had about the prescription of antibiotics for their child confirmed. They also trusted their physician's decision to prescribe or not to prescribe antibiotics. Contrary to what general practitioners often think, most parents do not expect them to readily prescribe an antibiotic. The interviews also showed that the information on bacterial resistance is often difficult for parents to understand. 

About the future of this program, Anne Dekker says, "We know that the effect of a one-off training program wears off over time. We should therefore consider what the options are for keeping general practitioners alert with regard to their prescription behavior, for example by including the RAAK intervention in the practice accreditation of the Dutch College of General Practitioners."


Anne Dekker (1989, Leiden) took her PhD on September 27, 2018 at Utrecht University on the thesis 'Rational antibiotic prescribing for children with respiratory tract infections'. Supervisor was Prof. Th.J.M. Verheij, and co-supervisor was Dr A.W. van der Velden, both from the Department of General Medicine and affiliated with the Julius Center for Health Sciences and Primary Medicine, UMC Utrecht. Anne Dekker will continue her training as a general practitioner at UMC Utrecht in October 2018.