Managing patients' antibiotic expectations

15 minutes to Read
Lauren Smith
14 March 2023
Managing antibiotic expectations

Despite limited indications, amoxicillin + clavulanic acid remains the second most used antibiotic in Aotearoa after amoxicillin. Inappropriate use of antibiotics may stem partly from meeting patient expectations for treatment.

Billy has a cold

Five-year-old Billy is a Pākehā boy, who lives with his parents and eight-year-old brother on a small, lifestyle block in Canterbury. Billy has a five-day history of sneezing, runny nose, nasal congestion and sore throat. For the past three days he’s had a cough, which was initially dry but is now productive with yellowish sputum. Billy's mum has administered several rapid antigen tests, which have all returned negative results. The family received COVID-19 and influenza vaccinations two months ago.

Mum tells you they are all going camping for a week and she thinks Billy should start on antibiotics “just in case” he has an infection that could worsen while they are away.

On examination, Billy has erythema of the posterior pharynx with tonsillar enlargement but no exudates. The tympanic membranes are mildly erythematous bilaterally, with no evidence of fluid or retraction. There is no palpable lymphadenopathy in his neck, and lung auscultation reveals only a few scattered expiratory wheezes bilaterally. He does not have a fever.

Billy’s signs and symptoms show strong evidence of a viral respiratory tract infection. There are no signs suggestive of bacterial infection at this time, so you are of the opinion he does not require antibiotics.

Mum expects antibiotics

How do you explain to Billy’s mum that antibiotics are not needed, given her expectation for them?

Reassure Billy’s mum that he has a cold that is caused by a virus, and that viral cold infections get better of their own accord, usually within a week.

Billy does not have any features of a bacterial infection – his sore throat will be due to his cold. Explain that antibiotics are not effective against viruses and will not reduce the time taken for Billy to get better. However, he may benefit from some rest and symptom relief such as:1,2

  • warm honey and/or lemon drinks
  • ice blocks or cool drinks
  • paracetamol or ibuprofen (these should be dosed by weight)
  • gargling with a warm saline solution (1 teaspoon salt in 250ml water) if Billy is capable of gargling
  • throat sprays, if appropriate for Billy.

Medicated throat lozenges may not be appropriate in a child of Billy’ age because of choking risk.

Together with Billy’s mum, devise a clear plan of action. Provide a printout of advice and red flag information, such as that from Health Navigator or KidsHealth. Let her know that these patient handouts include the Healthline number (0800 611 116), which is a 24-hour, seven-days-a-week service providing free health advice.

Stress that the development of red flag symptoms is highly unlikely but if any were to occur, she should take Billy to the nearest hospital. Red flags for children with viral respiratory tract infections include:1,2

  • drooling/dribbling – indicates difficulty in swallowing saliva
  • difficulty breathing – struggling or grunting when trying to breathe
  • bluish lips or tongue
  • stiff neck
  • extreme drowsiness or confusion.

Additionally, Billy’s mum should seek out a healthcare provider for review if Billy:1,2

  • develops a very high temperature
  • is unable to drink much or has a dry mouth, difficulty swallowing or reduced urine output
  • develops severe pain at the back of his throat
  • breaks out in a rash
  • has increased snoring episodes or stops breathing occasionally while asleep
  • has a cough lasting more than four weeks
  • has no improvement in symptoms after 48 hours.

Our Virus Action Plans can help you manage patient expectations around the use of antibiotics

These concise, editable information sheets help to reinforce when symptomatic and supportive care is the best medicine for your patient.
Click here to view the plans and download an adult or child version – available in multiple languages

What about Strep throat?

Billy’s mum is still not convinced that antibiotics are not needed, and asks if it could be strep throat?

Explain to Billy’s mum that he has features of a cold (caused by a virus) such as a runny nose and a productive cough, and these symptoms would be unusual in strep throat, which is caused by bacteria. Additionally, antibiotics would be used for strep throat only if he was at high risk of developing rheumatic fever - a rare complication of a strep throat infection. Given that Billy’s risk of rheumatic fever is very low and he is not significantly unwell, he doesn’t require a throat swab to check for strep.3,4

Explain that it is important to use antibiotics only when needed to avoid possibly experiencing adverse effects such as diarrhoea, and to limit the development of resistance and safeguard their usefulness.

Māori, Pacific children more at risk

Billy is of European ethnicity; how would his management change if he were of Māori or Pacific ethnicity? What other history would be important?

Māori or Pacific children are at increased risk of developing rheumatic fever, relative to children of other ethnicities. Risk criteria for rheumatic fever include:3

Personal, family or household history of rheumatic fever or two or more of:

  • Māori or Pacific ethnicity
  • aged 3–35 years (with emphasis on children and adolescents)
  • living in poor or crowded living conditions.

If Billy was a Māori or Pacific child, he would have two of the high-risk criteria (age and ethnicity). Early treatment of his sore throat would be needed as antibiotics can stop the development of rheumatic fever following infections caused by Group A Streptococcus. Billy’s throat would be swabbed to check for GAS and he would need a prescription for 10 days of empiric penicillin or amoxicillin. If the swab was positive for GAS, Billy would need to be isolated at home for 24 hours after starting the antibiotics, which should be continued for the 10 days. If the swab was negative, the antibiotics would be stopped.3

It would be important to know if anyone else in the household or family was sick. Strep throat is spread through coughing and sneezing, and sharing cups and utensils. The incubation period is between two days and one week. If someone in the family has strep throat, often others in the household are also infected, so it is recommended that all symptomatic household members have their throats swabbed, especially if they are children or adolescents.3

How can decision-making be shared?

Given that the decision-making process should be shared, how can we manage patient objections or concerns to a recommendation they receive no medicine, when they think one is required?

Shared decision making aligns the goals of patient and healthcare provider, acknowledging that each have a degree of expertise: the provider with medical evidence and clinical experience, and the patient with what is important to them and the treatment and outcomes they will accept. Complete agreement between provider and patient may not occur, but their expertise combines to evaluate available options and a resultant informed final decision.5

Overestimating benefits of antibiotics and underestimating their risks can be a common theme among both providers and patients. Engage in discussion about the benefits and risks of antibiotics for the condition the patient is presenting with, if the patient is interested.5 Inform them that resolution of a viral infection will not be any quicker with antibiotic use relative to supportive treatment, and unwanted side effects (such as nausea, diarrhoea, thrush and rash) may occur. Ask about goals and expectations from antibiotic use. When do they expect to feel better? What would be the impact on them of nausea and diarrhoea caused by an antibiotic?

Seek out decision aids to help inform the patient, and provide these in printed or electronic form.

Finally, healthcare providers may presuppose the patient wants an antibiotic prescription when the patient just desires a clear plan of action.5 If the patient is willing, work together on a specific plan, including non-pharmacological measures to relieve symptoms, and detailed criteria for when the patient should return to their provider to seek further advice.

Notes about amoxicillin + clavulanic acid

Prescribers, including pharmacist and nurse prescribers, can use the EPiC dashboard to freely access their own prescribing data. They can compare their data with practice data and national data. Non-prescribers can also access the online EPiC dashboard to explore national dispensing data.

Amoxicillin + clavulanic acid dispensing is high

The addition of clavulanic acid to amoxicillin extends amoxicillin’s spectrum of activity, adding cover against anaerobic and gram-negative bacteria. In primary care, amoxicillin + clavulanic acid is recommended first-line for only a small number of clinical indications.6 Generally, these are:

  • human and animal bites
  • diabetic foot ulcer
  • mastitis in males and non-lactating females.

Given these few first-line indications, low levels of amoxicillin + clavulanic acid dispensing in the community would be expected. However, data from the EPiC Antibiotics dashboard clearly show high use of amoxicillin + clavulanic acid in Aotearoa New Zealand. In fact, this drug combination remains the second most used antibiotic after amoxicillin.7

There is a seasonal shift in prescribing

The EPiC dashboard also shows a seasonal shift in antibiotic prescribing, indicating they are likely being used inappropriately, and possibly for viral illnesses, over the winter months.7

Amoxicillin + clavulanic acid should not be used to treat community-acquired pneumonia; this condition is most commonly a result of gram-positive bacteria. Treatment guidelines suggest community-acquired pneumonia can usually be sufficiently treated with amoxicillin alone.6

Including indications on prescriptions may reduce use

Before prescribers provide a script for amoxicillin + clavulanic acid, they should be considering whether this extended cover is required for the infection they are treating.

One of the World Antimicrobial Awareness Week recommendations, from a WHO initiative, is for prescribers to add a meaningful indication to a prescription for antibiotics. This prompts the prescriber to reflect on their choice of antibiotic and facilitates communication between healthcare providers and patients.8

Infectious diarrhoea is more likely

Nearly all antibiotics can increase susceptibility to colonisation and overgrowth of toxin-secreting Clostridioides difficile (previously called Clostridium difficile) but amoxicillin + clavulanic acid along with cephalosporins, fluoroquinolones and clindamycin increase risk to the greatest extent.9

Using the EPiC dashboard

The EPiC Antibiotics theme has three data stories: Amoxicillin + clavulanic acid, Urinary tract infection, and Topical antibiotics. Each dashboard has a set of Reflection Activities that are suitable for completing as part of your continuing professional development. Clicking on the EPiC Reflect button helps you, as an individual or as part of your team, to think about your current practice.

For example:

  • How does dispensing of antibiotics to different demographic groups compare nationally?
  • How do national dispensing data compare to the recommendations for UTI antibiotic choice and length of course?
  • Does the EPiC dashboard show a winter seasonality shift in antibiotic prescribing in your practice?
  • Are you prescribing amoxicillin + clavulanic acid when amoxicillin alone, or another narrow-spectrum antibiotic, would suffice?

Content updates

2 May 2023: Case history amended to make it clear that Billy is unlikely to have COVID-19, and to mention that free vaccinations for COVID and influenza are available.

30 June 2023: Link to Virus Action Plans added.


  1. Health Navigator New Zealand. Patient resources: Sore throat in children. (updated 26 Dec 2022); Cough in children (updated 24 Nov 2022); A cold or the flu? Or COVID-19? (reviewed 24 November 2022).
  2. KidsHealth. Patient resources: Sore throat in detail. (reviewed 5 Mar 2021); Cough in children. (reviewed 14 February 2022).
  3. Heart Foundation. New Zealand guidelines for rheumatic fever: Group A streptococcal sore throat management guideline: 2019 update. Auckland, National Heart Foundation of New Zealand.
  4. HealthPathways Community: Auckland Region. Sore throat. (updated 2 Feb 2023; log on required).
  5. Ko L, Ha R, Leung V, et al. Shared decision making and antibiotic stewardship: Will pharmacists rise to the challenge? Can Pharm J (Ott) 2020;153(1):12–14.
  6. BPACnz. Antibiotics: Choices for common infections. 2017 edition.
  7. He Ako Hiringa. EPiC: Antibiotics.
  8. NZ Antimicrobial Stewardship/Infection Pharmacist Expert Group. Document the Indication. World Antimicrobial Awareness Week 2020. Resources found at Accessed October 2022.
  9. Mullish BH, Williams HRT. Clostridium difficile infection and antibiotic-associated diarrhoea. Clin Med (Lond) 2018;18(3):237–41.


Written by: Gayle Robins, freelance medical writer and regular contributor to He Ako Hiringa resources

Reviewed by:

  • Lauren Smith (senior practice fellow at the School of Pharmacy at the University of Otago and a member of the New Zealand Antimicrobial Stewardship and Infection Pharmacist Expert Group NAMSIPEG)
  • Dr Jim Vause (emeritus GP)
  • Dr Noni Richards (BPharm, PhD, senior consultant at Matui Ltd, developers of the EPiC dashboard)

Professional college endorsements

This activity has been endorsed by The Royal New Zealand College of General Practitioners (RNZCGP) and has been approved for up to 0.25 CME credits for continuing professional development purposes (1 credit per learning hour). To claim your CPD credits, log in to your Te Whanake dashboard and record these activities under the appropriate learning category.

This activity has been endorsed by the PSNZ as suitable for inclusion in a pharmacist’s CE records for CPD purposes.

Professional college endorsements