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Schuh HB, Hooli S, Ahmed S, King C, Roy AD, Lufesi N, Islam ASMDA, Mvalo T, Chowdhury NH, Ginsburg AS, Colbourn T, Checkley W, Baqui AH, McCollum ED. Clinical hypoxemia score for outpatient child pneumonia care lacking pulse oximetry in Africa and South Asia. Front Pediatr 2023; 11:1233532. [PMID: 37859772 PMCID: PMC10582699 DOI: 10.3389/fped.2023.1233532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/07/2023] [Indexed: 10/21/2023] Open
Abstract
Background Pulse oximeters are not routinely available in outpatient clinics in low- and middle-income countries. We derived clinical scores to identify hypoxemic child pneumonia. Methods This was a retrospective pooled analysis of two outpatient datasets of 3-35 month olds with World Health Organization (WHO)-defined pneumonia in Bangladesh and Malawi. We constructed, internally validated, and compared fit & discrimination of four models predicting SpO2 < 93% and <90%: (1) Integrated Management of Childhood Illness guidelines, (2) WHO-composite guidelines, (3) Independent variable least absolute shrinkage and selection operator (LASSO); (4) Composite variable LASSO. Results 12,712 observations were included. The independent and composite LASSO models discriminated moderately (both C-statistic 0.77) between children with a SpO2 < 93% and ≥94%; model predictive capacities remained moderate after adjusting for potential overfitting (C-statistic 0.74 and 0.75). The IMCI and WHO-composite models had poorer discrimination (C-statistic 0.56 and 0.68) and identified 20.6% and 56.8% of SpO2 < 93% cases. The highest score stratum of the independent and composite LASSO models identified 46.7% and 49.0% of SpO2 < 93% cases. Both LASSO models had similar performance for a SpO2 < 90%. Conclusions In the absence of pulse oximeters, both LASSO models better identified outpatient hypoxemic pneumonia cases than the WHO guidelines. Score external validation and implementation are needed.
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Affiliation(s)
- Holly B. Schuh
- Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Shubhada Hooli
- Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- Division of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | | | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | | | | | - Tisungane Mvalo
- University of North Carolina (UNC) Project Malawi, Lilongwe, Malawi
- Department of Pediatrics, UNC, Chapel Hill, NC, United States
| | | | - Amy Sarah Ginsburg
- Clinical Trial Center, University of Washington, Seattle, WA, United States
| | - Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
| | - William Checkley
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Abdullah H. Baqui
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Eric D. McCollum
- Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Mvalo T, Smith AG, Eckerle M, Hosseinipour MC, Kondowe D, Vaidya D, Liu Y, Corbett K, Nansongole D, Mtimaukanena TA, Lufesi N, McCollum ED. Antibiotic treatment failure in children aged 1 to 59 months with World Health Organization-defined severe pneumonia in Malawi: A CPAP IMPACT trial secondary analysis. PLoS One 2022; 17:e0278938. [PMID: 36516197 PMCID: PMC9750006 DOI: 10.1371/journal.pone.0278938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 11/21/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Pneumonia is a leading cause of mortality in children <5 years globally. Early identification of hospitalized children with pneumonia who may fail antibiotics could improve outcomes. We conducted a secondary analysis from the Malawi CPAP IMPACT trial evaluating risk factors for antibiotic failure among children hospitalized with pneumonia. METHODS Participants were 1-59 months old with World Health Organization-defined severe pneumonia and hypoxemia, severe malnutrition, and/or HIV exposure/infection. All participants received intravenous antibiotics per standard care. First-line antibiotics were benzylpenicillin and gentamicin for five days. Study staff assessed patients for first-line antibiotic failure daily between days 3-6. When identified, patients failing antibiotics were switched to second-line ceftriaxone. Analyses excluded children receiving ceftriaxone and/or deceased by hospital day two. We compared characteristics between patients with and without treatment failure and fit multivariable logistic regression models to evaluate associations between treatment failure and admission characteristics. RESULTS From June 2015-March 2018, 644 children were enrolled and 538 analyzed. Antibiotic failure was identified in 251 (46.7%) participants, and 19/251 (7.6%) died. Treatment failure occurred more frequently with severe malnutrition (50.2% (126/251) vs 28.2% (81/287), p<0.001) and amongst those dwelling ≥10km from a health facility (22.3% (56/251) vs 15.3% (44/287), p = 0.026). Severe malnutrition occurred more frequently among children living ≥10km from a health facility than those living <10km (49.0% (49/100) vs 35.7% (275/428), p = 0.014). Children with severe malnutrition (adjusted odds ratio (aOR) 2.2 (95% CI 1.52, 3.24), p<0.001) and pre-hospital antibiotics ((aOR 1.47, 95% CI 1.01, 2.14), p = 0.043) had an elevated aOR for antibiotic treatment failure. CONCLUSION Severe malnutrition and pre-hospital antibiotic use predicted antibiotic treatment failure in this high-risk severe pneumonia pediatric population in Malawi. Our findings suggest addressing complex sociomedical conditions like severe malnutrition and improving pneumonia etiology diagnostics will be key for better targeting interventions to improve childhood pneumonia outcomes.
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Affiliation(s)
- Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- * E-mail:
| | - Andrew G. Smith
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - Michelle Eckerle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
- Division of Pediatric Emergency Medicine, Cincinnati Children’s Hospital, Cincinnati, OH, United States of America
| | - Mina C. Hosseinipour
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Division of Infectious Disease, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Davie Kondowe
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Dhananjay Vaidya
- Department of Medicine, Epidemiology and the BEAD Core, Johns Hopkins University, Baltimore, MD, United States of America
| | - Yisi Liu
- Department of Pediatrics and the BEAD Core, Johns Hopkins University, Baltimore, MD, United States of America
| | - Kelly Corbett
- Department of Pediatrics, Section of Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America
| | - Dan Nansongole
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | | | | | - Eric D. McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Global Program for Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States of America
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Rahman AE, Ameen S, Hossain AT, Perkins J, Jabeen S, Majid T, Uddin AFMA, Shaikh MZH, Islam MS, Islam MJ, Ashrafee S, Md. Shah Alam H, Saberin A, Ahmed S, Banik G, Kabir ANME, Ahmed A, Chisti MJ, Cunningham S, Dockrell DH, Nair H, Arifeen SE, Campbell H. Introducing pulse oximetry for outpatient management of childhood pneumonia: An implementation research adopting a district implementation model in selected rural facilities in Bangladesh. EClinicalMedicine 2022; 50:101511. [PMID: 35795715 PMCID: PMC9251564 DOI: 10.1016/j.eclinm.2022.101511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 05/19/2022] [Accepted: 05/25/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pulse oximetry has potential for identifying hypoxaemic pneumonia and substantially reducing under-five deaths in low- and middle-income countries (LMICs) setting. However, there are few examples of introducing pulse oximetry in resource-constrained paediatric outpatient settings, such as Integrated Management of Childhood Illness (IMCI) services. METHODS The National IMCI-programme of Bangladesh designed and developed a district implementation model for introducing pulse oximetry in routine IMCI services through stakeholder engagement and demonstrated the model in Kushtia district adopting a health system strengthening approach. Between December 2020 and June 2021, two rounds of assessment were conducted based on WHO's implementation research framework and outcome variables, involving 22 IMCI service-providers and 1680 children presenting with cough/difficulty-in-breathing in 12 health facilities. The data collection procedures included structured-observations, re-assessments, interviews, and data-extraction by trained study personnel. FINDINGS We observed that IMCI service-providers conducted pulse oximetry assessments on all eligible children in routine outpatient settings, of which 99% of assessments were successful; 85% (95% CI 83,87) in one attempt, and 69% (95% CI 67,71) within one minute. The adherence to standard operating procedure related to pulse oximetry was 92% (95% CI 91,93), and agreement regarding identifying hypoxaemia was 97% (95% CI 96,98). The median performance-time was 36 seconds (IQR 20,75), which was longer among younger children (2-11 months: 44s, IQR 22,78; 12-59 months: 30s, IQR 18,53, p < 0.01) and among those classified as pneumonia/severe-pneumonia than as no-pneumonia (41s, IQR 22,70; 32s, IQR 20,62, p < 0.01). We observed improvements in almost all indicators in round-2. IMCI service-providers and caregivers showed positive attitudes towards using this novel technology for assessing their children. INTERPRETATION This implementation research study suggested the adoption, feasibility, fidelity, appropriateness, acceptability, and sustainability of pulse oximetry introduction in routine IMCI services in resource-poor settings. The learning may inform the evidence-based scale-up of pulse oximetry linked with an oxygen delivery system in Bangladesh and other LMICs. FUNDING This research was funded by the UK National Institute for Health Research (NIHR) (Global Health Research Unit on Respiratory Health (RESPIRE); 16/136/109) using UK aid from the UK Government to support global health research.
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Affiliation(s)
- Ahmed Ehsanur Rahman
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, UK
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
- Corresponding author at: Edinburgh Medical School: Molecular, Genetic and Population Health Sciences, The University of Edinburgh, Edinburgh, UK, Associate Scientist, Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh.
| | - Shafiqul Ameen
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Aniqa Tasnim Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Janet Perkins
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Sabrina Jabeen
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Tamanna Majid
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - AFM Azim Uddin
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Md. Ziaul Haque Shaikh
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Muhammad Shariful Islam
- Directorate General of Health Services, Ministry of Health and Family Welfare, Government of Bangladesh, Bangladesh
| | - Md. Jahurul Islam
- Directorate General of Health Services, Ministry of Health and Family Welfare, Government of Bangladesh, Bangladesh
| | - Sabina Ashrafee
- Directorate General of Health Services, Ministry of Health and Family Welfare, Government of Bangladesh, Bangladesh
| | - Husam Md. Shah Alam
- Directorate General of Health Services, Ministry of Health and Family Welfare, Government of Bangladesh, Bangladesh
| | - Ashfia Saberin
- Directorate General of Health Services, Ministry of Health and Family Welfare, Government of Bangladesh, Bangladesh
| | | | | | | | - Anisuddin Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Steve Cunningham
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - David H Dockrell
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Harish Nair
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Harry Campbell
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, UK
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Extended Versus Standard Antibiotic Course Duration in Children <5 Years of Age Hospitalized With Community-acquired Pneumonia in High-risk Settings: Four-week Outcomes of a Multicenter, Double-blind, Parallel, Superiority Randomized Controlled Trial. Pediatr Infect Dis J 2022; 41:549-555. [PMID: 35476706 DOI: 10.1097/inf.0000000000003558] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND High-level evidence is limited for antibiotic duration in children hospitalized with community-acquired pneumonia (CAP) from First Nations and other at-risk populations of chronic respiratory disorders. As part of a larger study, we determined whether an extended antibiotic course is superior to a standard course for achieving clinical cure at 4 weeks in children 3 months to ≤5 years old hospitalized with CAP. METHODS In our multinational (Australia, New Zealand, Malaysia), double-blind, superiority randomized controlled trial, children hospitalized with uncomplicated, radiographic-confirmed, CAP received 1-3 days of intravenous antibiotics followed by 3 days of oral amoxicillin-clavulanate (80 mg/kg, amoxicillin component, divided twice daily) and then randomized to extended (13-14 days duration) or standard (5-6 days) antibiotics. The primary outcome was clinical cure (complete resolution of respiratory symptoms/signs) 4 weeks postenrollment. Secondary outcomes included adverse events, nasopharyngeal bacterial pathogens and antimicrobial resistance at 4 weeks. RESULTS Of 372 children enrolled, 324 fulfilled the inclusion criteria and were randomized. Using intention-to-treat analysis, between-group clinical cure rates were similar (extended course: n = 127/163, 77.9%; standard course: n = 131/161, 81.3%; relative risk = 0.96, 95% confidence interval = 0.86-1.07). There were no significant between-group differences for adverse events (extended course: n = 43/163, 26.4%; standard course, n = 32/161, 19.9%) or nasopharyngeal carriage of Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and Staphylococcus aureus or antimicrobial resistance. CONCLUSIONS Among children hospitalized with pneumonia and at-risk of chronic respiratory illnesses, an extended antibiotic course was not superior to a standard course at achieving clinical cure at 4 weeks. Additional research will identify if an extended course provides longer-term benefits.
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Rahman AE, Hossain AT, Nair H, Chisti MJ, Dockrell D, Arifeen SE, Campbell H. Prevalence of hypoxaemia in children with pneumonia in low-income and middle-income countries: a systematic review and meta-analysis. THE LANCET GLOBAL HEALTH 2022; 10:e348-e359. [PMID: 35180418 PMCID: PMC8864303 DOI: 10.1016/s2214-109x(21)00586-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/31/2021] [Accepted: 12/07/2021] [Indexed: 12/23/2022] Open
Abstract
Background Pneumonia accounts for around 15% of all deaths of children younger than 5 years globally. Most happen in resource-constrained settings and are potentially preventable. Hypoxaemia is one of the strongest predictors of these deaths. We present an updated estimate of hypoxaemia prevalence among children with pneumonia in low-income and middle-income countries. Methods We conducted a systematic review using the following key concepts “children under five years of age” AND “pneumonia” AND “hypoxaemia” AND “low- and middle-income countries” by searching in 11 bibliographic databases and citation indices. We included all articles published between Nov 1, 2008, and Oct 8, 2021, based on observational studies and control arms of randomised and non-randomised controlled trials. We excluded protocol papers, articles reporting hypoxaemia prevalence based on less than 100 pneumonia cases, and articles published before 2008 from the review. Quality appraisal was done with the Joanna Briggs Institute tools. We reported pooled prevalence of hypoxaemia (SpO2 <90%) by classification of clinical severity and by clinical settings by use of the random-effects meta-analysis models. We combined our estimate of the pooled prevalence of pneumonia with a previously published estimate of the number of children admitted to hospital due to pneumonia annually to calculate the total annual number of children admitted to hospital with hypoxaemic pneumonia. Findings We identified 2825 unique records from the databases, of which 57 studies met the eligibility criteria: 26 from Africa, 23 from Asia, five from South America, and four from multiple continents. The prevalence of hypoxaemia was 31% (95% CI 26–36; 101 775 children) among all children with WHO-classified pneumonia, 41% (33–49; 30 483 children) among those with very severe or severe pneumonia, and 8% (3–16; 2395 children) among those with non-severe pneumonia. The prevalence was much higher in studies conducted in emergency and inpatient settings than in studies conducted in outpatient settings. In 2019, we estimated that over 7 million children (95% CI 5–8 million) were admitted to hospital with hypoxaemic pneumonia. The studies included in this systematic review had high τ2 (ie, 0·17), indicating a high level of heterogeneity between studies, and a high I2 value (ie, 99·6%), indicating that the heterogeneity was not due to chance. This study is registered with PROSPERO, CRD42019126207. Interpretation The high prevalence of hypoxaemia among children with severe pneumonia, particularly among children who have been admitted to hospital, emphasises the importance of overall oxygen security within the health systems of low-income and middle-income countries, particularly in the context of the COVID-19 pandemic. Even among children with non-severe pneumonia that is managed in outpatient and community settings, the high prevalence emphasises the importance of rapid identification of hypoxaemia at the first point of contact and referral for appropriate oxygen therapy. Funding UK National Institute for Health Research (Global Health Research Unit on Respiratory Health [RESPIRE]; 16/136/109).
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Affiliation(s)
- Ahmed Ehsanur Rahman
- The University of Edinburgh, Edinburgh, UK; International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh.
| | - Aniqa Tasnim Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | | | | | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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Morrison JM, Chojnacki M, Fadrowski JJ, Bauza C, Dunman PM, Dudas RA, Goldenberg NA, Berman DM. Serum-Associated Antibiotic Tolerance in Pediatric Clinical Isolates of Pseudomonas aeruginosa. J Pediatric Infect Dis Soc 2019; 9:671-679. [PMID: 31886511 PMCID: PMC7974018 DOI: 10.1093/jpids/piz094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 12/05/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND When grown in human serum, laboratory isolates of Pseudomonas aeruginosa exhibit tolerance to antibiotics at inhibitory concentrations. This phenomenon, known as serum-associated antibiotic tolerance (SAT), could lead to clinical treatment failure of pseudomonal infections. Our purpose in this study was to determine the prevalence and clinical impact of SAT in Pseudomonas isolates in hospitalized children. METHODS The SAT phenotype was assessed in patients aged <18 years admitted with respiratory or blood cultures positive for P. aeruginosa. The SAT phenotype was a priori defined as a ≥2-log increase in colony-forming units when grown in human serum compared with Luria-Bertani medium in the presence of minocycline or tobramycin. RESULTS SAT was detected in 29 (64%) patients. Fourteen patients each (34%) had cystic fibrosis (CF) and tracheostomies. Patient demographics and comorbidities did not differ by SAT status. Among CF patients, SAT was associated with longer duration of intravenous antibiotics (10 days vs 5 days; P < .01). CONCLUSIONS This study establishes that SAT exists in P. aeruginosa from human serum and may be a novel factor that contributes to differences in clinical outcomes. Future research should investigate the mechanisms that contribute to SAT in order to identify novel targets for adjunctive antimicrobial therapies.
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Affiliation(s)
- John M Morrison
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Department of Medicine, Division of Hospital Medicine, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, USA,Correspondence: John M. Morrison, 601 Fifth Street South Suite 501, Saint Petersburg, FL 33701 ()
| | - Michaelle Chojnacki
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, New York, USA
| | - Jeffrey J Fadrowski
- Department of Pediatrics, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Colleen Bauza
- Department of Health Informatics, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, USA
| | - Paul M Dunman
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, New York, USA
| | - Robert A Dudas
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Department of Medicine, Division of Hospital Medicine, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, USA
| | - Neil A Goldenberg
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, and All Children’s Research Institute, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, USA
| | - David M Berman
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, USA
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Chang AB, Fong SM, Yeo TW, Ware RS, McCallum GB, Nathan AM, Ooi MH, de Bruyne J, Byrnes CA, Lee B, Nachiappan N, Saari N, Torzillo P, Smith-Vaughan H, Morris PS, Upham JW, Grimwood K. HOspitalised Pneumonia Extended (HOPE) Study to reduce the long-term effects of childhood pneumonia: protocol for a multicentre, double-blind, parallel, superiority randomised controlled trial. BMJ Open 2019; 9:e026411. [PMID: 31023759 PMCID: PMC6502017 DOI: 10.1136/bmjopen-2018-026411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/06/2018] [Accepted: 01/08/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Early childhood pneumonia is a common problem globally with long-term complications that include bronchiectasis and chronic obstructive pulmonary disease. It is biologically plausible that these long-term effects may be minimised in young children at increased risk of such sequelae if any residual lower airway infection and inflammation in their developing lungs can be treated successfully by longer antibiotic courses. In contrast, shortened antibiotic treatments are being promoted because of concerns over inducing antimicrobial resistance. Nevertheless, the optimal treatment duration remains unknown. Outcomes from randomised controlled trials (RCTs) on paediatric pneumonia have focused on short-term (usually <2 weeks) results. Indeed, no long-term RCT-generated outcome data are available currently. We hypothesise that a longer antibiotic course, compared with the standard treatment course, reduces the risk of chronic respiratory symptoms/signs or bronchiectasis 24 months after the original pneumonia episode. METHODS AND ANALYSIS This multicentre, parallel, double-blind, placebo-controlled randomised trial involving seven hospitals in six cities from three different countries commenced in May 2016. Three-hundred-and-fourteen eligible Australian Indigenous, New Zealand Māori/Pacific and Malaysian children (aged 0.25 to 5 years) hospitalised for community-acquired, chest X-ray (CXR)-proven pneumonia are being recruited. Following intravenous antibiotics and 3 days of amoxicillin-clavulanate, they are randomised (stratified by site and age group, allocation-concealed) to receive either: (i) amoxicillin-clavulanate (80 mg/kg/day (maximum 980 mg of amoxicillin) in two-divided doses or (ii) placebo (equal volume and dosing frequency) for 8 days. Clinical data, nasopharyngeal swab, bloods and CXR are collected. The primary outcome is the proportion of children without chronic respiratory symptom/signs of bronchiectasis at 24 months. The main secondary outcomes are 'clinical cure' at 4 weeks, time-to-next respiratory-related hospitalisation and antibiotic resistance of nasopharyngeal respiratory bacteria. ETHICS AND DISSEMINATION The Human Research Ethics Committees of all the recruiting institutions (Darwin: Northern Territory Department of Health and Menzies School of Health Research; Auckland: Starship Children's and KidsFirst Hospitals; East Malaysia: Likas Hospital and Sarawak General Hospital; Kuala Lumpur: University of Malaya Research Ethics Committee; and Klang: Malaysian Department of Health) have approved the research protocol version 7 (13 August 2018). The RCT and other results will be submitted for publication. TRIAL REGISTRATION ACTRN12616000046404.
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Affiliation(s)
- Anne B Chang
- Child Health Division, Menzies School of Health Research, Charles Darwin Univ, Darwin, Northern Territory, Australia
- Qld Children's Hospital, Brisbane, Queensland, Australia
| | | | - Tsin Wen Yeo
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Robert S Ware
- School of Population Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Gabrielle B McCallum
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | | | - Mong H Ooi
- Universiti Malaysia Sarawak, Kuching, Malaysia
| | | | | | - Bilawara Lee
- Charles Darwin University, Darwin, Northern Territory, Australia
| | | | | | - Paul Torzillo
- Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Heidi Smith-Vaughan
- Child Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Peter S Morris
- Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - John W Upham
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Keith Grimwood
- Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
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Pneumonia Risk Stratification Scores for Children in Low-Resource Settings: A Systematic Literature Review. Pediatr Infect Dis J 2018; 37:743-748. [PMID: 29278608 PMCID: PMC6014863 DOI: 10.1097/inf.0000000000001883] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Pneumonia is the leading infectious cause of death among children less than 5 years of age. Predictive tools, commonly referred to as risk scores, can be employed to identify high-risk children early for targeted management to prevent adverse outcomes. This systematic review was conducted to identify pediatric pneumonia risk scores developed, validated and implemented in low-resource settings. METHODS We searched CAB Direct, Cochrane Reviews, Embase, PubMed, Scopus and Web of Science for studies that developed formal risk scores to predict treatment failure or mortality among children less than 5 years of age diagnosed with a respiratory infection or pneumonia in low-resource settings. Data abstracted from articles included location and study design, sample size, age, diagnosis, score features and model discrimination. RESULTS Three pediatric pneumonia risk scores predicted mortality specifically, and 2 treatment failure. Scores developed using World Health Organization-recommended variables for pneumonia assessment demonstrated better predictive fit than scores developed using alternative features. Scores developed using routinely collected healthcare data performed similarly well as those developed using clinical trial data. No score has been implemented in low-resource settings. CONCLUSIONS While pediatric pneumonia-specific risk scores have been developed and validated, it is yet unclear if implementation is feasible, what impact, if any, implemented scores may have on child outcomes, or how broadly scores may be generalized. To increase the feasibility of implementation, future research should focus on developing scores based on routinely collected data.
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McCollum ED, Ginsburg AS. Outpatient Management of Children With World Health Organization Chest Indrawing Pneumonia: Implementation Risks and Proposed Solutions. Clin Infect Dis 2018; 65:1560-1564. [PMID: 29020216 PMCID: PMC5850637 DOI: 10.1093/cid/cix543] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/08/2017] [Indexed: 02/03/2023] Open
Abstract
This Viewpoints article details our recommendation for the World Health Organization Integrated Management of Childhood Illness guidelines to consider additional referral or daily monitoring criteria for children with chest indrawing pneumonia in low-resource settings. We review chest indrawing physiology in children and relate this to the risk of adverse pneumonia outcomes. We believe there is sufficient evidence to support referring or daily monitoring of children with chest indrawing pneumonia and signs of severe respiratory distress, oxygen saturation <93% (when not at high altitude), moderate malnutrition, or an unknown human immunodeficiency virus (HIV) status in an HIV-endemic setting. Pulse oximetry screening should be routine and performed at the earliest point in the patient care pathway as possible. If outpatient clinics lack capacity to conduct pulse oximetry, nutritional assessment, or HIV testing, then we recommend considering referral to complete the evaluation. When referral is not possible, careful daily monitoring should be performed.
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Affiliation(s)
- Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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10
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Zhang S, Incardona B, Qazi SA, Stenberg K, Campbell H, Nair H. Cost-effectiveness analysis of revised WHO guidelines for management of childhood pneumonia in 74 Countdown countries. J Glob Health 2018; 7:010409. [PMID: 28400955 PMCID: PMC5344007 DOI: 10.7189/jogh.07.010409] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background Treatment of childhood pneumonia is a key priority in low–income countries, with substantial resource implications. WHO revised their guidelines for the management of childhood pneumonia in 2013. We estimated and compared the resource requirements, total direct medical cost and cost-effectiveness of childhood pneumonia management in 74 countries with high burden of child mortality (Countdown countries) using the 2005 and 2013 revised WHO guidelines. Methods We constructed a cost model using a bottom up approach to estimate the cost of childhood pneumonia management using the 2005 and 2013 WHO guidelines from a public provider perspective in 74 Countdown countries. The cost of pneumonia treatment was estimated, by country, for year 2013, including costs of medicines and service delivery at three different management levels. We also assessed country–specific lives saved and disability adjusted life years (DALYs) averted due to pneumonia treated in children aged below five years. The cost-effectiveness of pneumonia treatment was estimated in terms of cost per DALY averted by fully implementing WHO treatment guidelines relative to no treatment intervention for pneumonia. Results Achieving full treatment coverage with the 2005 WHO guidelines was estimated to cost US$ 2.9 (1.9–4.2) billion compared to an estimated US$ 1.8 (0.8–3.0) billion for the revised 2013 WHO guidelines in these countries. Pneumonia management in young children following WHO treatment guidelines could save up to 39.8 million DALYs compared to a zero coverage scenario in the year 2013 in the 74 Countdown countries. The median cost-effectiveness ratio per DALY averted in 74 countries was substantially lower for the 2013 guidelines: US$ 26.6 (interquartile range IQR: 17.7–45.9) vs US$ 38.3 (IQR: US$ 26.2–86.9) per DALY averted for the 2005 guideline respectively. Conclusions Child pneumonia management as detailed in standard WHO guidelines is a very cost–effective intervention. Implementation of the 2013 WHO guidelines is expected to result in a 39.5% reduction in treatment costs compared to the 2005 guidelines which could save up to US$ 1.16 (0.68–1.23) billion in the 74 Countdown countries, with potential savings greatest in low HIV burden countries which can implement effective community case management of pneumonia.
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Affiliation(s)
- Shanshan Zhang
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK; Department of Preventive Dentistry, Peking University School and Hospital of Stomatology, Beijing, China
| | | | - Shamim A Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Karin Stenberg
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
| | - Harry Campbell
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Harish Nair
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK; Public Health Foundation of India, New Delhi, India
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11
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Agweyu A, Lilford RJ, English M. Appropriateness of clinical severity classification of new WHO childhood pneumonia guidance: a multi-hospital, retrospective, cohort study. Lancet Glob Health 2018; 6:e74-e83. [PMID: 29241618 PMCID: PMC5732316 DOI: 10.1016/s2214-109x(17)30448-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 09/23/2017] [Accepted: 11/02/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Management of pneumonia in many low-income and middle-income countries is based on WHO guidelines that classify children according to clinical signs that define thresholds of risk. We aimed to establish whether some children categorised as eligible for outpatient treatment might have a risk of death warranting their treatment in hospital. METHODS We did a retrospective cohort study of children aged 2-59 months admitted to one of 14 hospitals in Kenya with pneumonia between March 1, 2014, and Feb 29, 2016, before revised WHO pneumonia guidelines were adopted in the country. We modelled associations with inpatient mortality using logistic regression and calculated absolute risks of mortality for presenting clinical features among children who would, as part of revised WHO pneumonia guidelines, be eligible for outpatient treatment (non-severe pneumonia). FINDINGS We assessed 16 162 children who were admitted to hospital in this period. 832 (5%) of 16 031 children died. Among groups defined according to new WHO guidelines, 321 (3%) of 11 788 patients with non-severe pneumonia died compared with 488 (14%) of 3434 patients with severe pneumonia. Three characteristics were strongly associated with death of children retrospectively classified as having non-severe pneumonia: severe pallor (adjusted risk ratio 5·9, 95% CI 5·1-6·8), mild to moderate pallor (3·4, 3·0-3·8), and weight-for-age Z score (WAZ) less than -3 SD (3·8, 3·4-4·3). Additional factors that were independently associated with death were: WAZ less than -2 to -3 SD, age younger than 12 months, lower chest wall indrawing, respiratory rate of 70 breaths per min or more, female sex, admission to hospital in a malaria endemic region, moderate dehydration, and an axillary temperature of 39°C or more. INTERPRETATION In settings of high mortality, WAZ less than -3 SD or any degree of pallor among children with non-severe pneumonia was associated with a clinically important risk of death. Our data suggest that admission to hospital should not be denied to children with these signs and we urge clinicians to consider these risk factors in addition to WHO criteria in their decision making. FUNDING Wellcome Trust.
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Affiliation(s)
- Ambrose Agweyu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya; Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Richard J Lilford
- Department of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya; Nuffield Department of Medicine, University of Oxford, Oxford, UK
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12
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Keitel K, Kagoro F, Samaka J, Masimba J, Said Z, Temba H, Mlaganile T, Sangu W, Rambaud-Althaus C, Gervaix A, Genton B, D’Acremont V. A novel electronic algorithm using host biomarker point-of-care tests for the management of febrile illnesses in Tanzanian children (e-POCT): A randomized, controlled non-inferiority trial. PLoS Med 2017; 14:e1002411. [PMID: 29059253 PMCID: PMC5653205 DOI: 10.1371/journal.pmed.1002411] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 09/19/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The management of childhood infections remains inadequate in resource-limited countries, resulting in high mortality and irrational use of antimicrobials. Current disease management tools, such as the Integrated Management of Childhood Illness (IMCI) algorithm, rely solely on clinical signs and have not made use of available point-of-care tests (POCTs) that can help to identify children with severe infections and children in need of antibiotic treatment. e-POCT is a novel electronic algorithm based on current evidence; it guides clinicians through the entire consultation and recommends treatment based on a few clinical signs and POCT results, some performed in all patients (malaria rapid diagnostic test, hemoglobin, oximeter) and others in selected subgroups only (C-reactive protein, procalcitonin, glucometer). The objective of this trial was to determine whether the clinical outcome of febrile children managed by the e-POCT tool was non-inferior to that of febrile children managed by a validated electronic algorithm derived from IMCI (ALMANACH), while reducing the proportion with antibiotic prescription. METHODS AND FINDINGS We performed a randomized (at patient level, blocks of 4), controlled non-inferiority study among children aged 2-59 months presenting with acute febrile illness to 9 outpatient clinics in Dar es Salaam, Tanzania. In parallel, routine care was documented in 2 health centers. The primary outcome was the proportion of clinical failures (development of severe symptoms, clinical pneumonia on/after day 3, or persistent symptoms at day 7) by day 7 of follow-up. Non-inferiority would be declared if the proportion of clinical failures with e-POCT was no worse than the proportion of clinical failures with ALMANACH, within statistical variability, by a margin of 3%. The secondary outcomes included the proportion with antibiotics prescribed on day 0, primary referrals, and severe adverse events by day 30 (secondary hospitalizations and deaths). We enrolled 3,192 patients between December 2014 and February 2016 into the randomized study; 3,169 patients (e-POCT: 1,586; control [ALMANACH]: 1,583) completed the intervention and day 7 follow-up. Using e-POCT, in the per-protocol population, the absolute proportion of clinical failures was 2.3% (37/1,586), as compared with 4.1% (65/1,583) in the ALMANACH arm (risk difference of clinical failure -1.7, 95% CI -3.0, -0.5), meeting the prespecified criterion for non-inferiority. In a non-prespecified superiority analysis, we observed a 43% reduction in the relative risk of clinical failure when using e-POCT compared to ALMANACH (risk ratio [RR] 0.57, 95% CI 0.38, 0.85, p = 0.005). The proportion of severe adverse events was 0.6% in the e-POCT arm compared with 1.5% in the ALMANACH arm (RR 0.42, 95% CI 0.20, 0.87, p = 0.02). The proportion of antibiotic prescriptions was substantially lower, 11.5% compared to 29.7% (RR 0.39, 95% CI 0.33, 0.45, p < 0.001). Using e-POCT, the most common indication for antibiotic prescription was severe disease (57%, 103/182 prescriptions), while it was non-severe respiratory infections using the control algorithm (ALMANACH) (70%, 330/470 prescriptions). The proportion of clinical failures among the 544 children in the routine care cohort was 4.6% (25/544); 94.9% (516/544) of patients received antibiotics on day 0, and 1.1% (6/544) experienced severe adverse events. e-POCT achieved a 49% reduction in the relative risk of clinical failure compared to routine care (RR 0.51, 95% CI 0.31, 0.84, p = 0.007) and lowered antibiotic prescriptions to 11.5% from 94.9% (p < 0.001). Though this safety study was an important first step to evaluate e-POCT, its true utility should be evaluated through future implementation studies since adherence to the algorithm will be an important factor in making use of e-POCT's advantages in terms of clinical outcome and antibiotic prescription. CONCLUSIONS e-POCT, an innovative electronic algorithm using host biomarker POCTs, including C-reactive protein and procalcitonin, has the potential to improve the clinical outcome of children with febrile illnesses while reducing antibiotic use through improved identification of children with severe infections, and better targeting of children in need of antibiotic prescription. TRIAL REGISTRATION ClinicalTrials.gov NCT02225769.
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Affiliation(s)
- Kristina Keitel
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Ambulatory Care and Community Medicine, University Hospital Lausanne, Lausanne, Switzerland
- * E-mail:
| | - Frank Kagoro
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Josephine Samaka
- Ifakara Health Institute, Dar es Salaam, Tanzania
- Amana Hospital, Dar es Salaam, Tanzania
| | - John Masimba
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Zamzam Said
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | | | | | | | - Alain Gervaix
- Pediatric Emergency Medicine Department, Child and Adolescent Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Blaise Genton
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Ambulatory Care and Community Medicine, University Hospital Lausanne, Lausanne, Switzerland
- Infectious Diseases Service, University Hospital Lausanne, Lausanne, Switzerland
| | - Valérie D’Acremont
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Ambulatory Care and Community Medicine, University Hospital Lausanne, Lausanne, Switzerland
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13
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King C, McCollum ED, Mankhambo L, Colbourn T, Beard J, Hay Burgess DC, Costello A, Izadnegahdar R, Lufesi N, Masache G, Mwansambo C, Nambiar B, Johnson E, Platt R, Mukanga D. Can We Predict Oral Antibiotic Treatment Failure in Children with Fast-Breathing Pneumonia Managed at the Community Level? A Prospective Cohort Study in Malawi. PLoS One 2015; 10:e0136839. [PMID: 26313752 PMCID: PMC4551481 DOI: 10.1371/journal.pone.0136839] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 08/10/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pneumonia is the leading cause of infectious death amongst children globally, with the highest burden in Africa. Early identification of children at risk of treatment failure in the community and prompt referral could lower mortality. A number of clinical markers have been independently associated with oral antibiotic failure in childhood pneumonia. This study aimed to develop a prognostic model for fast-breathing pneumonia treatment failure in sub-Saharan Africa. METHOD We prospectively followed a cohort of children (2-59 months), diagnosed by community health workers with fast-breathing pneumonia using World Health Organisation (WHO) integrated community case management guidelines. Cases were followed at days 5 and 14 by study data collectors, who assessed a range of pre-determined clinical features for treatment outcome. We built the prognostic model using eight pre-defined parameters, using multivariable logistic regression, validated through bootstrapping. RESULTS We assessed 1,542 cases of which 769 were included (32% ineligible; 19% defaulted). The treatment failure rate was 15% at day 5 and relapse was 4% at day 14. Concurrent malaria diagnosis (OR: 1.62; 95% CI: 1.06, 2.47) and moderate malnutrition (OR: 1.88; 95% CI: 1.09, 3.26) were associated with treatment failure. The model demonstrated poor calibration and discrimination (c-statistic: 0.56). CONCLUSION This study suggests that it may be difficult to create a pragmatic community-level prognostic child pneumonia tool based solely on clinical markers and pulse oximetry in an HIV and malaria endemic setting. Further work is needed to identify more accurate and reliable referral algorithms that remain feasible for use by community health workers.
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Affiliation(s)
- Carina King
- Institute for Global Health, University College London, London, United Kingdom
| | - Eric D. McCollum
- Institute for Global Health, University College London, London, United Kingdom
- Department of Pediatrics, Division of Pulmonology, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | | | - Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
| | - James Beard
- Institute for Global Health, University College London, London, United Kingdom
| | | | - Anthony Costello
- Institute for Global Health, University College London, London, United Kingdom
| | - Raza Izadnegahdar
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Norman Lufesi
- Acute Respiratory Infection Unit, Ministry of Health, Lilongwe, Malawi
| | | | | | - Bejoy Nambiar
- Institute for Global Health, University College London, London, United Kingdom
| | - Eric Johnson
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, United States of America
| | | | - David Mukanga
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
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14
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Chiappini E, Mazzantini R, Bruzzese E, Capuano A, Colombo M, Cricelli C, Di Mauro G, Esposito S, Festini F, Guarino A, Miniello VL, Principi N, Marchisio P, Rafaniello C, Rossi F, Sportiello L, Tancredi F, Venturini E, Galli L, de Martino M. Rational use of antibiotics for the management of children's respiratory tract infections in the ambulatory setting: an evidence-based consensus by the Italian Society of Preventive and Social Pediatrics. Paediatr Respir Rev 2014; 15:231-6. [PMID: 24666567 DOI: 10.1016/j.prrv.2013.11.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 11/30/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Several guidelines for the management of respiratory tract infections in children are available in Italy, as well as in other European countries and the United States of America. However, poor adherence to guidelines and the sustained inappropriate use of antibiotics have been reported. In the outpatient setting, almost half of antibiotics are prescribed for the treatment of common respiratory tract infections. In Italy the antibiotic prescription rate is significantly higher than in other European countries, such as Denmark or the Netherlands, and also the levels of antibiotic resistance for a large variety of bacteria are higher. Therefore, the Italian Society of Preventive and Social Paediatrics organised a consensus conference for the treatment of respiratory tract infections in children to produce a brief, easily readable, evidence-based document. METHODS The conference method was used, according to the National Institute of Health and the National Plan Guidelines. A literature search was performed focusing on the current guidelines for the treatment of airway infections in children aged 1 month-18 years in the ambulatory setting. RESULTS Recommendations for the treatment of acute pharyngitis, acute otitis media, sinusitis, and pneumonia have been summarized. Conditions for which antibiotic treatment should not be routinely prescribed have been highlighted. CONCLUSION This evidence-based document is intended to accessible to primary care pediatricians and general practice physicians in order to make clinical practice uniform, in accordance with the recommendations of the current guidelines.
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Affiliation(s)
- Elena Chiappini
- Department of Health Sciences, Paediatric Section, Anna Meyer Children's University Hospital, Florence, Italy
| | - Rachele Mazzantini
- Department of Health Sciences, Paediatric Section, Anna Meyer Children's University Hospital, Florence, Italy
| | - Eugenia Bruzzese
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples
| | - Annalisa Capuano
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", Second University of Naples, Naples, Italy
| | | | - Claudio Cricelli
- Health Search Institute, Italian College of General Practitioners, Florence, Italy
| | - Giuseppe Di Mauro
- President Italian Society of Preventive and Social Pediatrics Primary care Pediatrician, Caserta, Italy
| | - Susanna Esposito
- Department of Pathophysiology and Transplantation, Pediatric Clinic 1, Università degli Studi di Milano, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Via Commenda 9, 20122, Milan, Italy
| | - Filippo Festini
- Department of Health Sciences, Paediatric Section, Anna Meyer Children's University Hospital, Florence, Italy
| | - Alfredo Guarino
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples
| | | | - Nicola Principi
- Department of Pathophysiology and Transplantation, Pediatric Clinic 1, Università degli Studi di Milano, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Via Commenda 9, 20122, Milan, Italy
| | - Paola Marchisio
- Department of Pathophysiology and Transplantation, Pediatric Clinic 1, Università degli Studi di Milano, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Via Commenda 9, 20122, Milan, Italy
| | - Concetta Rafaniello
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", Second University of Naples, Naples, Italy
| | - Francesco Rossi
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", Second University of Naples, Naples, Italy
| | - Liberata Sportiello
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", Second University of Naples, Naples, Italy
| | | | - Elisabetta Venturini
- Department of Health Sciences, Paediatric Section, Anna Meyer Children's University Hospital, Florence, Italy
| | - Luisa Galli
- Department of Health Sciences, Paediatric Section, Anna Meyer Children's University Hospital, Florence, Italy
| | - Maurizio de Martino
- Department of Health Sciences, Paediatric Section, Anna Meyer Children's University Hospital, Florence, Italy
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Elemraid MA, Rushton SP, Thomas MF, Spencer DA, Eastham KM, Gennery AR, Clark JE. Changing clinical practice: management of paediatric community-acquired pneumonia. J Eval Clin Pract 2014; 20:94-9. [PMID: 24118607 PMCID: PMC4291095 DOI: 10.1111/jep.12091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2013] [Indexed: 11/04/2022]
Abstract
RATIONALE AND AIM To compare clinical features and management of paediatric community-acquired pneumonia (PCAP) following the publication of UK pneumonia guidelines in 2002 with data from a similar survey at the same hospitals in 2001-2002 (pre-guidelines). METHODS A prospective survey of 11 hospitals in Northern England was undertaken during 2008-2009. Clinical and laboratory data were recorded on children aged ≤16 years who presented with clinical and radiological features of pneumonia. RESULTS 542 children were included. There was a reduction in all investigations performed (P < 0.001) except C-reactive protein (P = 0.448) between surveys. These included full blood count (76% to 61%); blood culture (70% to 53%) and testing of respiratory secretions for viruses (24% to 12%) and bacteria (18% to 8%). Compared to pre-guidelines, there was a reduction in the use of intravenous antibiotics as a proportion of the total prescribed from 47% to 36% (P < 0.001) and a change in the route of antibiotic administration with increasing preference for oral alone (16% pre-compared to 50% post-guidelines, P < 0.001). CONCLUSION Apart from the acute phase reactants that should not be measured routinely, these changes are in line with the guideline recommendations. Improvements in antibiotic use are possible and have implications for future antimicrobial stewardship programmes. Further work using cost-effectiveness analysis may also demonstrate a financial benefit to health services from adoption of guidelines.
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Affiliation(s)
- Mohamed A Elemraid
- Department of Paediatric Infectious Disease and Immunology, Newcastle upon Tyne Hospitals NHS Trust, Newcastle, UK; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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