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Nguyen PT, Nguyen TT, Huynh LT, Graham SM, Marais BJ. Clinical algorithm reduces antibiotic use among children presenting with respiratory symptoms to hospital in central Vietnam. Pneumonia (Nathan) 2023; 15:11. [PMID: 37488633 PMCID: PMC10367404 DOI: 10.1186/s41479-023-00113-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 06/29/2023] [Indexed: 07/26/2023] Open
Abstract
OBJECTIVE To assess the safety and utility of a pragmatic clinical algorithm to guide rational antibiotic use in children presenting with respiratory infection. METHODS The effect of an algorithm to guide the management of young (< 5 years) children presenting with respiratory symptoms to the Da Nang Hospital for Women and Children, Vietnam, was evaluated in a before-after intervention analysis. The main outcome was reduction in antibiotic use, with monitoring of potential harm resulting from reduced antibiotic use. The intervention comprised a single training session of physicians in the use of an algorithm informed by local evidence; developed during a previous prospective observational study. The evaluation was performed one month after the training. RESULTS Of the 1290 children evaluated before the intervention, 102 (7.9%) were admitted to hospital and 556/1188 (46.8%) were sent home with antibiotics. Due to COVID-19, only 166 children were evaluated after the intervention of whom 14 (8.4%) were admitted to hospital and 54/152 (35.5%) were sent home with antibiotics. Antibiotic use was reduced (from 46.8% to 35.5%; p = 0.009) after clinician training, but adequate comparison was compromised. The reduction was most pronounced in children with wheeze or runny nose and no fever, or a normal chest radiograph, where antibiotic use declined from 46.7% to 28.8% (p < 0.0001). The frequency of repeat presentation to hospital was similar between the two study periods (141/1188; 11.9% before and 10/152; 6.6% after; p = 0.10). No child represented with serious disease after being sent home without antibiotics. CONCLUSIONS We observed a reduction in antibiotic use in young children with a respiratory infection after physician training in the use of a simple evidence-based management algorithm. However, the study was severely impacted by COVID-19 restrictions, requiring further evaluation to confirm the observed effect.
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Affiliation(s)
- Phuong Tk Nguyen
- Respiratory Department, Da Nang Hospital for Women and Children, Da Nang, Vietnam.
- Sydney Vietnam Initiative, The University of Sydney, Sydney, Australia.
| | - Tam Tm Nguyen
- Respiratory Department, Da Nang Hospital for Women and Children, Da Nang, Vietnam
| | - Lan Tb Huynh
- Respiratory Department, Da Nang Hospital for Women and Children, Da Nang, Vietnam
| | - Stephen M Graham
- Centre for International Child Health, University of Melbourne and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
| | - Ben J Marais
- Discipline of Paediatrics and Adolescent Medicine, The Children's Hospital at Westmead, Westmead, Australia
- Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Sydney, Australia
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2
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Su W, Ju L, Hua Q, Hu J, Qian W. Values of combined C-reactive protein, procalcitonin and serum amyloid A in differential diagnosis of bacterial and non-bacterial community acquired pneumonia in children. Diagn Microbiol Infect Dis 2023; 105:115865. [PMID: 36521211 DOI: 10.1016/j.diagmicrobio.2022.115865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/25/2022] [Accepted: 11/19/2022] [Indexed: 11/26/2022]
Abstract
This research aimed to explore the clinical value of C-reactive protein (CRP), procalcitonin (PCT), and serum amyloid A (SAA) in early diagnosis of bacterial pneumonia. CRP, PCT, and SAA levels of children with bacterial pneumonia, children with non-bacterial pneumonia, and healthy children were compared. The sensitivity and specificity of CRP, PCT, and SAA in the diagnosis of bacterial pneumonia in children were compared. CRP, PCT, and SAA levels were significantly lower in healthy children when compared with children with Community acquired pneumonia (CAP). ROC analyses showed that CRP, PCT, and SAA all had good accuracy in distinguishing bacterial pneumonia from non-bacterial pneumonia. The combination of CRP, PCT, and SAA further enhanced the accuracy in distinguishing bacterial pneumonia from non-bacterial pneumonia. In conclusion, the expression levels of CRP, PCT, and SAA could indicate the status of bacterial pneumonia. The combined test of CRP, PCT, and SAA had the highest diagnostic accuracy.
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Affiliation(s)
- Weiwei Su
- Department of Pediatric Cardiology, the Affiliated Wuxi Children's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China
| | - Liang Ju
- Department of Pediatric Cardiology, the Affiliated Wuxi Children's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China
| | - Qi Hua
- Department of Pediatric Cardiology, the Affiliated Wuxi Children's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China
| | - Jing Hu
- Department of Pediatric Cardiology, the Affiliated Wuxi Children's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China
| | - Wei Qian
- Department of Pediatric Cardiology, the Affiliated Wuxi Children's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China.
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3
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Nguyen PTK, Robinson PD, Fitzgerald DA, Marais BJ. The dilemma of improving rational antibiotic use in pediatric community-acquired pneumonia. Front Pediatr 2023; 11:1095166. [PMID: 36846166 PMCID: PMC9945262 DOI: 10.3389/fped.2023.1095166] [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: 11/10/2022] [Accepted: 01/10/2023] [Indexed: 02/11/2023] Open
Abstract
Pneumonia is the number one cause of disease and deaths in children under five years old, outside the neonatal period, with the greatest number of cases reported from resource-limited settings. The etiology is variable, with not much information on the local etiology drug resistance profile in many countries. Recent studies suggest an increasing contribution from respiratory viruses, also in children with severe pneumonia, with an increased relative contribution in settings that have good vaccine coverage against common bacterial pathogens. Respiratory virus circulation was greatly reduced during highly restrictive measures to contain the spread of COVID-19 but rebounded once COVID-19 restrictions were relaxed. We conducted a comprehensive literature review of the disease burden, pathogens, case management and current available prevention of community acquired childhood pneumonia, with a focus on rational antibiotic use, since the treatment of respiratory infections is the leading cause of antibiotic use in children. Consistent application of revised World Health Organisation (WHO) guidance that children presenting with coryzal symptoms or wheeze can be managed without antibiotics in the absence of fever, will help to reduce unnecessary antibiotic use, as will increased availability and use of bedside inflammatory marker tests, such as C-reactive protein (CRP) in children with respiratory symptoms and fever.
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Affiliation(s)
- Phuong T K Nguyen
- Department of General Medicine, The Children's Hospital Westmead, Westmead, NSW, Australia
| | - Paul D Robinson
- Department of Respiratory Medicine, The Children's Hospital Westmead, NSW, Australia
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital Westmead, NSW, Australia.,The University of Sydney, Discipline of Child and Adolescent Health, Faculty of Medicine and Health, Sydney, NSW, Australia
| | - Ben J Marais
- The University of Sydney, Discipline of Child and Adolescent Health, Faculty of Medicine and Health, Sydney, NSW, Australia.,Department of Infectious Diseases, The Children's Hospital Westmead, Westmead, NSW, Australia
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4
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Jambo A, Edessa D, Adem F, Gashaw T. Appropriateness of antimicrobial selection for treatment of pneumonia in selected public hospitals of Eastern Ethiopia: A cross-sectional study. SAGE Open Med 2023; 11:20503121231163792. [PMID: 37065976 PMCID: PMC10102944 DOI: 10.1177/20503121231163792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 02/27/2023] [Indexed: 04/18/2023] Open
Abstract
Objective Inappropriate antimicrobial use leads to drug resistance and poor clinical outcomes. Considering the lack of data regarding the drug use patterns in the treatment of pneumonia in selected study areas, the authors felt compelled to assess the appropriateness of antimicrobial usage in the treatment of pneumonia at Hiwot Fana Specialized Comprehensive University Hospital and Jugal Hospital from May 1 to 31, 2021. Methods A cross-sectional retrospective study was conducted using the medical cards of 693 admitted patients with pneumonia. The collected data were analyzed using SPSS version 26. Bivariable and multivariable logistic regression analyses were used to identify the factors associated with an initial inappropriate antibiotic use. A p value of 0.05 was used to determine the statistical significance of the association using an adjusted odds ratio with 95% confidence interval. Results Of the total participants, 116 (16.74%, 95% confidence interval: 14.1-19.6) of them received an initial inappropriate antimicrobial regimen. Ceftriaxone plus azithromycin was the most prescribed antimicrobial agent. Patients who were younger than 5 years (adjusted odds ratio = 1.71; 95% confidence interval: 1.00-2.94), between 6 and 14 years (adjusted odds ratio = 3.14; 95% confidence interval: 1.64-6.00), and older than 65 years (adjusted odds ratio = 2.97; 95% confidence interval: 1.07-2.66), with comorbid conditions (adjusted odds ratio = 1.74; 95% confidence interval: 1.10-2.72) and prescribed by medical interns (adjusted odds ratio = 1.80; 95% confidence interval: 1.14-2.84) were associated with an initial inappropriate antimicrobial use. Conclusion Around one out of every six patients had received initial inappropriate treatments. Adherence to the recommendation of guidelines and attention to extreme-aged groups and comorbidity may improve antimicrobial use.
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Affiliation(s)
- Abera Jambo
- Clinical Pharmacy Department, School of
Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar,
Ethiopia
- Abera Jambo, Clinical Pharmacy Department,
School of Pharmacy, College of Health and Medical Sciences, Haramaya University,
Harar, Ethiopia.
| | - Dumessa Edessa
- Clinical Pharmacy Department, School of
Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar,
Ethiopia
| | - Fuad Adem
- Clinical Pharmacy Department, School of
Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar,
Ethiopia
| | - Tigist Gashaw
- Department of Pharmacology and
Toxicology, School of Pharmacy, College of Health and Medical Sciences, Haramaya
University, Harar, Ethiopia
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5
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Kazi S, Hernstadt H, Abo YN, Graham H, Palmer M, Graham SM. The utility of chest x-ray and lung ultrasound in the management of infants and children presenting with severe pneumonia in low-and middle-income countries: A pragmatic scoping review. J Glob Health 2022; 12:10013. [PMID: 36560909 PMCID: PMC9789364 DOI: 10.7189/jogh.12.10013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Chest x-ray (CXR) is commonly used (when available) to support clinical management decisions for child pneumonia and provide a reference standard for diagnosis in research studies. However, its diagnostic and technical limitations for both purposes are well recognised. Recent evidence suggests that lung ultrasound (LUS) may have diagnostic utility in pneumonia. This systematic scoping review of research on the utility of CXR and LUS in the management of severe childhood pneumonia aims to inform pragmatic guidelines for low- and middle-income countries (LMICs) and identify gaps in knowledge. Methods We included peer-reviewed studies published between 2000 and 2020 in infants and children aged from one month to nine years, presenting with severe pneumonia. CXR studies were limited to those from LMICs, while LUS studies included any geographic region. LUS and CXR articles were mapped into the following themes: indications, role in diagnosis, role in management, impact on outcomes, and practical considerations for LMIC settings. Results 85 articles met all eligibility criteria, including 27 CXR studies and 58 LUS studies. CXR studies were primarily observational and examined associations between radiographic abnormalities and pneumonia aetiology or outcomes. The most consistent finding was an association between CXR consolidation and risk of mortality. Difficulty obtaining quality CXR images and inter-reader variability in interpretation were commonly reported challenges. Research evaluating indications for CXR, role in management, and impact on patient outcomes was very limited. LUS studies primarily focused on diagnostic accuracy. LUS had higher sensitivity for identification of consolidation than CXR. There are gaps in knowledge regarding diagnostic criteria, as well as the practical utility of LUS in the diagnosis and management of pneumonia. Most LUS studies were conducted in HIC settings with experienced operators; however, small feasibility studies indicate that good inter-operator reliability may be achieved by training of novice clinicians in LMIC settings. Conclusions The available evidence does not support the routine use of CXR or LUS as essential tools in the diagnosis and initial management of severe pneumonia. Further evaluation is required to determine the clinical utility and feasibility of both imaging modalities in low-resource settings.
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Affiliation(s)
- Saniya Kazi
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia,Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia,Monash Health, Melbourne, Victoria, Australia
| | | | - Yara-Natalie Abo
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia,Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia,University of Melbourne Department of Paediatrics, Melbourne, Victoria, Australia
| | - Hamish Graham
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia,Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia,University of Melbourne Department of Paediatrics, Melbourne, Victoria, Australia
| | - Megan Palmer
- Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Stephen M Graham
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia,Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia,Monash Health, Melbourne, Victoria, Australia,University of Melbourne Department of Paediatrics, Melbourne, Victoria, Australia
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6
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Nguyen TKP, Bui BBS, Ngo QC, Fitzgerald DA, Graham SM, Marais BJ. Applying lessons learnt from research of child pneumonia management in Vietnam. Paediatr Respir Rev 2021; 39:65-70. [PMID: 33158773 DOI: 10.1016/j.prrv.2020.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 09/24/2020] [Indexed: 02/03/2023]
Abstract
Pneumonia is the leading cause of paediatric hospitalisation in Vietnam, placing a huge burden on the health care system. Pneumonia is also the main reason for antibiotic use in children. Unfortunately many hospital admissions for child pneumonia in Vietnam are unnecessary and inappropriate use of antibiotics is common, as in the rest of Asia, with little awareness of its adverse effects. We explored the value of an alternative approach that, instead of focusing on the identification of children with severe bacterial pneumonia, focuses on the identification of children with 'unlikely bacterial pneumonia' to improve patient care and rational antibiotic use. Implementing improved models of care require pragmatic management algorithms that are well validated, but it is ultimately dependent on financial structures, management support and evidence-based training of healthcare providers at all relevant levels. Apart from better case management, sustained reductions in the pneumonia disease burden also require increased emphasis on primary prevention.
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Affiliation(s)
- T K P Nguyen
- Respiratory Department, Da Nang Hospital for Women and Children, Viet Nam.
| | - B B S Bui
- Discipline of Paediatrics, Hue University of Medicine and Pharmacy, Viet Nam
| | - Q C Ngo
- Vietnam Respiratory Society, Ha Noi, Viet Nam
| | - D A Fitzgerald
- Respiratory Medicine, The Children's Hospital at Westmead, The University of Sydney, Australia
| | - S M Graham
- Centre for International Child Health, University of Melbourne and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia; International Union Against Tuberculosis and Lung Diseases, Paris, France
| | - B J Marais
- Discipline of Child and Adolescent Health, The Children's Hospital at Westmead, The University of Sydney, Australia
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7
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Shakeel S, Iffat W, Qamar A, Ghuman F, Yamin R, Ahmad N, Ishaq SM, Gajdács M, Patel I, Jamshed S. Pediatricians' Compliance to the Clinical Management Guidelines for Community-Acquired Pneumonia in Infants and Young Children in Pakistan. Healthcare (Basel) 2021; 9:healthcare9060701. [PMID: 34207813 PMCID: PMC8227315 DOI: 10.3390/healthcare9060701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/26/2021] [Accepted: 06/04/2021] [Indexed: 11/16/2022] Open
Abstract
Community-acquired pneumonia (CAP) is among the most commonly prevailing acute infections in children that may require hospitalization. Inconsistencies among suggested care and actual management practices are usually observed, which raises the need to assess local clinical practices. The current study was conducted to evaluate pediatricians’ compliance with the standard clinical practice guidelines and their antibiotic-prescribing behavior for the management of CAP in children. Methods: A descriptive cross-sectional study was conducted using a self-administered questionnaire; which was provided to pediatricians by the researchers. Statistical analysis was performed with SPSS 25 Statistics; χ2 tests (or Fisher-exact tests) with the p-value set at < 0.05 as the threshold for statistical significance. Results: The overall response rate was 59.2%. Male respondents were (n = 101; 42.6%), and the respondents (n = 163; 68.7%) were under 30 years of age. Amoxicillin (n = 122; 51.5%) was considered as the most commonly used first-line treatment for non-severe pneumonia, whereas a smaller proportion (n = 81; 34.2%) of respondents selected amoxicillin–clavulanate. Likewise, amoxicillin (n = 100; 42.2%) was the most popular choice for non-severe pneumonia in hospitalized children; however, if children had used antibiotics earlier to admission, respondents showed an inclination to prescribe a macrolide (n = 95; 40.0%) or second-generation cephalosporin (n = 90; 37.9%). More than 90% responded that children <6 months old with suspected bacterial CAP will probably receive better therapeutic care by hospitalization. Restricting exposure to the antibiotic as much as possible (n = 71; 29.9%), improving antibiotic prescribing (n = 59; 24.8%), and using the appropriate dose of antimicrobials (n = 29; 12.2%) were considered the major factors by the respondents to reduce antimicrobials resistance. Conclusions: The selection of antibiotics and diagnostic approach was as per the recommendations, but indication, duration of treatment, and hospitalization still can be further improved.
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Affiliation(s)
- Sadia Shakeel
- Faculty of Pharmaceutical Sciences, Dow College of Pharmacy, Dow University of Health Sciences, Karachi 74200, Pakistan; (S.S.); (W.I.)
| | - Wajiha Iffat
- Faculty of Pharmaceutical Sciences, Dow College of Pharmacy, Dow University of Health Sciences, Karachi 74200, Pakistan; (S.S.); (W.I.)
| | - Ambreen Qamar
- Department of Physiology, Dr. Ishrat Ul Ebad Khan Institute of Oral Health Sciences (DIKIOHS), Dow University of Health Sciences, Karachi 74200, Pakistan;
| | - Faiza Ghuman
- Dow University Hospital, Dow University of Health Sciences, Karachi 74200, Pakistan;
| | - Rabia Yamin
- Department of Pediatrics, National Institute of Child Health, Karachi 74200, Pakistan;
| | - Nausheen Ahmad
- Jinnah Postgraduate Medical Centre, Department of Chest Medicine, Karachi 74200, Pakistan;
| | - Saqib Muhammad Ishaq
- Scientific Assistant, Karachi Institute of Radiotherapy and Nuclear Medicine (KIRAN), Karachi 74200, Pakistan;
| | - Márió Gajdács
- Faculty of Medicine, Institute of Medical Microbiology, Semmelweis University, 1089 Budapest, Hungary;
- Department of Pharmacodynamics and Biopharmacy, Faculty of Pharmacy, University of Szeged, 6720 Szeged, Hungary
| | - Isha Patel
- School of Pharmacy, Marshall University, Huntington, WV 25755, USA;
| | - Shazia Jamshed
- Department of Clinical Pharmacy and Practice, Faculty of Pharmacy, Universiti Sultan Zainal Abidin, (UniSZA), Kuala Terengganu 21300, Malaysia
- Qualitative Research-Methodological Application in Health Sciences Research Group, Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan 25200, Malaysia
- Correspondence:
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8
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Nguyen PT, Tran HT, Fitzgerald DA, Graham SM, Marais BJ. Antibiotic use in children hospitalised with pneumonia in Central Vietnam. Arch Dis Child 2020; 105:713-719. [PMID: 32079569 DOI: 10.1136/archdischild-2019-317733] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 12/11/2019] [Accepted: 01/22/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVES Excessive use of antibiotics has been noted in children with respiratory tract infections in Vietnam, but antibiotic use in hospitalised children is poorly documented. Antibiotic use and direct healthcare costs in children hospitalised with pneumonia in central Vietnam were assessed. METHODS A prospective descriptive study of children under 5 years old admitted with a primary admission diagnosis of 'pneumonia' to the Da Nang Hospital for Women and Children over 1 year. RESULTS Of 2911 children hospitalised with pneumonia, 2735 (94.0%) were classified as 'non-severe' pneumonia by the admitting physician. In total, 2853 (98.0%) children received antibiotics. Intravenous antibiotics were given to 336 (12.3%) children with 'non-severe' and 157/176 (89.2%) children with 'severe' pneumonia; those with 'non-severe' pneumonia accounted for 68.2% (336/493) of intravenous antibiotics given. Only 19.3% (95/493) of children on intravenous antibiotics were stepped down to an oral antibiotic. Cefuroxime was the preferred oral agent, and ceftriaxone was the preferred injectable agent. Hospital admission for oral antibiotics in 'non-severe' pneumonia was a major cost driver, with an average direct cost of US$78.9 per patient, accounting for 54.0% of the total hospitalisation cost in the study cohort. In addition, 336 (12.3%) children with non-severe pneumonia received intravenous antibiotics without indication, accounting for a further 23.2% of hospitalisation costs. CONCLUSION Limiting unnecessary hospitalisation and considering early intravenous to oral step down antibiotic will reduce direct health system costs and morbidity in children with respiratory tract infections in Vietnam.
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Affiliation(s)
- Phuong Tk Nguyen
- Department of Respirology, Da Nang Hospital for Women and Children, Da Nang, Vietnam .,Discipline of Paediatrics and Adolescent Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Hoang T Tran
- Department of Neonatology, Da Nang Hospital for Women and Children, Da Nang, Vietnam
| | - Dominic A Fitzgerald
- Discipline of Paediatrics and Adolescent Medicine, The University of Sydney, Sydney, New South Wales, Australia.,Respiratory Medicine, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Steve M Graham
- Department of Paediatrics, Centre for International Child Health, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia, Melbourne, Victoria, Australia
| | - Ben J Marais
- Discipline of Paediatrics and Adolescent Medicine, The University of Sydney, Sydney, New South Wales, Australia
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