Treatment of severe community-acquired pneumonia with oral amoxicillin in under-five children in developing country: a systematic review

WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections

The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML have been reviewed and categorized into three groups: Access, Watch, and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance and the implications for their appropriate use. The 2023 AWaRe classification provides empirical guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes. This article describes the development of AWaRe, focussing on the clinical evidence base that guided the selection of Access, Watch, or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimizing the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update national prescribing guidelines, and supervise antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.

In-hospital mortality risk stratification in children aged under 5 years with pneumonia with or without pulse oximetry: A secondary analysis of the Pneumonia REsearch Partnership to Assess WHO REcommendations (PREPARE) dataset

OBJECTIVES

We determined the pulse oximetry benefit in pediatric pneumonia mortality risk stratification and chest-indrawing pneumonia in-hospital mortality risk factors.

METHODS

We report the characteristics and in-hospital pneumonia-related mortality of children aged 2-59 months who were included in the Pneumonia Research Partnership to Assess WHO Recommendations dataset. We developed multivariable logistic regression models of chest-indrawing pneumonia to identify mortality risk factors.

RESULTS

Among 285,839 children, 164,244 (57.5%) from hospital-based studies were included. Pneumonia case fatality risk (CFR) without pulse oximetry measurement was higher than with measurement (5.8%, 95% confidence interval [CI] 5.6-5.9% vs 2.1%, 95% CI 1.9-2.4%). One in five children with chest-indrawing pneumonia was hypoxemic (19.7%, 95% CI 19.0-20.4%), and the hypoxemic CFR was 10.3% (95% CI 9.1-11.5%). Other mortality risk factors were younger age (either 2-5 months [adjusted odds ratio (aOR) 9.94, 95% CI 6.67-14.84] or 6-11 months [aOR 2.67, 95% CI 1.71-4.16]), moderate malnutrition (aOR 2.41, 95% CI 1.87-3.09), and female sex (aOR 1.82, 95% CI 1.43-2.32).

CONCLUSION

Children with a pulse oximetry measurement had a lower CFR. Many children hospitalized with chest-indrawing pneumonia were hypoxemic and one in 10 died. Young age and moderate malnutrition were risk factors for in-hospital chest-indrawing pneumonia-related mortality. Pulse oximetry should be integrated in pneumonia hospital care for children under 5 years.

Qiangli Wuhu mixture alleviates LPS-induced pneumonia by inhibiting the TLR4/NF-κB/NLRP3 pathway: a study based on network pharmacology

CONTEXT

Qiangli Wuhu (QLWH) mixture is a concoction approved and registered by Ningxia Medical Products Administration. It has therapeutic effects on various types of pneumonia.

OBJECTIVE

To clarify the mechanisms of QLWH in treating pneumonia.

MATERIALS AND METHODS

The potential targets of QLWH in the treatment of pneumonia were predicted by network pharmacology. Male, Institute of Cancer Research (ICR) mice were randomly divided into five groups of 12 mice, control, vehicle, QLWH (10 and 20 mg/kg) and dexamethasone (DXM), and orally treated twice daily with normal saline, QLWH or DXM. The pneumonia model was established by tracheal instillation of lipopolysaccharide (LPS). After treatment five days, ELISA, H&E staining and Western blot were used to investigate protective effects of QLWH.

RESULTS

Nine hundred and ninety-four active ingredients were found through network pharmacology, corresponding to 135 targets for the treatment of pneumonia; compared to the vehicle group, QLWH (10 and 20 mg/kg) significantly decreased the levels of TNF-α (14.3% and 28.8%), IL-1β (23.9% and 42.8%) and IL-6 (13.2% and 16.1%), increased the levels of IL-10 (134.3% and 172.9%); in terms of mechanism, QLWH down-regulated TLR4/NF-κB/NLRP3 axis related proteins in lung tissue of pneumonia model mice (p < 0.05).

DISCUSSION AND CONCLUSIONS

This study combined network pharmacology and animal experiments, providing effective evidence for the clinical promotion of QLWH. Meanwhile, it is of significance for further development.

Higher childhood pneumonia admission threshold remains in Lao PDR: an observational study

OBJECTIVES

WHO Integrated Management of Childhood Illness (IMCI) guidelines changed pneumonia hospitalisation criteria in 2014, which was implemented in Lao People's Democratic Republic (Lao PDR) in 2015. We determined adherence to: current (2014) IMCI guidelines for children presenting to hospitals with pneumonia, current outpatient management guidelines and identified hospitalisation predictors.

DESIGN

Prospective observational study (January 2017 to December 2018).

SETTING

Outpatient and emergency departments of four hospitals in Vientiane, Lao PDR.

PATIENTS

594 children aged 2-59 months diagnosed with pneumonia.

MAIN OUTCOME MEASURES

Number of children diagnosed, hospitalised, managed, administered preventive measures and followed-up accordant with current guidelines.

RESULTS

Non-severe and severe pneumonia were correctly diagnosed in 97% and 43% of children, respectively. Non-severe pneumonia with lower chest wall indrawing (LCI) was diagnosed as severe in 15%. Hospitalisation rates were: 80% for severe pneumonia, 86% and 3% for non-severe pneumonia with and without LCI, respectively. Outpatient oral antibiotic prescribing was high (99%), but only 30% were prescribed both the recommended antibiotic and duration. Appropriate planned follow-up was 89%. Hospitalisation predictors included age 2-5 months (compared with 24-59 months; OR 3.95, 95% CI 1.90 to 8.24), public transport to hospital (compared with private vehicle; OR 2.60, 95% CI 1.09 to 6.24) and households without piped drinking water (OR 4.67, 95% CI 2.75 to 7.95).

CONCLUSIONS

Hospitalisation practice for childhood pneumonia in Lao PDR remains more closely aligned with the 2005 WHO IMCI guidelines than the currently implemented 2014 iteration. Compliance with current outpatient antibiotic prescribing guidelines was low.

Incidence of recovery from severe pneumonia and its predictors among children 2-59 months admitted to pediatric ward of Ayder Comprehensive Specialized Hospital, Tigray, Ethiopia: A retrospective Cohort study

Background

Pneumonia is a major reason for hospital admission among children, particularly in resource-poor areas. A hospital stay (length of stay) alone is found to contribute for 46.8% of a household cost for single episode of severe pneumonia. The aim of this study was to determine the incidence of recovery from severe pneumonia and predictors among children 2-59 months of age admitted to pediatric ward of Ayder Comprehensive Specialized Hospital (ACSH).

Methods

A retrospective facility-based cohort study was conducted among under-five-year-old children admitted in ACSH. Three years medical records from July 7, 2015 to July 6, 2018 were reviewed. A total of 285 children with severe pneumonia admitted to pediatric ward of ACSH were included. Kaplan-Meier Survival Curve was used to estimate recovery time. The independent effects of covariates on recovery time are analyzed using multivariate Cox-proportional adjusted model.

Result

The median survival time was four days (95% CI = 3.732 - 4.268). The incidence of recovery was 92.3%. Co-morbidity (AOR: 3.47, 95%CI, 2.21, 5.4), malnutrition (AOR = 1.9, 95%CI, 1.2, 3.1), duration of chief complaint (AOR = 0.72, 95%CI: 0.54, 0.94), and vaccination (AOR = 0.32, 95% CI, 0.13, 0.81) were significant predictors of time to recovery from severe pneumonia.

Conclusion

High recovery rate and short length of hospital stay was observed in this study. Increased duration of chief complaint, presence of co-morbidity, being malnourished, and vaccination were factors that associated with time to recovery. Therefore focuses have to be given in increasing the community's health seeking behavior to visit health facility early and especial attention should be given for children with co-morbidity, malnutrition, and unvaccinated children.

Which children with chest-indrawing pneumonia can be safely treated at home, and under what conditions is it safe to do so? A systematic review of evidence from low- and middle-income countries

Background

WHO pneumonia guidelines recommend that children (aged 2-59 months) with chest indrawing pneumonia and without any “general danger sign” can be treated with oral amoxicillin without hospital admission. This recommendation was based on trial data from limited contexts whose generalisability is unclear. This review aimed to identify which children with chest-indrawing pneumonia in low- and middle-income countries can be safely treated at home, and under what conditions is it safe to do so.

Methods

We searched MEDLINE, EMBASE, and PubMed for observational and interventional studies of home-based management of children (aged 28 days to four years) with chest-indrawing pneumonia in low- or middle-income countries.

Results

We included 14 studies, including seven randomised trials, from a variety of urban and rural contexts in 11 countries. Two community-based and two hospital-based trials in Pakistan and India found that home treatment of chest-indrawing pneumonia was associated with similar or superior treatment outcomes to hospital admission. Evidence from trials (n = 3) and observational (n = 6) studies in these and other countries confirms the acceptability and feasibility of home management of chest-indrawing pneumonia in low-risk cases, so long as safeguards are in place. Risk assessment includes clinical danger signs, oxygen saturation, and the presence of comorbidities such as undernutrition, anaemia, or HIV. Pulse oximetry is a critical risk-assessment tool that is currently not widely available and can identify severely ill patients with hypoxaemia otherwise possibly missed by clinical assessment alone. Additional safeguards include caregiver understanding and ability to return for review.

Conclusions

Home treatment of chest-indrawing pneumonia can be safe but should only be recommended for children confirmed to be low-risk and in contexts where appropriate care and safety measures are in place.

Implementation of lung ultrasound in low- to middle-income countries: a new challenge global health?

Pneumonia remains the leading cause of death globally in children under the age of five. The poorest children are the ones most at risk of dying. In the recent years, lung ultrasound has been widely documented as a safe and easy tool for the diagnosis and monitoring of pneumonia and several other respiratory infections and diseases. During the pandemic, it played a primary role to achieve early suspicion and prediction of severe COVID-19, reducing the risk of exposure of healthcare workers to positive patients. However, innovations that can improve diagnosis and treatment allocation, saving hundreds of thousands of lives each year, are not reaching those who need them most. In this paper, we discuss advantages and limits of different tools for the diagnosis of pneumonia in low- to middle-income countries, highlighting potential benefits of a wider access to lung ultrasound in these settings and barriers to its implementation, calling international organizations to ensure the indiscriminate access, quality, and sustainability of the provision of ultrasound services in every setting. What is Known: • Pneumonia remains the leading cause of death globally in children under the age of five. The poorest children are the ones most at risk of dying. In the recent years, lung ultrasound has been widely documented as a safe and easy tool for the diagnosis and monitoring of pneumonia and several other respiratory infections and diseases. During the pandemic, it played a primary role to achieve early suspicion and prediction of severe COVID-19, reducing the risk of exposure of healthcare workers to positive patients. However, innovations that can improve diagnosis and treatment allocation, saving hundreds of thousands of lives each year, are not reaching those who need them most. What is New: • We discuss advantages and limits of different tools for the diagnosis of pneumonia in low- to middle-income countries, highlighting potential benefits of a wider access to lung ultrasound in these settings and barriers to its implementation, calling international organizations to ensure the indiscriminate access, quality, and sustainability of the provision of ultrasound services in every setting.

Impact of pulse oximetry on hospital referral acceptance in children under 5 with severe pneumonia in rural Pakistan (district Jamshoro): protocol for a cluster randomised trial

BACKGROUND

Pneumonia is a leading cause of death among children under 5 specifically in South Asia and sub-Saharan Africa. Hypoxaemia is a life-threatening complication among children under 5 with pneumonia. Hypoxaemia increases risk of mortality by 4.3 times in children with pneumonia than those without hypoxaemia. Prevalence of hypoxaemia varies with geography, altitude and severity (9%-39% Asia, 3%-10% African countries). In this protocol paper, we describe research methods for assessing impact of Lady Health Workers (LHWs) identifying hypoxaemia in children with signs of pneumonia during household visits on acceptance of hospital referral in district Jamshoro, Sindh.

METHODS AND ANALYSIS

A cluster randomised controlled trial using pulse oximetry as intervention for children with severe pneumonia will be conducted in community settings. Children aged 0-59 months with signs of severe pneumonia will be recruited by LHWs during routine visits in both intervention and control arms after consent. Severe pneumonia will be defined as fast breathing and/or chest in-drawing, and, one or more danger sign and/or hypoxaemia (Sa02 <92%) in PO (intervention) group and fast breathing and/or chest in-drawing and one or more danger sign in clinical signs (control) group. Recruits in both groups will receive a stat dose of oral amoxicillin and referral to designated tertiary health facility. Analysis of variance will be used to compare baseline referral acceptance in both groups with that at end of study.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Ethics Review Committee of the Aga Khan University (4722-Ped-ERC-17), Karachi. Study results will be shared with relevant government and non-governmental organisations, presented at national and international research conferences and published in international peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT03588377.

Time-to-Recovery from Severe Pneumonia and Its Determinants Among Children Under-Five Admitted to University of Gondar Comprehensive Specialized Hospital in Ethiopia: A Retrospective Follow-Up Study; 2015-2020

Background

Pneumonia, which is an infection and inflammation of an air-space in the lungs due to an impurity. Child mortality due to pheumonia is estimated at 921,000 children under 5 years (U5) in 2015.

Objective

To determine the TTR and factors of severe pneumonia among U5 children admitted at UOGCSH, Northwest Ethiopia.with

Methods

A facility-based retrospective follow-up study was conducted on children U5 severe pneumonia from 2015 to 2020. The data were collected using pre-test and structured questionnaires. Statistical analysis was performed using Stata version 14.1.

Result

The average TTR was 3 days IQR (3–6). TTR from severe pneumonia was 13.5 (95% CI: 13.54–17.15) per 100-persons. The cumulative time for children at risk was 1112 days, with a TTR of 29.7 per 100 children per day. Severity, signs and symptoms of pneumonia (AHR, 3.88 (95% CI =3.12–5.57)); mode of infancy feeding (cows milk feeding) (AHR, 2.4, (95% CI: 2.22–6.6)), and formula feeding (AHR, 0.68, (95% CI 0.58–1.25)) as compared to breastfeeding; nutritional status (underweight) (AHR, 2.2, (95% CI: (2.1–3.76)) as compared to normal, age (2–3-years) (AHR, 1.4, (95% CI: 1.31–2.22)), and ≥4-years (AHR, 1.32, (95% CI: 1.3–2.32)) as compared to age of ≤1 year were important factors of TTR.

Conclusion

The overall TTR was 3 days IQR (2–6). This study identifies severity, signs, and symptoms of pneumonia, Mode of infancy feeding (cows milk feeding, formula feeding), nutritional status, and age were main determinants of TTR.

Amoxicillin for 3 or 5 Days for Chest-Indrawing Pneumonia in Malawian Children

BACKGROUND

Evidence regarding the appropriate duration of treatment with antibiotic agents in children with pneumonia in low-resource settings in Africa is lacking.

METHODS

We conducted a double-blind, randomized, controlled, noninferiority trial in Lilongwe, Malawi, to determine whether treatment with amoxicillin for 3 days is less effective than treatment for 5 days in children with chest-indrawing pneumonia (cough lasting <14 days or difficulty breathing, along with visible indrawing of the chest wall with or without fast breathing for age). Children not infected with human immunodeficiency virus (HIV) who were 2 to 59 months of age and had chest-indrawing pneumonia were randomly assigned to receive amoxicillin twice daily for either 3 days or 5 days. Children were followed for 14 days. The primary outcome was treatment failure by day 6; noninferiority of the 3-day regimen to the 5-day regimen would be shown if the percentage of children with treatment failure in the 3-day group was no more than 1.5 times that in the 5-day group. Prespecified secondary analyses included assessment of treatment failure or relapse by day 14.

RESULTS

From March 29, 2016, to April 1, 2019, a total of 3000 children underwent randomization: 1497 children were assigned to the 3-day group, and 1503 to the 5-day group. Among children with day 6 data available, treatment failure had occurred in 5.9% in the 3-day group (85 of 1442 children) and in 5.2% (75 of 1456) in the 5-day group (adjusted difference, 0.7 percentage points; 95% confidence interval [CI], -0.9 to 2.4) - a result that satisfied the criterion for noninferiority of the 3-day regimen to the 5-day regimen. Among children with day 14 data available, 176 of 1411 children (12.5%) in the 3-day group and 154 of 1429 (10.8%) in the 5-day group had had treatment failure by day 6 or relapse by day 14 (between-group difference, 1.7 percentage points; 95% CI, -0.7 to 4.1). The percentage of children with serious adverse events was similar in the two groups (9.8% in the 3-day group and 8.8% in the 5-day group).

CONCLUSIONS

In HIV-uninfected Malawian children, treatment with amoxicillin for chest-indrawing pneumonia for 3 days was noninferior to treatment for 5 days. (Funded by the Bill and Melinda Gates Foundation; ClinicalTrials.gov number, NCT02678195.).

Childhood community-acquired pneumonia: A review of etiology- and antimicrobial treatment studies

Community acquired pneumonia (CAP) is a leading cause of childhood morbidity worldwide. Because of the rising antimicrobial resistance rates and adverse effects of childhood antibiotic use on the developing microbiome, rational prescribing of antibiotics for CAP is important. This review summarizes and critically reflects on the available evidence for the epidemiology, etiology and antimicrobial management of childhood CAP. Larger prospective studies on antimicrobial management derive mostly from low- or middle-income countries as they have the highest burden of CAP. Optimal antimicrobial management depends on the etiology, age, local vaccination policies and resistance patterns. As long as non-rapid surrogate markers are used to distinguish viral- from bacterial pneumonia, the management is probably suboptimal. For a young child with signs of non-severe pneumonia (with or without wheezing), watchful waiting is recommended because of probable viral etiology. For children with more severe CAP with fever, a five-day oral amoxicillin course would be the first choice therapy and dosage will depend on local resistance rates. There is no clear evidence yet for superiority of a macrolide-based regimen for all ages. For cases with CAP requiring hospitalization, several studies have shown that narrow-spectrum IV beta-lactam therapy is as effective as a broad-spectrum cephalosporin therapy. For most severe disease, broad-spectrum therapy with or without a macrolide is suggested. In case of empyema, rapid IV-to-oral switch seems to be equivalent to prolonged IV treatment.

A randomized controlled trial of hospital versus home based therapy with oral amoxicillin for severe pneumonia in children aged 3 - 59 months: The IndiaCLEN Severe Pneumonia Oral Therapy (ISPOT) Study

Background

Pneumonia is the leading cause of child mortality under five years of age worldwide. For pneumonia with chest indrawing in children aged 3–59 months, injectable penicillin and hospitalization was the recommended treatment. This increased the health care cost and exposure to nosocomial infections. We compared the clinical and cost outcomes of a seven day treatment with oral amoxicillin with the first 48 h of treatment given in the hospital (hospital group) or at home (home group).

Methods

We conducted an open-label, multi-center, two-arm randomized clinical trial at six tertiary hospitals in India. Children aged 3 to 59 months with chest indrawing pneumonia were randomized to home or hospital group. Clinical outcomes, treatment adherence, and patient safety were monitored through home visits on day 3, 5, 8, and 14 with an additional visit for the home group at 24 h. Clinical outcomes included treatment failure rates up to 7 days (primary outcome) and between 8–14 days (secondary outcome) using the intention to treat and per protocol analyses. Cost outcomes included direct medical, direct non-medical and indirect costs for a random 17 % subsample using the micro-costing technique.

Results

1118 children were enrolled and randomized to home (n = 554) or hospital group (n = 564). Both groups had similar baseline characteristics. Overall treatment failure rate was 11.5 % (per protocol analysis). The hospital group was significantly more likely to fail treatment than the home group in the intention to treat analysis. Predictors with increased risk of treatment failure at any time were age 3–11 months, receiving antibiotics within 48 h prior to enrolment and use of high polluting fuel. Death rates at 7 or 14 days did not differ significantly. (Difference −0.0 %; 95 % CI −0.5 to 0.5). The median total treatment cost was Rs. 399 for the home group versus Rs. 602 for the hospital group (p < 0.001), for the same effect of 5 % failure rate at the end of 7 days of treatment in the random subsample.

Conclusions

Home based oral amoxicillin treatment was equivalent to hospital treatment for first 48 h in selected children of chest indrawing pneumonia and was cheaper. Consistent with the recent WHO simplified guidelines, management with home based oral amoxicillin for select children with only fast breathing and chest-indrawing can be a cost effective intervention.

Trial Registration

ClinicalTrials.gov NCT01386840, registered 25^th June 2011 and the Indian Council of Medical Research REFCTRI/2010/000629.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0510-9) contains supplementary material, which is available to authorized users.

Zinc for Acute Diarrhea and Amoxicillin for Pneumonia, Do They Work? : Delivered at the AIIMS, IJP Excellence Award for the year 2013 on 7th September 2014

Acute diarrhea and pneumonia are the two largest killers of under-five children in the world. Zinc, used in management of acute diarrhea and Amoxicillin, used in community acquired pneumonia, feature in the list of 13 Life Saving Commodities for Women's and Children Health by the UN Commission. Zinc has caught wide scientific attention for the conceptual promise it has to offer for prevention, control and treatment of acute diarrhea. This presentation focuses on author's research on the mechanisms by which zinc might contribute to the pathogenesis of acute diarrhea and the degree of success achieved in diarrhea control and treatment by zinc supplementation including its impact on mortality. However, emerging evidence in terms of controlled studies in humans beckons a more complete understanding of the mechanistic basis for zinc supplementation. Current evidence indicates that studies specifically addressing the variability in response to zinc supplementation need to be undertaken to better comprehend these mechanisms. Similarly, the author presented her research that examined the role of oral amoxicillin in community management of severe pneumonia in children and the need to assess its universal efficacy in all children with severe pneumonia.

Burden of invasive pneumococcal disease in children aged 1 month to 12 years living in South Asia: a systematic review

Objective

The primary objective was to estimate the burden of invasive pneumococcal disease (IPD) in children aged 1 month to 12 years in South Asian countries.

Methods

We searched three electronic databases (PubMed, Embase and the Cochrane Library) using a comprehensive search strategy, we manually searched published databases (Index Medicus and Current Contents) and we also searched the bibliographies of the included studies and retrieved reviews. The searches were current through June 2013. Eligible studies (community-based and hospital-based) were pooled and a separate analysis for India was also completed. A meta-regression analysis and heterogeneity analysis were performed. The protocol was registered with PROSPERO registration number CRD42013004483.

Results

A total of 22 studies surveying 36,714 children were included in the systematic review. Hospital-based prospective studies from South Asia showed that 3.57% of children had IPD, and 15% of all bacterial pneumonia cases were due to Streptococcus pneumoniae. Indian studies showed that the incidence of IPD was 10.58% in children admitted to hospitals with suspected invasive bacterial diseases, and 24% of all bacterial pneumonia cases were due to S. pneumonia. Population-based studies from South Asian countries showed that 12.8% of confirmed invasive bacterial diseases were caused by S. pneumonia whereas retrospective hospital-based studies showed that 28% of invasive bacterial diseases were due to S. pneumoniae. Meta-regression showed that there was a significant influence of the antigen testing method for diagnosing IPD on IPD prevalence.

Conclusion

S. pneumoniae is responsible for a substantial bacterial disease burden in children of South Asian countries including India despite the presence of high heterogeneity in this meta-analysis. Treatment guidelines must be formulated, and preventive measures like vaccines must also be considered.