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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] [What about the content of this article? (0)] [Affiliation(s)] [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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