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Can We Predict Oral Antibiotic Treatment Failure in Children with Fast-Breathing Pneumonia Managed at the Community Level? A Prospective Cohort Study in Malawi.

King C, McCollum ED, Mankhambo L, Colbourn T, Beard J, Hay Burgess DC, Costello A, Izadnegahdar R, Izadnegahdar R, Lufesi N, Masache G, Mwansambo C, Nambiar B, Johnson E, Platt R, Mukanga D - PLoS ONE (2015)

Bottom Line: 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).Further work is needed to identify more accurate and reliable referral algorithms that remain feasible for use by community health workers.

View Article: PubMed Central - PubMed

Affiliation: Institute for Global Health, University College London, London, United Kingdom.

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.

No MeSH data available.


Related in: MedlinePlus

Participant flow diagram for inclusion in the prognostic algorithm model.
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pone.0136839.g001: Participant flow diagram for inclusion in the prognostic algorithm model.

Mentions: The VDCs assessed 1,542 children diagnosed with fast-breathing pneumonia by the CHWs for enrollment over a 9 month period, of which 1,055 were eligible. Reasons for ineligibility were: presence of lower chest indrawing and/or danger signs (60%), no fast breathing (20%), children were not given antibiotics (16%) or children were too old or too young (4%). A total of 197 children (19%) were lost to follow-up; Table 1 shows their baseline characteristics separately from those with follow-up data. Among the 858 children with complete follow-up, we included 769 in the final analysis (Fig 1). Of these, 114 had treatment failure at day five of follow-up, a risk of 14.8% (95% CI: 12.3 to 17.3). Of these treatment failure cases, 29 (25.4%) had not recovered at day 14 and of those without treatment failure we observed an additional 25 children with relapse at day 14 of follow up (3.8%; 95% CI: 2.8 to 6.2). The main reasons for being classified as a treatment failure case were: persistence of fast breathing (65%); grunting (12%); fever (9%) and prescription of an alternative antibiotic (9%)—Table 2.


Can We Predict Oral Antibiotic Treatment Failure in Children with Fast-Breathing Pneumonia Managed at the Community Level? A Prospective Cohort Study in Malawi.

King C, McCollum ED, Mankhambo L, Colbourn T, Beard J, Hay Burgess DC, Costello A, Izadnegahdar R, Izadnegahdar R, Lufesi N, Masache G, Mwansambo C, Nambiar B, Johnson E, Platt R, Mukanga D - PLoS ONE (2015)

Participant flow diagram for inclusion in the prognostic algorithm model.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4551481&req=5

pone.0136839.g001: Participant flow diagram for inclusion in the prognostic algorithm model.
Mentions: The VDCs assessed 1,542 children diagnosed with fast-breathing pneumonia by the CHWs for enrollment over a 9 month period, of which 1,055 were eligible. Reasons for ineligibility were: presence of lower chest indrawing and/or danger signs (60%), no fast breathing (20%), children were not given antibiotics (16%) or children were too old or too young (4%). A total of 197 children (19%) were lost to follow-up; Table 1 shows their baseline characteristics separately from those with follow-up data. Among the 858 children with complete follow-up, we included 769 in the final analysis (Fig 1). Of these, 114 had treatment failure at day five of follow-up, a risk of 14.8% (95% CI: 12.3 to 17.3). Of these treatment failure cases, 29 (25.4%) had not recovered at day 14 and of those without treatment failure we observed an additional 25 children with relapse at day 14 of follow up (3.8%; 95% CI: 2.8 to 6.2). The main reasons for being classified as a treatment failure case were: persistence of fast breathing (65%); grunting (12%); fever (9%) and prescription of an alternative antibiotic (9%)—Table 2.

Bottom Line: 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).Further work is needed to identify more accurate and reliable referral algorithms that remain feasible for use by community health workers.

View Article: PubMed Central - PubMed

Affiliation: Institute for Global Health, University College London, London, United Kingdom.

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.

No MeSH data available.


Related in: MedlinePlus