Home treatment of severe pneumonia in children with oral antibiotics is as safe and effective as treatment in hospital, according to an Article in this week’s issue of The Lancet. In light of these findings, WHO recommendations on the treatment of severe pneumonia need to be revised, say the authors.
Pneumonia is responsible for the deaths of more than 2 million children under the age of 5 years every year—almost four a minute. WHO guidelines for the case management of acute lower respiratory tract infections recommend that children with fast breathing (non-severe pneumonia) be treated at home with oral antibiotics, and those with lower chest indrawing (severe pneumonia) and general danger signs (very severe disease) be referred to hospital and treated with parenteral antibiotics (benzylpenicilllin or ampicillin). However, in developing areas many children with severe pneumonia referred to hospitals never reach them for reasons such as poor transportation, cost, distance, and lack of childcare at home. This makes the current guidelines ineffective in practice. Safe community-based treatment alternatives would substantially increase the number of children receiving effective care, prevent many deaths, decrease the potential hazards of in-hospital treatment, and reduce costs.
Dr Donald Thea (Boston University School of Public Health, Boston, USA) and colleagues studied 2037 children aged 3–59 months at seven study sites in Pakistan to determine whether home-based treatment of severe pneumonia with oral antibiotics is as safe and as effective as inpatient parenteral treatment. About half the children were randomly assigned to receive oral amoxicillin syrup and were sent home, and the other half to receive intravenous ampicillin for 48h as an inpatient.
The researchers found that there were 87 treatment failures in the hospitalised group and 77 in the home-based group (8.6% vs 7.5%) by day 6. Five children died within 14 days of enrolment, one in the home-based group and four in the hospitalised group. In each case, treatment failure was declared before death and the antibiotic was changed. The authors noted that none of the deaths were considered to be associated with study treatment, and that there were no serious adverse events reported in the trial.
The authors say: “Home treatment with high-dose oral amoxicillin is equivalent to currently recommended hospitalisation and parenteral ampicillin for treatment of severe pneumonia without underlying complications, suggesting that WHO recommendations for treatment of severe pneumonia need to be revised.”
The authors conclude: “Because the agents that cause pneumonia in Pakistani children do not differ from those in most other developing countries, our findings have important public-health policy and programmatic implications, particularly for Integrated Management of Childhood Illness (IMCI) guidelines…Ambulatory management of severe pneumonia in children has the potential to improve access to care and inequity while reducing costs and mortality from pneumonia.”
In an accompanying Comment, Dr Shams El Arifeen (International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh) and Dr Abdullah Baqui (John Hopkins Bloomberg School of Public Health, Baltimore, USA) say: “[The] finding that oral treatment outside a hospital is safe and efficacious is a milestone...[and] should change the management of severe pneumonia in children in developing countries.” They continue: “We would benefit from considering severe pneumonia without danger signs, complications, or other severe conditions as a distinct category that could be safely and effectively treated with oral antibiotics outside hospitals, with the possible exceptions of patients less then 6 months of age, those with very fast breathing, or those moderately underweight.”
For Dr Donald Thea contact Lisa Brown, Boston University School of Public Health, Boston, USA. brownl@bu.edu T) +1 617 414 1401
Dr Shams El Arifeen, International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B), Dhaka, Bangladesh. shams@icddrb.org T) +880 2 881 0115
View the PDF associated with this press release at http://multimedia.thelancet.com/pdf/press/Severe pneumonia in children p49-56 Jan 5.pdf.
Journal
The Lancet