A child with severe pneumonia can be treated with oral antibiotics as safely and effective at home as in hospital, says an article in The Lancet, this week’s issue. The authors say that the World Health Organization’s (WHO’s) recommendations for severe pneumonia treatment should be modified.

Approximately four children under five years of age die as a result of pneumonia every minute – 2 million per year worldwide.

WHO guidelines recommend that children with non-severe pneumonia (acute lower respiratory tract infections with fast breathing) be treated at home, while children with severe pneumonia and very severe pneumonia be hospitalized and treated with such parenteral antibiotics as benzylpenicilllin or ampicillin.

Getting children with severe pneumonia into a hospital is often not possible in several parts of the world. In areas where transportation is inadequate, the cost of transportation is prohibitive, distances are huge, and there is a lack of childcare at home, sick children often do not get to hospital. In practice, the current guidelines for such children are ineffective. The authors stress that community-based treatment options would significantly boost the number of children who would receive treatment, many deaths would be prevented, money would be saved, and there would be a reduction in the potential hazards of in-hospital treatment.

Dr Donald Thea, Boston University School of Public Health, Boston, USA, and team looked at 2,037 children aged from 3 months to just under six years at seven sites in Pakistan. They wanted to find out whether the treatment for severe pneumonia at home with oral antibiotics was as safe and effective as parenteral treatment in hospital. Half the children were randomly selected to receive oral amoxicillin syrup and sent back home, while the other half were hospitalized and received intravenous ampicillin for forty-eight hours.

By the sixth day there were 77 treatment failures among the children who stayed at home, compared to 87 among the hospitalized children – a percentage treatment failure rate of 7.5% and 8.6% respectively. Within 14 days of enrolment 5 children died, four of them from the hospitalized group. In each case, treatment failure was declared before death and the antibiotic was changed. No serious adverse events were reported in the trial, and none of the deaths were thought to be linked to study treatment, the researchers wrote.

“Home treatment with high-dose oral amoxicillin is equivalent to currently recommended hospitalization 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 researchers say.

“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,” they concluded.

Accompanying Comment

“(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..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,” 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, wrote in an Accompanying Comment.

“Ambulatory short-course high-dose oral amoxicillin for treatment of severe pneumonia in children: a randomised equivalency trial”
Tabish Hazir FCPS, LeAnne M Fox MD, Yasir Bin Nisar MBBS, Matthew P Fox DSc, Yusra Pervaiz Ashraf MBBS, William B MacLeod DSc, Prof Afroze Ramzan FCPS, Prof Sajid Maqbool FRCP [Edin], Tahir Masood FCPS, Prof Waqar Hussain FRCPCH [Lon], Prof Asifa Murtaza PhD, Prof Nadeem Khawar MRCP [Ire], Prof Parveen Tariq FCPS, Prof Rai Asghar FCPS, Jonathon L Simon DSc, Prof, Dr Donald M Thea MD and Shamim A Qazi MD
The Lancet 2008; 371:49-56 DOI:10.1016/S0140-6736(08)60071-9
Click here to see Abstract online

Accompanying Comment
“Treating severe pneumonia in children: we can do better”
Shams El Arifeen, Abdullah H Baqui
The Lancet 2008; 371:7-8
Click here to see Accompanying Comment in full (Login required)

Written by – Christian Nordqvist