ECWA Evangel Hospital, Jos, Nigeria - Better first line treatment needed for children with severe pneumonia

Better first line treatment needed for children with severe pneumonia

published 13-11-2007

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This Lancet article reports an important observational study from South Africa. The authors investigated 358 children aged 1–59 months, regardless of HIV status, who presented with WHO-defined severe or very severe pneumonia. Sixty-eight percent of the children were HIV infected. The empiric treatment used was benzylpenicillin, gentamicin and, for those less than a year old, high-dose trimethoprim-sulfamethoxazole.

FIndings included the fact that in the infants, 42% failed therapy by 48 hours and 6% subsequently. Many of those failing had polymicrobial infections (more than one organism). M. tuberculosis, S. aureus and, in infants, PCP were common among those failing treatment. The authors conclude that (in this HIV-prevalent area) existing empiric treatment recommendations for children with severe pneumonia are inadequate, since nearly half the children failed treatment.

Read more to see a table of organisms isolated from those failing treatment, then see the original article as well.
Organisms isolated from patients who were investigated for failing to respond (Data from Table 5 in article)

Organism	% of infants (n=90)	%of older children (n=20)
CMV	45%	20%
PCP	32%	0%
M. tuberculosis	17%	45%
S. aureus	14%	30%
RSV	12%	10%
S. pneumoniae	10%	15%
Klebsiella pneumoniae	10%	0%
E. coli	9%	0%
adenovirus	7%	15%
H. influenzae	6%	20%
Other gram negatives	13%	14%
Other gram positives	7%	15%
Other virus	9%	15%
Fungal	< 1%	10%

*The percentages add to more than 100% since more than one organism could be isolated from a child. Note that the small sample size in the children > 1 year of age makes the

It appears that gram negative infections were at least as common as gram positive ones in infants. Of note, S. aureus was fairly common in those failing treatment and was associated with a poor outcome.

Effect of age, polymicrobial disease, and maternal HIV status on treatment response and cause of severe pneumonia in South African children: a prospective descriptive study. The Lancet, Volume 369, Number 9571, 28 April 2007. DOI:10.1016/S0140-6736(07)60670-9. Free full text via Hinari.