Prevalence and correlates of treatment failure among Kenyan children hospitalised with severe community-acquired pneumonia: a prospective study of the clinical effectiveness of WHO pneumonia case management guidelines

Abstract

Objective: To determine the extent and pattern of treatment failure (TF) among children hospitalised with community-acquired pneumonia at a large tertiary hospital in Kenya.

Methods: We followed up children aged 2-59 months with WHO-defined severe pneumonia (SP) and very severe pneumonia (VSP) for up to 5 days for TF using two definitions: (i) documentation of pre-defined clinical signs resulting in change of treatment (ii) primary clinician's decision to change treatment with or without documentation of the same pre-defined clinical signs.

Results: We enrolled 385 children. The risk of TF varied between 1.8% (95% CI 0.4-5.1) and 12.4% (95% CI 7.9-18.4) for SP and 21.4% (95% CI 15.9-27) and 39.3% (95% CI 32.5-46.4) for VSP depending on the definition applied. Higher rates were associated with early changes in therapy by clinician in the absence of an obvious clinical rationale. Non-adherence to treatment guidelines was observed for 70/169 (41.4%) and 67/201 (33.3%) of children with SP and VSP, respectively. Among children with SP, adherence to treatment guidelines was associated with the presence of wheeze on initial assessment (P = 0.02), while clinician non-adherence to guideline-recommended treatments for VSP tended to occur in children with altered consciousness (P < 0.001). Using propensity score matching to account for imbalance in the distribution of baseline clinical characteristics among children with VSP revealed no difference in TF between those treated with the guideline-recommended regimen vs. more costly broad-spectrum alternatives [risk difference 0.37 (95% CI -0.84 to 0.51)].

Conclusion: Before revising current pneumonia case management guidelines, standardised definitions of TF and appropriate studies of treatment effectiveness of alternative regimens are required.

Keywords: Neumonía; Organisation Mondiale de la Santé; Organización Mundial de la Salud; World Health Organization; case management; fallo en el tratamiento; manejo de casos; pneumonia; pneumonie; prise en charge des cas; treatment failure; échec du traitement.

Figure 1

Flow of study patients.

Figure 2

Diagnosis showing subgroups of initial treatment assigned. *Other antibiotics: 53 benzyl penicillin and gentamicin, eight benzyl penicillin and chloramphenicol, two ceftriaxone, three ceftriaxone and amikacin, one cloxacillin and gentamicin, one amoxicillin/clavulanate, one benzyl penicillin, gentamicin and erythromycin, one benzyl penicillin and erythromycin. **Other antibiotics: 18 benzyl penicillin and chloramphenicol, three ceftriaxone, nine ceftriaxone and amikacin, one ceftazidime and amikacin, one ceftazidime, one cloxacillin and erythromycin, one amoxicillin/clavulanate.