Virulent Klebsiella pneumoniae ST11 clone carrying blaKPC and blaNDM from patients with and without COVID-19 in Brazil.

AIMS: Investigated and compared the occurrence of virulence genes fimH, mrkD, irp2, entB, cps, rmpA, and wabG, resistance genes blaKPC and blaNDM, and the genetic variability and clonal relationship of 29 Klebsiella pneumoniae clinical isolates of patients with and without COVID-19, from a hospital in Brazil. METHODS AND RESULTS: All isolates were resistant to beta-lactams. The genes were investigated by PCR, and for molecular typing, enterobacterial repetitive intergenic consensus-polymerase chain reaction (ERIC-PCR) and MLST were used. The detection of blaNDM was greater (n = 23) when compared to that of blaKPC (n = 14). The virulence genes that most occurred were fimH, entB, cps, and wabG, which are responsible for adhesins, siderophore enterobactin, capsule, and lipopolysaccharides, respectively. Among the isolates, 21 distinct genetic profiles were found by ERIC-PCR, with multiclonal dissemination. Four isolates belonged to the ST11 clone. CONCLUSIONS: The occurrence of the ST11 is worrying as it is a high-risk clone involved in the dissemination of virulent strains throughout the world.

New Library of Iodo-Quinoline Derivatives Obtained by an Alternative Synthetic Pathway and Their Antimicrobial Activity.

6-Iodo-substituted carboxy-quinolines were obtained using a one-pot, three-component method with trifluoroacetic acid as a catalyst under acidic conditions. Iodo-aniline, pyruvic acid and 22 phenyl-substituted aldehydes (we varied the type and number of radicals) or O-heterocycles, resulting in different electronic effects, were the starting components. This approach offers advantages such as rapid response times, cost-effective catalysts, high product yields and efficient purification procedures. A comprehensive investigation was conducted to examine the impact of aldehyde structure on the synthesis pathway. A library of compounds was obtained and characterized by FT-IR, MS, 1H NMR and 13C NMR spectroscopy and single-ray crystal diffractometry. Their antimicrobial activity against S. epidermidis, K. pneumonie and C. parapsilosis was tested in vitro. The effect of iodo-quinoline derivatives on microbial adhesion, the initial stage of microbial biofilm development, was also investigated. This study suggests that carboxy-quinoline derivatives bearing an iodine atom are interesting scaffolds for the development of novel antimicrobial agents.

Clinical study of pulmonary CT lesions and associated bronchiectasis in 115 convalescent patients with novel coronavirus pneumonia (COVID-19) in China.

A total of 115 convalescent inpatients with COVID-19 were enrolled. According to the results of scans of lung lesions via computed tomography (CT), the patients were divided into mild, moderate, and severe groups. The clinical data of the patients were collected, including age, gender, finger pulse oxygen pressure, ventricular rate, body temperature, etc. The correlation between the clinical indicators and the lesions of high-resolution CT (HRCT) and bronchiectasis was analyzed. Among the 115 patients, 82 had no bronchiectasis and 33 had bronchiectasis. The bronchodilation-prone layers mainly included the left and right lower lobe of the lung. The probability of branching in the inflamed area was greater than that in the noninflamed area in patients with COVID-19. There were significant differences in gender, CT lesion range, and number of incidents of bronchiectasis between noninflamed and inflamed areas (P < 0.05). Moreover, there were significant differences in age, total proportion of CT lesions, volume of CT lesions, and total number of patients with bronchiectasis among the three groups (P < 0.05). CT lesion range was positively correlated with the total number of patients with bronchiectasis and patient age (respectively, r = 0.186, P < 0.05; r = 0.029, P < 0.05). The lesion range in HRCT images of lungs in patients with COVID-19 is correlated with bronchodilation. The larger the lesion, the higher the probability of bronchiectasis and the more incidents of bronchiectasis.

Diabetes is a major cause of influenza-associated mortality in Mexico.

BACKGROUND: Influenza is a major cause of mortality worldwide. Most influenza-associated deaths are associated with cardiovascular or respiratory disorders. However, a large proportion of influenza-associated deaths do not have respiratory or cardiovascular disorders declared as the underlying cause of death. Diabetic individuals are at increased risk for influenza-mortality. In this study, we assessed the contribution of diabetes to influenza-associated mortality in Mexico. METHODS: Diabetes influenza-associated mortality was estimated for the Mexican population using National Mortality Databases from the Mexican Ministry of Health from 1998 through 2015. Diabetes influenza-associated mortality was calculated applying Serfling cyclical regression models to weekly mortality rates for persons 20-59 years, 60 and more years, and all ages, and by sex. RESULTS: There was a high correlation between weekly pneumonia and influenza mortality and diabetes-related mortality. Yearly influenza-associated diabetes mortality rates varied between 2.0 and 5.9/100,000. Up until the 2005-2006 season, diabetes-associated mortality rates were higher in females, while after that season rates were higher in males. Yearly influenza-associated diabetes mortality rates for adults 20-59 years of age ranged between 1.7 and 3.4/100,000, while estimates for adults 60 years and older ranged between 16.3 and 46.1/100,000. Approximately one third of estimated diabetes influenza-associated deaths occurred in adults 20-59 years of age. On average, diabetes deaths accounted for 19.6% of estimated influenza-associated all-cause mortality. CONCLUSION: Diabetes is a major cause of estimated influenza-associated mortality in Mexico. Health-care authorities and professionals in countries with high diabetes prevalence should be aware of the potential impact of influenza in individuals with this condition.

Der Pneumonie keine Chance geben.

No chance for pneumonia - A campaign for mobilization in the context of a practice project addressing pneumonia prevention Abstract. Background: Healthcare-associated infections (HAI) in inpatients are associated with complicated treatment. In Europe, 5.5 % of inpatients develop HAI. About half of these infections could be avoided. In the Clinic for traumatology of the university hospital Zurich, we developed interventions to reduce HAI. Thereby, we focused on non-ventilator-associated hospital-acquired pneumonia (nvHAP). Aim: Besides reducing nvHAP rates, we intended to improve patient mobility, to empower nurses, and to strengthen interprofessional collaboration. Methods: To achieve these aims, we performed a practice development project comprising inhouse training, workshops, information posters, structural changes and a mobilization campaign. Results: Patient mobilization increased by 40 %, duration of mobilization sessions by 46.5 %. The semi-annual comparison shows a sustainable improvement of 7.6 %. Nurses reported knowledge gain, considerably improved interprofessional collaboration and increased quality of caring. Discussion: Combining various methods and following an interprofessional approach resulted in sustainable effects. Limitations and transfer: Targeted practice development proves to be suitable for promoting patient mobility. Regular repetitions and physiotherapy services at off-peak times are essential to ensure sustainability.

'Know-Can' gap: gap between knowledge and skills related to childhood diarrhoea and pneumonia among frontline workers in rural Uttar Pradesh, India.

OBJECTIVES: In India, frontline workers (FLWs) - public accredited social health activists (ASHAs) and private rural medical providers (RMPs) - are important for early detection and treatment of childhood diarrhoea and pneumonia. This cross-sectional study aims to measure knowledge and skills, and the gap between the two ('know-can' gap), regarding assessment of childhood diarrhoea with dehydration and pneumonia among FLWs, and to explore factors associated with them. METHODS: We surveyed 473 ASHAs and 447 RMPs in six districts of Uttar Pradesh. We assessed knowledge and skills using face-to-face interviews and video vignettes, respectively, about key signs of both conditions. The 'know-can' gap corresponds to absent skills among FLWs with correct knowledge. We used logistic regression to identify the correlates of knowledge and skills. RESULTS: FLWs' correct knowledge ranged from 23% to 48% for dehydration signs and 27% to 37% for pneumonia signs. Their skills ranged from 3% to 42% for dehydration and 3% to 18% for pneumonia. There was a significant 'know-can' gap in all the signs, except 'sunken eyes'. Training and supervisory support was associated with better knowledge and skills for diarrhoea with dehydration, but only better knowledge for pneumonia. CONCLUSIONS: FLWs are crucial to the Indian health system, and high-quality FLW services are necessary for continued progress against under-five deaths. The gap between FLWs' knowledge and skills warrants immediate attention. In particular, our results suggest that knowledge-focused trainings are insufficient for FLWs to convert knowledge into appropriate assessment skills.

OBJECTIFS: En Inde, les travailleurs de première ligne (TPL) - activistes de la santé sociale accrédités par le public (ASSAP) et prestataires médicaux ruraux privés (PMRP) - sont importants pour la détection et le traitement précoces de la diarrhée et de la pneumonie infantiles. Cette étude transversale vise à mesurer les connaissances et les compétences, et l'écart entre les deux (écart ''savoir-pouvoir''), en ce qui concerne l'évaluation de la diarrhée infantile avec déshydratation et la pneumonie chez les TPL et à explorer les facteurs qui leur sont associés. MÉTHODES: Nous avons mené une enquête sur 473 ASSAP et 447 PMRP dans six districts de l'Uttar Pradesh. Nous avons évalué les connaissances et les compétences à l'aide d'entretiens de face à face et de vignettes vidéo, respectivement, sur les signes clés des deux conditions. L'écart «savoir-pouvoir¼ correspond à des compétences absentes parmi les TPL ayant des connaissances correctes. Nous avons utilisé la régression logistique pour identifier les corrélats des connaissances et des compétences. RÉSULTATS: Les connaissances correctes des TPL variaient de 23% à 48% pour les signes de déshydratation, 27% à 37% pour les signes de pneumonie. Leurs compétences variaient de 3% à 42% pour la déshydratation et de 3% à 18% pour la pneumonie. Il y avait un écart important dans le «savoir-pouvoir¼ pour tous les signes, à l'exception des «yeux enfoncés¼. La formation et le soutien à la supervision étaient associés à de meilleures connaissances et compétences pour la diarrhée avec déshydratation, mais seulement à de meilleures connaissances pour la pneumonie. CONCLUSIONS: Les TPL sont cruciaux pour le système de santé indien, et des services de TPL de haute qualité sont nécessaires pour continuer à lutter contre les décès d'enfants de moins de cinq ans. L'écart entre les connaissances et les compétences des TPL mérite une attention immédiate. En particulier, nos résultats suggèrent que les formations axées sur les connaissances sont insuffisantes pour que les TPL convertissent les connaissances en compétences d'évaluation appropriées.

Modifiable risk factors for community-acquired pneumonia in children under 5 years of age in resource-poor settings: a case-control study.

OBJECTIVE: Despite the availability of vaccines and antibiotics, pneumonia remains the leading cause of mortality among children under 5 years of age. The objective of this study was to identify modifiable risk factors for community-acquired pneumonia (CAP) in children under 5 years of age in a vaccinated population. METHODS: A case-control study was conducted between January and December 2017. The cases included children aged 2-59 months with X-ray-confirmed pneumonia, whereas the controls were children from the community with no history of respiratory infection. A multivariable logistic regression model was used to determine the modifiable risk factors for CAP. RESULTS: A total of 113 children with X-ray-confirmed pneumonia and 350 healthy children were enrolled in this study. The median ages for the cases and controls were 13.7 (IQR = 7.2-25.3) and 13.4 (IQR = 6.0-24.8) months respectively. One (0.9%) child died after the enrolment. The independent predictors of CAP included a lack of exclusive breastfeeding for 6 months (aOR = 1.7, 95% CI = 1.0-2.9), underweight (aOR = 2.1, 95% CI = 1.0-4.5), unclean cooking fuel (aOR = 1.8, 95% CI = 1.0-3.3) and low income (aOR = 2.9, 95% CI = 1.6-5.4). No association was found between vaccination status and CAP. CONCLUSION: In addition to a lack of exclusive breastfeeding, children from families of low-economic status were at risk of contracting CAP. Since the risk factors are complex, the study results call for more concerted efforts by and collaboration among the health, agriculture and development sectors to address mortality caused by CAP.

OBJECTIF: Malgré la disponibilité des vaccins et des antibiotiques, la pneumonie reste la principale cause de mortalité chez les enfants de moins de cinq ans. L'objectif de cette étude était d'identifier les facteurs de risque modifiables pour la pneumonie acquise en communauté (PAC) chez les enfants de moins de cinq ans dans une population vaccinée. MÉTHODES: Une étude cas-témoins a été menée entre janvier et décembre 2017. Les cas concernaient des enfants âgés de 2 à 59 mois atteints de pneumonie confirmée par la radiographie, alors que les témoins étaient des enfants de la communauté sans antécédents d'infection respiratoire. Un modèle de régression logistique multivariée a été utilisé pour déterminer les facteurs de risque modifiables pour la PAC. RÉSULTATS: Au total, 113 enfants atteints de pneumonie confirmée par la radiographie et 350 enfants en bonne santé ont été inclus dans cette étude. Les âges médians pour les cas et les témoins étaient respectivement de 13,7 (IQR = 7,2 - 25,3) et de 13,4 (IQR = 6,0 - 24,8) mois. Un enfant (0,9%) est décédé après l'inscription. Les prédicteurs indépendants de la PAC comprenaient une absence d'allaitement exclusif pendant six mois (aOR = 1,7; IC95%: 1,0 - 2,9), un poids insuffisant (aOR = 2,1; IC95%: 1,0 - 4,5), un combustible de cuisson non propre (aOR = 1,8; IC95%: 1,0 - 3,3) et un faible revenu (aOR = 2,9; IC95%: 1,6 - 5,4). Aucune association n'a été trouvée entre le statut de vaccination et la PAC. CONCLUSION: Outre l'absence d'allaitement maternel exclusif, les enfants issus de familles à faible statut économique étaient à risque de contracter la PAC. Les facteurs de risque étant complexes, les résultats de l'étude appellent à des efforts plus concertés et une collaboration accrue entre les secteurs de la santé, de l'agriculture et du développement afin de lutter contre la mortalité causée par la PAC.

Day clinic vs. hospital care of pneumonia and severe malnutrition in children under five: a randomised trial.

OBJECTIVES: To evaluate the clinical outcomes and costs of managing pneumonia and severe malnutrition in a day clinic (DC) management model (outpatient) vs. hospital care (inpatient). METHODS: Randomised clinical trial where children aged 2 months to 5 years with pneumonia and severe malnutrition were randomly allocated to DC or inpatient hospital care. We used block randomisation of variable length from 8 to 20 and produced computer-generated random numbers that were assigned to one of the two interventions. Successful management was defined as resolution of clinical signs of pneumonia and being discharged from the model of care (DC or hospital) without need for referral to a hospital (DC), or referral to another hospital. All the children in both DC and hospital received intramuscular ceftriaxone, daily nutrition support and micronutrients. RESULTS: Four hundred and seventy children were randomly assigned to either DC or hospital care. Successful management was achieved for 184 of 235 (78.3%) by DC alone, vs. 201 of 235 (85.5%) by hospital inpatient care [RR (95% CI) = 0.79 (0.65-0.97), P = 0.02]. During 6 months of follow-up, 30/235 (12.8%) in the DC group and 36/235 (15.3%) required readmission to hospital in the hospital care group [RR (95% CI) = 0.89 (0.67-1.18), P = 0.21]. The average overall healthcare and societal cost was 34% lower in DC (US$ 188 ± 11.7) than in hospital (US$ 285 ± 13.6) (P < 0.001), and costs for households were 33% lower. CONCLUSIONS: There was a 7% greater probability of successful management of pneumonia and severe malnutrition when inpatient hospital care rather than the outpatient day clinic care was the initial method of care. However, where timely referral mechanisms were in place, 94% of children with pneumonia and severe malnutrition were successfully managed initially in a day clinic, and costs were substantially lower than with hospital admission.

OBJECTIFS: Evaluer les résultats cliniques et les coûts de la prise en charge de la pneumonie et de la malnutrition sévère dans un modèle de prise en charge en clinique de jour (CJ) (patients ambulatoires) par rapport à des soins hospitaliers (patients hospitalisés). MÉTHODES: Essai clinique randomisé où les enfants âgés de 2 mois à 5 ans avec une pneumonie et une malnutrition sévère ont été répartis de façon aléatoire en CJ ou à des soins hospitaliers. Nous avons utilisé la randomisation par blocs de longueur variable de 8 à 20 et avons généré des nombres aléatoires par ordinateur qui ont été attribués à l'une des deux interventions. Une prise en charge réussie a été définie comme la résolution des signes cliniques de pneumonie et la sortie du modèle de soins (CJ ou hospitalisation) sans nécessiter un transfert à un hôpital (CJ), ni à un autre hôpital. Tous les enfants du bras CJ et du bras soins hospitaliers ont reçu de la ceftriaxone par voie intramusculaire, un soutien nutritionnel quotidien et des micronutriments. RÉSULTATS: 470 enfants ont été assignés aléatoirement soit à des soins en CJ ou hospitaliers. Une prise en charge réussie a été obtenue pour 184 patients sur 235 (78,3%) en CJ seule contre 201 sur 235 (85,5%) en soins hospitaliers [RR (IC95%) = 0,79 (0,65 - 0,97), p = 0,02]. Au cours des six mois de suivi, 30/235 (12,8%) du groupe CJ et 36/235 (15,3%) du groupe soins hospitaliers ont nécessité une réadmission à l'hôpital [RR (IC95%) = 0,89 (0,67 - 1,18), p = 0,21]. Le coût moyen global des soins de santé et pour la société était de 34% plus faible dans le groupe CJ (188 ± 11,7 USD) que dans le groupe soins hospitaliers (285 ± 13,6 USD) (p < 0,001) et les coûts pour les ménages étaient de 33% inférieurs. CONCLUSIONS: La probabilité d'une prise en charge réussie de la pneumonie et de la malnutrition sévère était 7% plus élevée lorsque les soins hospitaliers plutôt que les soins en CJ étaient les moyens initiaux. Cependant, là où des mécanismes de référence rapides étaient en place, 94% des enfants atteints de pneumonie et de malnutrition sévère ont été pris en charge avec succès dans une clinique de jour et les coûts étaient nettement inférieurs à ceux de soins hospitaliers.

Disease spectrum and management of children admitted with acute respiratory infection in Viet Nam.

OBJECTIVE: To assess the acute respiratory infection (ARI) disease spectrum, duration of hospitalisation and outcome in children hospitalised with an ARI in Viet Nam. METHODS: We conducted a retrospective descriptive study of ARI admissions to primary (Hoa Vang District Hospital), secondary (Da Nang Hospital for Women and Children) and tertiary (National Hospital of Paediatrics in Ha Noi) level hospitals in Viet Nam over 12 months (01/09/2015 to 31/08/2016). RESULTS: Acute respiratory infections accounted for 27.9% (37 436/134 061) of all paediatric admissions; nearly half (47.6%) of all children admitted to Hoa Vang District Hospital. Most (64.6%) of children hospitalised with an ARI were <2 years of age. Influenza/pneumonia accounted for 69.4% of admissions; tuberculosis for only 0.3%. Overall 284 (0.8%) children died; most deaths (269/284; 94.7%) occurred at the tertiary referral hospital. The average duration of hospitalisation was 7.6 days (median 7 days). The average direct hospitalisation cost per ARI admission was 157.5 USD in Da Nang Provincial Hospital. In total, 62.6% of admissions were covered by health insurance. CONCLUSION: Acute respiratory infection is a major cause of paediatric hospitalisation in Viet Nam, characterised by prolonged hospitalisation for relatively mild disease. There is huge potential to reduce unnecessary hospital admission and cost.

Rhinovirus species and clinical features in children hospitalised with pneumonia from Mozambique.

OBJECTIVES: To describe the prevalence of human rhinovirus (RV) species in children hospitalised with pneumonia in Manhiça, Mozambique, and the associations between RV species and demographic, clinical and laboratory features. METHODS: Nasopharyngeal aspirates were collected from children 0 to 10 years of age (n = 277) presenting to Manhiça District Hospital with clinical pneumonia. Blood samples were collected for HIV and malaria testing, blood culture and full blood counts, and a chest X-ray was performed. A panel of common respiratory viruses was investigated using two independent multiplex RT-PCR assays with primers specific for each virus and viral type. RV species and genotypes were identified by seminested PCR assays, sequencing and phylogenetic tree analyses. RESULTS: At least one respiratory virus was identified in 206 (74.4%) children hospitalised with clinical pneumonia. RV was the most common virus identified in both HIV-infected (17 of 38, 44.7%) and HIV-uninfected (74 of 237, 31.2%; P = 0.100) children. RV-A was the most common RV species identified (47 of 275, 17.0%), followed by RV-C (35/275, 12.6%) and RV-B (8/275, 2.9%). Clinical presentation of the different RV species was similar and overlapping, with no particular species being associated with specific clinical features. CONCLUSIONS: RV-A and RV-C were the most common respiratory viruses identified in children hospitalised with clinical pneumonia in Manhiça. Clinical presentation of RV-A and RV-C was similar and overlapping.

Hypoxaemia in Mozambican children <5 years of age admitted to hospital with clinical severe pneumonia: clinical features and performance of predictor models.

OBJECTIVE: To determine the prevalence of hypoxaemia among under-five children admitted to hospital with clinical severe pneumonia and to assess the performance to diagnose hypoxaemia of models based on clinical signs. METHODS: We conducted a hospital-based survey in a district hospital from Southern Mozambique. RESULTS: A total of 825 children were recruited after obtaining an informed consent. The prevalence of hypoxaemia on admission was 27.9%, and 19.8% of these children died (OR compared with non-hypoxaemic children 3.22, 95% CI 1.98-5.21, P < 0.001). The model with larger area under the ROC curve (AUC-ROC) to predict hypoxaemia included cyanosis or thoracoabdominal breathing or respiratory rate ≥70 breaths per minute. None of the models performed well when tested in different case scenarios of oxygen availability through mathematical modelling, with over 50% of hypoxaemic children not receiving oxygen even in favourable case scenarios. CONCLUSIONS: Clinical signs alone or in combination are not suitable to diagnose hypoxaemia. The use of pulse oximeters should be strongly encouraged.

Effect of deploying community health assistants on appropriate treatment for diarrhoea, malaria and pneumonia: quasi-experimental study in two districts of Zambia.

OBJECTIVE: A critical shortage of human resources for health in Zambia remains a great challenge. In response, the Zambian Ministry of Health developed a national community health assistant (CHA) programme, aiming to create a well-trained and motivated community-based health workforce. This study assessed whether CHAs increased treatment rates for diarrhoea, confirmed malaria or pneumonia in the first programme year. METHODS: This study used a quasi-experimental difference-in-difference design, comparing changes in the catchment areas of health posts with CHAs to those without. Baseline and end line household surveys were conducted to measure the proportion of children under 5 years treated for diarrhoea, malaria or pneumonia in the 2 weeks before the survey and immunisation rates and malaria rapid diagnostic test rates. RESULTS: We surveyed 2330 women with children under five from the intervention area and 2314 from comparison areas at baseline and end line. Treatment for diarrhoea, malaria or pneumonia increased by 18.0% (P < 0.01) and 23.5% (P < 0.01) in the intervention and comparison groups, respectively, but DID analysis was not significant (P = 0.27). The proportion of fully immunised children grew by 7.5% in the intervention, but shrank by 7.5% in the comparison group (DID: 0.14; 95% CI 0.12-0.16, P < 0.01). CONCLUSION: Although we observed no significant difference between the intervention and comparison groups in the DID estimates for the primary outcome, there were significant increases after one year in treatment for all three diseases in the intervention group from baseline to end line and in the proportion of fully immunised children.

Stunting is associated with poor outcomes in childhood pneumonia.

OBJECTIVE: Stunting affects 26.7% of children worldwide, and little is known about its effects on the outcomes of childhood pneumonia. We evaluated the effect of stunting on the outcomes of pneumonia among children enrolled in two large clinical trials. METHODS: We analysed data from two WHO and USAID-sponsored inpatient treatment trials, the Severe Pneumonia Evaluation Antimicrobial Research study (n = 958) and the Amoxicillin Penicillin Pneumonia International Study (n = 1702), which enrolled children aged 2-59 months across 16 sites in LMICs. We assessed the effect of stunting (height-for-age Z score < -2) on treatment outcome and time to resolution of hypoxaemic pneumonia. RESULTS: Among 2542 (96%) children with valid data for height, 28% were stunted and 12.8% failed treatment by 5 days. The failure rate among stunted patients was 16.0% vs. 11.5% among non-stunted patients [unadjusted RR = 1.24 (95% CI 1.08, 1.41); adjusted RR = 1.28 (95% CI 1.10, 1.48)]. An inverse relationship was observed between height and failure rates, even among non-stunted children. Among 845 patients with hypoxaemic pneumonia, stunting was associated with a lower probability of normalisation of respiratory rate [HR = 0.63 (95% CI 0.52, 0.75)] and oxygen saturation [HR = 0.74 (95% CI 0.61, 0.89)]. CONCLUSIONS: Stunting increases the risk of treatment failure and is associated with a longer course of recovery in children with pneumonia. Strategies to decrease stunting may decrease the burden of adverse outcomes in childhood pneumonia in low-resource settings.

Effect of context on respiratory rate measurement in identifying non-severe pneumonia in African children.

OBJECTIVE: Cough or difficult breathing and an increased respiratory rate for their age are the commonest indications for outpatient antibiotic treatment in African children. We aimed to determine whether respiratory rate was likely to be transiently raised by a number of contextual factors in a busy clinic leading to inaccurate diagnosis. METHODS: Respiratory rates were recorded in children aged 2-59 months presenting with cough or difficulty breathing to one of the two busy outpatient clinics and then repeated at 10-min intervals over 1 h in a quiet setting. RESULTS: One hundred and sixty-seven children were enrolled with a mean age of 7.1 (SD ± 2.9) months in infants and 27.6 (SD ± 12.8) months in children aged 12-59 months. The mean respiratory rate declined from 42.3 and 33.6 breaths per minute (bpm) in the clinic to 39.1 and 32.6 bpm after 10 min in a quiet room and to 39.2 and 30.7 bpm (P < 0.001) after 60 min in younger and older children, respectively. This resulted in 11/13 (85%) infants and 2/15 (13%) older children being misclassified with non-severe pneumonia. In a random effects linear regression model, the variability in respiratory rate within children (42%) was almost as much as the variability between children (58%). Changing the respiratory rates cut-offs to higher thresholds resulted in a small reduction in the proportion of non-severe pneumonia mis-classifications in infants. CONCLUSION: Noise and other contextual factors may cause a transient increase in respiratory rate and consequently misclassification of non-severe pneumonia. However, this effect is less pronounced in older children than infants. Respiratory rate is a difficult sign to measure as the variation is large between and within children. More studies of the accuracy and utility of respiratory rate as a proxy for non-severe pneumonia diagnosis in a busy clinic are needed.

Disease mapping for informing targeted health interventions: childhood pneumonia in Bohol, Philippines.

BACKGROUND: Acute lower respiratory tract infections (ALRI) are the leading cause of childhood mortality worldwide. Currently, most developing countries assign resources at a district level, and yet District Medical Officers have few tools for directing targeted interventions to high mortality or morbidity areas. Mapping of ALRI at the local level can guide more efficient allocation of resources, coordination of efforts and targeted interventions, which are particularly relevant for health management in resource-scarce settings. METHODS: An efficacy study of 11-valent pneumococcal vaccine was conducted in six municipalities in the Bohol Province of central Philippines from July 2000 to December 2004. Geocoded under-five pneumonia cases (using WHO classifications) were mapped to create spatial patterns of pneumonia at the local health unit (barangay) level. RESULTS: There were 2951 children with WHO-defined clinical pneumonia, of whom 1074 were severe or very severely ill, 278 were radiographic, and 219 were hypoxaemic. While most children with pneumonia were from urban barangays, there was a disproportionately higher distribution of severe/very severe pneumonia in rural barangays and the most severe hypoxaemic children were concentrated in the northern barangays most distant from the regional hospital. CONCLUSIONS: Mapping of ALRI at the local administrative health level can be performed relatively simply. If these principles are applied to routinely collected IMCI classification of disease at the district level in developing countries, such efforts can form the basis for directing public health and healthcare delivery efforts in a targeted manner.

Development of quality indicators to evaluate antibiotic treatment of patients with community-acquired pneumonia in Indonesia.

OBJECTIVE: To develop an instrument for evaluating the quality of antibiotic management of patients with community-acquired pneumonia (CAP) applicable in a middle-income developing country. METHOD: A previous study and Indonesian guidelines were reviewed to derive potential quality of care indicators (QIs). An expert panel performed a two-round Delphi consensus procedure on the QI's relevance to patient recovery, reduction of antimicrobial resistance and cost containment. Applicability in practice, including reliability, feasibility and opportunity for improvement, was determined in a data set of 128 patients hospitalised with CAP in Semarang, Indonesia. RESULTS: Fifteen QIs were selected by the consensus procedure. Five QIs did not pass feasibility criteria, because of inappropriate documentation, inefficient laboratory services or patient factors. Three QIs provided minor opportunity for improvement. Two QIs contradicted each other; one of these was considered not valid and excluded. A final set of six QIs was defined for use in the Indonesian setting. CONCLUSION: Using the Delphi method, we defined a list of QIs for assessing the quality of care, in particular antibiotic treatment, for CAP in Indonesia. For further improvement, a modified Delphi method that includes discussion, a sound medical documentation system, improvement of microbiology laboratory services, and multi-center applicability tests are needed to develop a valid and applicable QI list for the Indonesian setting.

An update on the association of vitamin D deficiency with common infectious diseases.

Vitamin D plays an important role in modulating the immune response to infections. Deficiency of vitamin D is a common condition, affecting both the general population and patients in health care facilities. Over the last decade, an increasing body of evidence has shown an association between vitamin D deficiency and an increased risk for acquiring several infectious diseases, as well as poorer outcomes in vitamin D deficient patients with infections. This review details recent developments in understanding the role of vitamin D in immunity, the antibacterial actions of vitamin D, the association between vitamin D deficiency and common infections (like sepsis, pneumonia, influenza, methicillin-resistant Staphylococcus aureus, human immunodeficiency virus type-1 (HIV), and hepatitis C virus (HCV)), potential therapeutic implications for vitamin D replacement, and future research directions.

The economic burden of pneumonia and meningitis among children less than five years old in Hanoi, Vietnam.

OBJECTIVE: To estimate the average treatment costs of pneumonia and meningitis among children under five years of age in a tertiary hospital in Hanoi, Vietnam from societal, health sector and household perspectives. METHODS: We used a cost-of-illness approach to identify cost categories to be included for different perspectives. A prospective survey was conducted among eligible patients to get detailed personal costing items. RESULTS: From the perspective of the health sector, the mean costs for treating a case of pneumonia and meningitis were USD 180 and USD 300, respectively. From the household's perspective, the average treatment costs were USD 272 for pneumonia and USD 534 for meningitis. When also including indirect costs, the average total treatment costs from the societal perspective were USD 318 for pneumonia and USD 727 for meningitis. CONCLUSION: The study contributed to limited evidence on the high treatment costs of pneumonia and meningitis to the Vietnamese society, which is useful for a cost-effectiveness analysis of Haemophilus influenzae type b vaccine or other relevant disease preventions. It also indicated a need to re-evaluate the health insurance policy for children under 6 years old, so that the unnecessarily high out-of-pocket costs of these diseases are reduced.

Pneumocystis jirovecii colonisation in HIV-positive and HIV-negative subjects in Cameroon.

OBJECTIVE: To determine the prevalence of Pneumocystis pneumonia (PCP), a major opportunistic infection in AIDS patients in Europe and the USA, in Cameroon. MATERIALS AND METHODS: Induced sputum samples from 237 patients without pulmonary symptoms (126 HIV-positive and 111 HIV-negative outpatients) treated at a regional hospital in Cameroon were examined for the prevalence of Pneumocystis jirovecii by specific nested polymerase chain reaction (nPCR) and staining methods. CD4 counts and the history of antiretroviral therapy of the subjects were obtained through the ESOPE database system. RESULTS AND CONCLUSION: Seventy-five of 237 study participants (31.6%) were colonised with Pneumocystis, but none showed active PCP. The Pneumocystis colonisation rate in HIV-positive subjects was more than double that of HIV-negative subjects (42.9% vs. 18.9%, P < 0.001). In the HIV-positive group, the colonisation rate corresponds to the reduction in the CD4 lymphocyte counts. Subjects with CD4 counts >500 cells/µl were colonised at a rate of 20.0%, subjects with CD4 counts between 200 and 500 cells/µl of 42.5%, and subjects with CD4 counts <200 cells/µl of 57.1%. Colonisation with Pneumocystis in Cameroon seems to be comparable to rates found in Western Europe. Prophylactic and therapeutic measures against Pneumocystis should be taken into account in HIV care in western Africa.

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.

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.