Response to cotrimoxazole in the management of childhood pneumonia in first-level health care facilities.

BACKGROUND: Reports of high levels of antimicrobial resistance to cotrimoxazole in children with non-severe pneumonia (NSP) have prompted calls for a change to amoxicillin in the therapeutic guidelines at the first-level health care facility (FLHF). FLHFs lack data about the use of World Health Organization (WHO) acute respiratory infection (ARI) standard case management (SCM). OBJECTIVE: To apply ARI SCM guidelines at the FLHF, assess clinical outcome of NSP with oral cotrimoxazole and determine the risk factors influencing treatment outcome. DESIGN: Health care workers (HCWs) at 14 health centres managed children aged 2-59 months with NSP according to ARI SCM guidelines. The primary outcome was treatment failure, including change of antibiotic therapy and loss to follow-up. RESULTS: Of 949 children enrolled, 110 (11.6%) failed therapy with oral cotrimoxazole. Clinical failure was significantly higher among children presenting with a fast respiratory rate of > or = 15 breaths/min above normal for age and wheezing on examination. CONCLUSIONS: To treat children with NSP at the FLHF, oral cotrimoxazole is an acceptable treatment choice in view of the efficacy, cost and ease of use. In children with wheezing and signs of pneumonia, the decision to use antibiotic therapy should be made after a trial of bronchodilator therapy.

Standard management of acute respiratory infections in a children's hospital in Pakistan: impact on antibiotic use and case fatality.

Acute respiratory infections (ARI) are a leading cause of childhood morbidity and mortality in Pakistan. The National ARI Control Programme was launched in 1989 in order to reduce the mortality attributed to pneumonia, and rationalize the use of drugs in the management of patients with ARI. WHO's standard ARI case management guidelines were adopted to achieve these objectives. The medical staff at the Children's Hospital, Islamabad, were trained in such management in early 1990; further training sessions were conducted when new staff arrived. Data on outpatients were obtained from special ARI abstract registers, which have been maintained in the outpatient department since January 1990. Details on inpatients who were admitted with ARI were obtained from hospital registers. During the period 1989-92, the use of antibiotics in the outpatient department decreased from 54.6% to 22.9% (P < 0.0001). The case fatality rate (CFR) in children admitted with ARI fell from 9.9% to 4.9% (P < 0.0001), while the overall case fatality rate fell from 8.7% to 6.2%. Our results from a tertiary health care facility show that standard ARI case management reduced both antibiotic use and expenditure on drugs. Although the ARI case management criteria, which are more sensitive than the conventional diagnostic criteria of auscultation and radiography, led to more admissions, we believe that this strategy contributed to a significant reduction in the ARI case fatality rate.

PIP: Acute respiratory infection (ARI) is the leading cause of death among children in Pakistan. The Government's National ARI Control Program seeks to reduce pneumonia-related mortality in children under 5 years, standardize clinical assessment, and rationalize the use of drugs in case management. To assess the impact of this protocol on ARI case fatalities and antibiotic use, the registries of ARI patients presenting to Children's Hospital in Islamabad in 1989-92 were reviewed. Staff training in ARI case management was initiated in 1990. ARI admissions more than doubled from 776 in 1989 to 1673 in 1992. Many children admitted in 1990-92 would not have been admitted if the 1989 criteria, based on clinical auscultation and radiologic diagnosis, had been followed. Use of antibiotics decreased significantly from 54.6% of ARI outpatient cases in 1989 to 30.2% in 1992 as a result of no longer providing medication to children with viral ARI. The case fatality rate for all hospital admissions decreased by 28% during the study period (from 8.7% in 1989 to 6.2% in 1992), while that for ARI decreased by 50.5% (from 9.9% to 4.9%). The elimination of inappropriate antibiotic therapy associated with this protocol has the potential to save RS 39.8 million (US$1.2 million) from Pakistan's public health budget each year as well as to reduce both ARI and overall child mortality.

ARI concepts of mothers in Punjabi villages: a community-based study.

Pneumonia is a major child killer in the developing world; to prevent such deaths, mothers must be able to differentiate pneumonia from common cold. Local concepts regarding these illnesses were studied by interviewing 315 mothers of young children in their homes in Punjabi villages. Mothers described pneumonia differently from cough-and-cold but only a few volunteered fast breathing as a sign of pneumonia. Both illnesses were thought to be caused by "coldness," and were initially treated with "heat-producing" home remedies and feeding was continued in both. Spiritual healers were not consulted for cough-and-cold or pneumonia. Virtually all mothers said that allopathic medicines were necessary for both illnesses and 2/3rd said that if a child did not improve after 2 days of a given medicine, they would change the medicine and/or the doctor.

A community study of the application of WHO ARI management guidelines in Pakistan.

During a community-based study in four rural villages in Pakistan, 617 cases of acute respiratory infections (ARI) in children younger than 5 years of age were assessed, classified and managed according to the WHO ARI case management guidelines. Of these, 509 (82.5%) had 'cough and cold' without clinical evidence of pneumonia, 95 pneumonia, two severe pneumonia and 11 otitis media. Of the 509 without clinical evidence of pneumonia but with cough and cold, 491 (96.5%) were successfully treated without antibiotics and only 18 (3.5%) of these children needed antimicrobial therapy on follow-up. Of the 95 cases of pneumonia, 87 (91.4%) showed a satisfactory clinical response to oral cotrimoxazole and only eight (8.4%) required a change of antibiotic.

The Rett syndrome: the first case report from Pakistan.

We report an 11-yr-old girl who visited the outpatient department of Islamabad Children's Hospital with uncontrolled seizures, psychomotor retardation and hand washing movements since early childhood. She had an uneventful peri- and neonatal history with a normal head size at birth and fulfilled the criteria of classic Rett syndrome. This is the first report of the Rett syndrome in Pakistan.

Halofantrine hydrochloride--efficacy and safety in children with acute malaria.

Thirty two children with symptomatic malaria due to P. vivax and P. Falciparum infections were treated with three doses of Halofantrine hydrochloride 8 mg/kg body weight every 6 hours. Mean fever clearance was 30 hours (range 24-48 hours). No significant clinical or biochemical side effects were observed. Symptoms cleared rapidly. Halofantrine hydrochloride was found to be highly effective and appeared to have no side effects in children with acute malaria infections.