Treatment practices and outcomes of chest indrawing pneumonia in children aged 2–59 months in primary health facilities of Kamuli District, Eastern Uganda

TL;DR

This study shows that young children with chest indrawing pneumonia in Uganda can be effectively treated at home with oral antibiotics, with most recovering well.

Contribution

The study provides real-world evidence supporting the WHO's revised pneumonia guidelines for home-based oral antibiotic treatment in children.

Findings

Most children (95.2%) were cured after 15 days of treatment with oral amoxicillin.

Severe malnutrition increased the risk of hospitalization fourfold.

A longer duration of amoxicillin treatment reduced hospitalization risk by 66%.

Abstract

The World Health Organization revised its pneumonia guideline for managing children with chest indrawing and/or fast breathing, classifying them as 'pneumonia' and treating them with oral antibiotics at home; the Integrated Management of Childhood Illness (IMCI) protocol was revised accordingly. Evidence is needed on outcomes and treatment practices with the application of revised guidelines in programme settings.

This prospective observational cohort study was conducted in seven selected health centres in Uganda from November 2022 to May 2023. The IMCI-trained health workers identified and enrolled children aged 2–59 months presenting with cough and/or difficult breathing and chest indrawing without any general danger signs. The primary outcome was vital status at day 15 after the initial assessment. Secondary outcomes were prevalence of and adherence to antibiotic use, and hospitalisation. Enrolled children were given age-appropriate treatment.

Of the 316 children who were enrolled, 68.4% (n/N = 216/316) were aged 12–59 months, and 93.7% (n/N = 296/316) had comorbidities, primarily malaria and diarrhoea. All were prescribed oral amoxicillin. Two children were lost to follow-up; thus, we followed 314 children on day 15. In children aged 2–11 months, 93.9% (n/N = 93/99) received a correct prescription compared to 20% (n/N = 43/215) among 12–59-month-olds. Adherence to five days of treatment was reported for 64.3% (n/N = 202/314) of children. According to the mothers' self report, no deaths were reported, 95.2% (n/N = 299/314) were cured; 2.2% (n/N = 7/314) were worse with six of seven hospitalised, and 2.5% (n/N = 8/314) were the same as the condition at time of enrolment. Most children were well-nourished; 3.8% had a weight-for-height (WHZ) z-score<−3, 6.7% had a weight-for-age (WAZ) z-score<−3, and 0.3% had a mid-upper arm circumference (MUAC)<115 mm. At follow-up on day 15, of 16 children hospitalised at any time after enrolment, 10 (62.5%) had recovered and were discharged, while six (37.5%) were still hospitalised. The presence of any severe malnutrition was associated with a 4-fold increased risk of hospitalisation. In contrast, a longer duration of oral amoxicillin treatment was associated with a 66% decrease in risk of hospitalisation during the follow-up period.

Children aged 2–59 months with chest indrawing pneumonia without danger signs can be successfully managed at home with a five-day course of oral amoxicillin, highlighting the importance of the new policy and approach.

ISRCTN12687253.