Recommendations for treatment of childhood non-severe pneumonia

Abstract

WHO recommendations for early antimicrobial treatment of childhood pneumonia have been effective in reducing childhood mortality, but the last major revision was over 10 years ago. The emergence of antimicrobial resistance, new pneumonia pathogens, and new drugs have prompted WHO to assemble an international panel to review the literature on childhood pneumonia and to develop evidence-based recommendations for the empirical treatment of non-severe pneumonia among children managed by first-level health providers. Treatment should target the bacterial causes most likely to lead to severe disease, including Streptoccocus pneumoniae and Haemophilus influenzae. The best first-line agent is amoxicillin, given twice daily for 3-5 days, although co-trimoxazole may be an alternative in some settings. Treatment failure should be defined in a child who develops signs warranting immediate referral or who does not have a decrease in respiratory rate after 48-72 h of therapy. If failure occurs, and no indication for immediate referral exists, possible explanations for failure should be systematically determined, including non-adherence to therapy and alternative diagnoses. If failure of the first-line agent remains a possible explanation, suitable second-line agents include high-dose amoxicillin-clavulanic acid with or without an affordable macrolide for children over 3 years of age.

Figure 1

Absolute percentage difference in treatment failure among children with pneumonia treated with co-trimoxazole versus amoxicillin Analysis of two studies done in Pakistan and their pooled results given with 95% CIs. Straus et al showed a significant difference in the proportion of children with severe pneumonia who were treatment failures from 33% failing co-trimoxazole to 18% failing amoxicillin. The CATCHUP group showed 19% of children failing co-trimoxazole and 16% failing amoxicillin.

Figure 2

Example algorithm of how to systematically assess children aged >2 months and <5 years, initially diagnosed and treated with non-severe pneumonia and who returned for follow-up, in low HIV prevalence settings, based on the experience and recommendations of the panel This assessment is intended to supplement and not to replace the clinical judgment of the first-level health worker. If Integrated Management of Childhood Illness guidelines have been followed, the child should have been assessed for malnutrition and HIV in settings with high prevalence. This figure is offered only as an example of such an algorithm that can be developed.