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

Abstract

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.