Randomized Trial of Amoxicillin for Pneumonia in Pakistan

Jehan, Fyezah; Nisar, Imran; Kerai, Salima; Balouch, Benazir; Brown, Nick; Rahman, Najeeb; Rizvi, Arjumand; Shafiq, Yasir; Zaidi, Anita K. M.

doi:10.1056/nejmoa1911998

Cited by 40 publications

(38 citation statements)

References 24 publications

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“…A large number of children with viral-induced wheeze and/or viral bronchitis were also included using the WHO algorithm despite the addition of the bronchodilator challenge. This underscores that the WHO algorithm for clinical CAP, in our high-income setting, appears inappropriate for children immunized with PCV and would result in inappropriate antibiotic treatment [ 18 , 28 , 29 , 30 ]. In Sweden, the use of antibiotics is fairly restrictive and regulated, yet >20% of children with clinical CAP classified as viral etiology received antibiotic treatment in the study, indicating that there is still room for improvement for antimicrobial stewardship.…”

Section: Discussionmentioning

confidence: 99%

Etiology of Clinical Community-Acquired Pneumonia in Swedish Children Aged 1–59 Months with High Pneumococcal Vaccine Coverage—The TREND Study

et al. 2021

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(1) Immunization with pneumococcal conjugate vaccines has decreased the burden of community-acquired pneumonia (CAP) in children and likely led to a shift in CAP etiology. (2) The Trial of Respiratory infections in children for ENhanced Diagnostics (TREND) enrolled children 1-59 months with clinical CAP according to the World Health Organization (WHO) criteria at Sachs’ Children and Youth Hospital, Stockholm, Sweden. Children with rhonchi and indrawing underwent “bronchodilator challenge”. C-reactive protein and nasopharyngeal PCR detecting 20 respiratory pathogens, were collected from all children. Etiology was defined according to an a priori defined algorithm based on microbiological, biochemical, and radiological findings. (3) Of 327 enrolled children, 107 (32%) required hospitalization; 91 (28%) received antibiotic treatment; 77 (24%) had a chest X-ray performed; and 60 (18%) responded to bronchodilator challenge. 243 (74%) episodes were classified as viral, 11 (3%) as mixed viral-bacterial, five (2%) as bacterial, two (0.6%) as atypical bacterial and 66 (20%) as undetermined etiology. After exclusion of children responding to bronchodilator challenge, the proportion of bacterial and mixed viral-bacterial etiology was 1% and 4%, respectively. (4) The novel TREND etiology algorithm classified the majority of clinical CAP episodes as of viral etiology, whereas bacterial etiology was uncommon. Defining CAP in children <5 years is challenging, and the WHO definition of clinical CAP is not suitable for use in children immunized with pneumococcal conjugate vaccines.

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Section: Discussionmentioning

confidence: 99%

Etiology of Clinical Community-Acquired Pneumonia in Swedish Children Aged 1–59 Months with High Pneumococcal Vaccine Coverage—The TREND Study

et al. 2021

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“…7 A recently published among Pakistani children younger than 5 years of age with pneumonia with tachypnea randomized at amoxicillin vs placebo, the number of children with pneumonia and tachypnea who would have needed to be treated with amoxicillin to prevent one treatment failure was 44, suggesting that a significant number of CAP is of viral origin and does not requires antibiotic. 8…”

Section: Introductionmentioning

confidence: 99%

Role of Lung Ultrasound for the Etiological Diagnosis of Community- Acquired Pneumonia in Children: A Prospective Study

Buonsenso

Musolino

Ferro

et al. 2020

Preprint

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Objective and design: Our prospective study is one of the largest prospective study assessing the role of detailed lung ultrasound features to discriminate the etiological diagnosis of Community acquired pneumonia (CAP) in children. Methodology: We prospectively analysed patients aged from 1 month to 17 years admitted between March 2018 and April 2020 who were hospitalized for CAP. For all patients included in the study, history, clinical parameters, microbiological data, and lung ultrasound data were collected. Patients were stratified into three main groups (bacterial, viral, atypical) according to the presumed microbial aetiology and lung ultrasound findings evaluated according to the aetiological group. Results: We found that some ultrasound findings as size, number and distribution of consolidations, the position and motion of air bronchograms, pleural effusions and distribution of vertical artifacts significantly differ (p < 0.05) in children with bacterial, viral and atypical CAP. Conversely, clinical parameters and laboratory were not able to significantly distinguish between these groups. Chest x-ray, despite being still widely used, was the less useful tool in this discrimination. Conclusion: Our study provides a detailed analysis of LUS features able to predict the etiology CAP in children. These findings may help the physicians to better manage a child with CAP and to offer personalized approach, from diagnosis to treatment and follow-up. KEYWORDS: lung ultrasound, pneumonia, CAP, etiological diagnosis, children

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“…In children with severe clinical pneumonia and danger signs (e.g., dehydration or reduced level of consciousness), 5 days of intravenous antibiotic agents are recommended. In this issue of the Journal, two well-performed randomized, controlled trials challenge these recommendations in young children with nonsevere pneumonia: a trial by Jehan et al conducted in Pakistan (RETAPP, Randomized Trial of Amoxicillin versus Placebo for [Fast Breathing] Pneumonia) 2 and a trial by Ginsburg et al conducted in Malawi. 3 Both trials had a noninferiority design and were performed in lowincome communities in which pneumonia remains the leading cause of death in children younger than 5 years of age.…”

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confidence: 99%