Improving antibiotic and bronchodilator prescription in children presenting with difficult breathing: experience from an urban hospital in India.
OBJECTIVE
To evaluate the relative frequency of other conditions that share a clinical overlap with pneumonia as defined by the WHO case management algorithm and to determine the possibility of refining the antibiotic and bronchodilator prescription on the basis of simple clinical features.


METHODS
Prospective observational.


METHODS
Urban tertiary care center.


METHODS
Two hundred children, between the ages of 6 months to 5 years, presenting with difficult breathing (as defined by WHO algorithm) were prospectively evaluated for the diagnosis and the need for bronchodilator and antibiotic therapy (clinician s diagnosis). An additional independent blinded evaluation of the chest X-rays was done by a radiologist after the study (radiologist-aided diagnosis). On the basis of reliable predictors (sensitivity > 70% and specificity > 70%) of antibiotic and bronchodilator prescription, irrespective of the exact diagnostic category, two viable modifications of WHO case management algorithm emerged, which were compared by paired proportion test.


RESULTS
Acute asthma was the predominant condition (46% or 54%), pneumonia alone was rare (10%), co-existence of pneumonia with wheeze (bronchospasm) was more frequent (22% or 15%) and often diagnoses not related to the respiratory system were documented (18% or 17%). All the subjects in whom a preceding history of cough was not elicited had non-respiratory illnesses. An audible wheeze was appreciated in only 44 of the 150 cases (29.3%) with an auscultable wheeze. The two alternatives represented a significant (p < 0.0001) improvement over the WHO algorithm preventing inappropriate usage of both antibiotics and bronchodilators, primarily by restricting over-prescription of the former (14% and 26.5% for proposed algorithms 1 and 2, respectively) and under-utilization of the latter (40%). The performance of the alternative algorithms for the radiologist-aided diagnosis was marginally better for over-prescription of antibiotics (16.2% and 30.9% for proposed algorithms 1 and 2, respectively).


CONCLUSIONS
It is feasible to amalgamate simple clinical features (history of: (i) previous similar episode of cough and difficult breathing, and (ii) fever) in the WHO case management algorithm to significantly refine the antibiotic (95% CI range 7% to 33%) and bronchodilator (35%; 95% CI 27% to 43%) prescription.
Sachdev
H P
HP
Department of Pediatrics, Maulana Azad Medical College, New Delhi 110 002, India. drhpssachdev@yahoo.com
Mahajan
S C
SC
Garg
A
A
D000465:Algorithms; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D001993:Bronchodilator Agents / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D003906:Developing Countries; D003937:Diagnosis, Differential; D004417:Dyspnea / Q000188:drug therapy* / Q000209:etiology; D004636:Emergency Service, Hospital; D005260:Female; D006786:Hospitals, Urban; D006801:Humans; D007194:India; D007223:Infant; D008297:Male; D018410:Pneumonia, Bacterial / Q000175:diagnosis / Q000188:drug therapy*; D012135:Respiratory Sounds / Q000209:etiology*; D014505:Urban Population
D000900:Anti-Bacterial Agents; D001993:Bronchodilator Agents