title: Use of antibiotics within the IMCI guidelines in outpatient settings in Papua New Guinean children: an observational and effectiveness study.
abstract: BACKGROUND
  There is a need to investigate the effectiveness and appropriateness of antibiotics prescription within the Integrated Management of Childhood Illness (IMCI) strategy in the context of routine outpatient clinics.
  
  
  METHODS
  Making use of a passive case detection system established for a malaria prevention trial in outpatient clinics in Papua New Guinea, the appropriateness and effectiveness of the use of antibiotics within the IMCI was assessed in 1605 young children. Main outcomes were prescription of antibiotics and re-attendances within 14 days for mild pneumonia, mild diarrhoea and uncomplicated malaria whether they were managed with or without antibiotics (proxy of effectiveness). Appropriateness was assessed for both mild and severe cases, while effectiveness was assessed only for mild diseases.
  
  
  RESULTS
  A total of 6975 illness episodes out of 8944 fulfilled inclusion criteria (no previous attendance <14 days+full medical records). Clinical incidence rates (episodes/child/year; 95% CI) were 0.85 (0.81-0.90) for pneumonia, 0.62 (0.58-0.66) for malaria and 0.72 (0.65-0.93) for diarrhoea. Fifty three percent of 6975 sick children were treated with antibiotics, 11% were not treated with antibiotics when they should have been and in 29% antibiotics were prescribed when they should not have been. Re-attendance rates within 14 days following clinical diagnosis of mild pneumonia were 9% (126/1401) when managed with antibiotics compared to 8% (56/701) when managed without (adjusted Hazard Ratio (aHR) = 1.00 (0.57-1.76), p = 0.98). Rates for mild diarrhoea were 8% (73/874) and 9% (79/866) respectively (aHR = 0.8 (0.42-1.57), p = 0.53).
  
  
  CONCLUSIONS
  Non-adherence to IMCI recommendations for prescription of antibiotics is common in routine settings in Papua New Guinea. Although recommended, the use of antibiotics in young children with mild pneumonia as defined by IMCI criteria did not impact on their outcome. Better tools and new strategies for the identification of bacterial infections that require antibiotics are urgently needed.
authors.affiliation: Vector Born Unit, PNG Institute of Medical Research, Madang (MAD), Papua New Guinea; Health Intervention Unit, Swiss Tropical and Public Health Institute, Basel (BS), Switzerland; University of Basel, Basel (BS), Switzerland; Department of Medicine, University of Melbourne, Melbourne, Australia.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Senn
authors.affiliation: Vector Born Unit, PNG Institute of Medical Research, Madang (MAD), Papua New Guinea.
authors.forename: Patricia
authors.initials: P
authors.lastname: Rarau
authors.affiliation: Vector Born Unit, PNG Institute of Medical Research, Madang (MAD), Papua New Guinea.
authors.forename: Mary
authors.initials: M
authors.lastname: Salib
authors.affiliation: Vector Born Unit, PNG Institute of Medical Research, Madang (MAD), Papua New Guinea.
authors.forename: Doris
authors.initials: D
authors.lastname: Manong
authors.affiliation: Vector Born Unit, PNG Institute of Medical Research, Madang (MAD), Papua New Guinea.
authors.forename: Peter
authors.initials: P
authors.lastname: Siba
authors.affiliation: Department of Medicine, University of Melbourne, Melbourne, Australia.
authors.forename: Stephen
authors.initials: S
authors.lastname: Rogerson
authors.affiliation: Vector Born Unit, PNG Institute of Medical Research, Madang (MAD), Papua New Guinea; Dept. of Infections & Immunity, Walter & Eliza Hall Institute of Medical Research, Melbourne, Australia; Centre de Recerca en Salut Internacional de Barcelona (CRESIB), Barcelona, Spain.
authors.forename: Ivo
authors.initials: I
authors.lastname: Mueller
authors.affiliation: Health Intervention Unit, Swiss Tropical and Public Health Institute, Basel (BS), Switzerland; University of Basel, Basel (BS), Switzerland.
authors.forename: Blaise
authors.initials: B
authors.lastname: Genton
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002675:Child, Preschool; D003967:Diarrhea / Q000188:drug therapy / Q000453:epidemiology; D019983:Guideline Adherence; D006801:Humans; D057970:Inappropriate Prescribing / Q000706:statistics & numerical data*; D015994:Incidence; D007223:Infant; D008288:Malaria / Q000188:drug therapy / Q000453:epidemiology / Q000517:prevention & control*; D017063:Outcome Assessment, Health Care; D010045:Outpatients; D010219:Papua New Guinea; D011014:Pneumonia / Q000188:drug therapy / Q000453:epidemiology; D017410:Practice Guidelines as Topic; D015397:Program Evaluation
chemical_list: D000900:Anti-Bacterial Agents