title: Prevalence and correlates of treatment failure among Kenyan children hospitalised with severe community-acquired pneumonia: a prospective study of the clinical effectiveness of WHO pneumonia case management guidelines.
abstract: OBJECTIVE
  To determine the extent and pattern of treatment failure (TF) among children hospitalised with community-acquired pneumonia at a large tertiary hospital in Kenya.
  
  
  METHODS
  We followed up children aged 2-59 months with WHO-defined severe pneumonia (SP) and very severe pneumonia (VSP) for up to 5 days for TF using two definitions: (i) documentation of pre-defined clinical signs resulting in change of treatment (ii) primary clinician's decision to change treatment with or without documentation of the same pre-defined clinical signs.
  
  
  RESULTS
  We enrolled 385 children. The risk of TF varied between 1.8% (95% CI 0.4-5.1) and 12.4% (95% CI 7.9-18.4) for SP and 21.4% (95% CI 15.9-27) and 39.3% (95% CI 32.5-46.4) for VSP depending on the definition applied. Higher rates were associated with early changes in therapy by clinician in the absence of an obvious clinical rationale. Non-adherence to treatment guidelines was observed for 70/169 (41.4%) and 67/201 (33.3%) of children with SP and VSP, respectively. Among children with SP, adherence to treatment guidelines was associated with the presence of wheeze on initial assessment (P = 0.02), while clinician non-adherence to guideline-recommended treatments for VSP tended to occur in children with altered consciousness (P < 0.001). Using propensity score matching to account for imbalance in the distribution of baseline clinical characteristics among children with VSP revealed no difference in TF between those treated with the guideline-recommended regimen vs. more costly broad-spectrum alternatives [risk difference 0.37 (95% CI -0.84 to 0.51)].
  
  
  CONCLUSIONS
  Before revising current pneumonia case management guidelines, standardised definitions of TF and appropriate studies of treatment effectiveness of alternative regimens are required.
authors.affiliation: Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya; Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya.
authors.forename: Ambrose
authors.initials: A
authors.lastname: Agweyu
authors.forename: Minnie
authors.initials: M
authors.lastname: Kibore
authors.forename: Lina
authors.initials: L
authors.lastname: Digolo
authors.forename: Caroline
authors.initials: C
authors.lastname: Kosgei
authors.forename: Virginia
authors.initials: V
authors.lastname: Maina
authors.forename: Samson
authors.initials: S
authors.lastname: Mugane
authors.forename: Sarah
authors.initials: S
authors.lastname: Muma
authors.forename: John
authors.initials: J
authors.lastname: Wachira
authors.forename: Mary
authors.initials: M
authors.lastname: Waiyego
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Maleche-Obimbo
mesh_terms: D000658:Amoxicillin / Q000627:therapeutic use*; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D019090:Case Management / Q000458:organization & administration / Q000592:standards*; D002675:Child, Preschool; D017714:Community-Acquired Infections / Q000188:drug therapy / Q000453:epidemiology; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D017408:Guidelines as Topic; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007630:Kenya / Q000453:epidemiology; D008297:Male; D011014:Pneumonia / Q000188:drug therapy* / Q000453:epidemiology; D015995:Prevalence; D015397:Program Evaluation / Q000706:statistics & numerical data; D011446:Prospective Studies; D017211:Treatment Failure; D014944:World Health Organization
chemical_list: D000900:Anti-Bacterial Agents; D000658:Amoxicillin
keywords: Neumonía; Organisation Mondiale de la Santé; Organización Mundial de la Salud; World Health Organization; case management; fallo en el tratamiento; manejo de casos; pneumonia; pneumonie; prise en charge des cas; treatment failure; échec du traitement