title: Non-treatment of children with community health worker-diagnosed fast-breathing pneumonia in rural Malawi: exploratory subanalysis of a prospective cohort study.
abstract: Despite recent progress, pneumonia remains the largest infectious killer of children globally. This paper describes outcomes of not treating community-diagnosed fast-breathing pneumonia on patient recovery.
  
  
  
  We conducted an exploratory subanalysis of an observational prospective cohort study in Malawi. We recruited children (2-59 months) diagnosed by community health workers with fast-breathing pneumonia using WHO integrated community case management (iCCM) guidelines. Children were followed at days 5 and 14 with a clinical assessment of recovery. We conducted bivariate and multivariable logistic regression for the association between treatment of fast-breathing pneumonia and recovery, adjusting for potential confounders.
  
  
  
  We followed up 847 children, of whom 78 (9%) had not been given antibiotics (non-treatment). Non-treatment cases had higher baseline rates of diarrhoea, non-severe hypoxaemia and fever. Non-recovery (persistence or worsening of symptoms) was 13% and 23% at day 5 in those who did receive and those who did not receive co-trimoxazole. Non-recovery, when defined as worsening of symptoms only, at day 5 was 7% in treatment and 10% in non-treatment cases. For both definitions, combined co-trimoxazole and lumefantrine-artemether (LA) treatment trended towards protection (adjusted OR (aOR) 0.28; 95% CI 0.12 to 0.68/aOR 0.29; 95% CI 0.08 to 1.01).
  
  
  
  We found that children who did not receive co-trimoxazole treatment had worse clinical outcomes; malaria co-diagnosis and treatment also play a significant role in non-recovery. Further research into non-treatment of fast-breathing pneumonia, using a pragmatic approach with consideration for malaria co-diagnosis and HIV status is needed to guide refinement of community treatment algorithms in this region.
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Carina
authors.identifier: 0000-0002-6885-6716
authors.initials: C
authors.lastname: King
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Tim
authors.identifier: 0000-0002-6917-6552
authors.initials: T
authors.lastname: Colbourn
authors.affiliation: Parent and Child Health Initiative, Lilongwe, Malawi.
authors.forename: Limangeni
authors.initials: L
authors.lastname: Mankhambo
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: James
authors.initials: J
authors.lastname: Beard
authors.affiliation: Kimataifa Diagnostics & Devices Consulting LLC, Seattle, Washington, USA.
authors.forename: Debbie C
authors.initials: DC
authors.lastname: Hay Burgess
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Anthony
authors.initials: A
authors.lastname: Costello
authors.affiliation: Bill & Melinda Gates Foundation, Seattle, Washington, USA.
authors.forename: Rasa
authors.initials: R
authors.lastname: Izadnegahdar
authors.affiliation: Acute Respiratory Infection Unit, Ministry of Health, Lilongwe, Malawi.
authors.forename: Norman
authors.initials: N
authors.lastname: Lufesi
authors.affiliation: Parent and Child Health Initiative, Lilongwe, Malawi.|Ministry of Health, Lilongwe, Malawi.
authors.forename: Charles
authors.initials: C
authors.lastname: Mwansambo
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Bejoy
authors.initials: B
authors.lastname: Nambiar
authors.affiliation: Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA.
authors.forename: Eric S
authors.initials: ES
authors.lastname: Johnson
authors.affiliation: McGill University, Montreal, Quebec, Canada.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Platt
authors.affiliation: Science and Health Impact Group (SHI), Kampala, Uganda.
authors.forename: David
authors.initials: D
authors.lastname: Mukanga
authors.affiliation: Institute for Global Health, University College London, London, UK.|Division of Pulmonology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
authors.forename: Eric D
authors.initials: ED
authors.lastname: McCollum
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002675:Child, Preschool; D060085:Coinfection; D003153:Community Health Services; D005260:Female; D006801:Humans; D007223:Infant; D016015:Logistic Models; D008288:Malaria / Q000188:drug therapy; D008295:Malawi; D008297:Male; D015999:Multivariate Analysis; D011014:Pneumonia / Q000188:drug therapy*; D011446:Prospective Studies; D012424:Rural Population; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use*; D028761:Withholding Treatment / Q000706:statistics & numerical data*
chemical_list: D000900:Anti-Bacterial Agents; D015662:Trimethoprim, Sulfamethoxazole Drug Combination
keywords: fast-breathing pneumonia; iCCM; non-treatment; sub-Saharan Africa; treatment failure