Abstract:

Background: Despite recent advances in management and preventive strategies, high rates of first line antibiotics treatment failure and case fatality for SCAP continue to occur in children in low or middle income countries. The aim of this study is to identify the predictors of first line antibiotics treatment failure among children under-fives years of age with SCAP at BMC in Mwanza, Tanzania.

Methods: We conducted a prospective cross-sectional study involving children under five years of age (2-59 months) hospitalized at BMC with SCAP and treated with first line antibiotic treatment recommended by WHO guidelines (ampicillin and gentamycin). The primary outcome was first line antibiotics treatment failure at 48 hours. Patients with treatment failure were shifted to second line antibiotic treatment (ceftriaxone) and followed up for 7 days. Logistic regression analysis was performed to determine predictors of first line antibiotics treatment failure.

Results: A total 250 children with SCAP were enrolled during the study period, between October 2013 and February 2014. Of these, 145 (58.0%) were male, 144 (57.6%) were below 2 years, 70 (28.0%) had malnutrition, 21 (8.4%) had HIV infection and 202 (80.8%) were unable to breastfeed or drink. Of the 250 children with SCAP, 126 (50.4%) had first line antibiotics treatment failure. On the other hand, of the 158 children with severe pneumonia alone, 158 children with severe SCAP alone, 58 (36.7%) had first line antibiotics treatment failure. Predictors of first line treatment failure were; inability to breast feed, (OR 2.1; 95% CI [1.1 – 4.3]; p-value 0.026), convulsion (OR 3.7; 95% CI [1.1 – 12.3]; p-value 0.003], central cyanosis (OR 2.9; 95% CI [1.2 – 7.1]; p-value 0.015) and low oxygen saturation (OR 2.1; 95% CI [1.1 – 3.7]; p-value 0.016), HIV infection (OR 21.8; 95% CI [28 – 16.8]; p-value 0.003), moderate acute malnutrition (OR 2.7; 95% CI [1.1 – 6.5]; p-value 0.030) and severe acute malnutrition (OR 6.5; 95% CI [2.8 – 15.1]; p-value<0.001). Of note, out of 126 children who failed first line treatment, 6 (4.8%) died while on second line treatment. Others predictors of first line treatment failure of SCAP alone were: age below 2 years (OR 2.1[1.0 – 4.8]; p-value<0.045, respiratory distress (OR 2.3 [1.1 – 4.7); p-value<0.029, central cyanosis (OR 5.8 [2.0 – 16.7]; p-value 0.001 and abnormal chest X-ray (OR 2.2[1.1 – 4.6]; p-value 0.035

Conclusion: First line antibiotic treatment (ampicillin and gentamycin) first fail in half (50.4%) of children with SCAP and is independently predicted by inability to breast feed, convulsion, central cyanosis, respiratory distress, abnormal chest X-ray, low oxygen saturation, malnutrition and HIV infection. Clinicians should urgently institute second line treatment to all children with SCAP presented with one of these predictors in order to reduce associated morbidity and mortality.