Does 3-Day Course of Oral Amoxycillin Benefit Children of Non-Severe Pneumonia with Wheeze: A Multicentric Randomised Controlled Trial

WHO-defined pneumonias, treated with antibiotics, are responsible for a significant proportion of childhood morbidity and mortality in the developing countries. Since substantial proportion pneumonias have a viral etiology, where children are more likely to present with wheeze, there is a concern that currently antibiotics are being over-prescribed for it. Hence the current trial was conducted with the objective to show the therapeutic equivalence of two treatments (placebo and amoxycillin) for children presenting with non-severe pneumonia with wheeze, who have persistent fast breathing after nebulisation with salbutamol, and have normal chest radiograph.This multi-centric, randomised placebo controlled double blind clinical trial intended to investigate equivalent efficacy of placebo and amoxicillin and was conducted in ambulatory care settings in eight government hospitals in India. Participants were children aged 2-59 months of age, who received either oral amoxycillin (31-54 mg/Kg/day, in three divided doses for three days) or placebo, and standard bronchodilator therapy. Primary outcome was clinical failure on or before day- 4.We randomized 836 cases in placebo and 835 in amoxycillin group. Clinical failures occurred in 201 (24.0%) on placebo and 166 (19.9%) on amoxycillin (risk difference 4.2% in favour of antibiotic, 95% CI: 0.2 to 8.1). Adherence for both placebo and amoxycillin was >96% and 98.9% subjects were followed up on day- 4. Clinical failure was associated with (i) placebo treatment (adjusted OR = 1.28, 95% CI: 1.01 to1.62), (ii) excess respiratory rate of >10 breaths per minute (adjusted OR = 1.51, 95% CI: 1.19, 1.92), (iii) vomiting at enrolment (adjusted OR = 1.49, 95% CI: 1.13, 1.96), (iv) history of use of broncho-dilators (adjusted OR = 1.71, 95% CI: 1.30, 2.24) and (v) non-adherence (adjusted OR = 8.06, 95% CI: 4.36, 14.92).Treating children with non-severe pneumonia and wheeze with a placebo is not equivalent to treatment with oral amoxycillin.ClinicalTrials.gov NCT00407394

Characterization of hSAA1.1 and MetSAA1.1 by SDS-PAGE, SEC, far UV-CD, tryptophan fluorescence, and thermal denaturation studies.

<p>(A) SDS-PAGE gel (lanes: 1, protein ladder; 2, hSAA1.1; 3, MetSAA1.1 (B) SEC elution profiles of MetSAA1.1 (red solid line) and hSAA1.1 (blue solid line); (C) far UV-CD spectra of MetSAA1.1 (red solid line) and hSAA1.1 (blue solid line); (D) Thermal denaturation profiles of MetSAA1.1 (red solid line) and hSAA1.1 (blue solid line) (E) Tryptophan emission spectra of MetSAA1.1 (red solid line) and hSAA1.1 (blue solid line); (F) Tryptophan fluorescence-based thermal denaturation profiles of MetSAA1.1 (red solid line) and hSAA1.1 (blue solid line). The concentration of protein used in all the experiments was 20 µM. All experiments were performed at 4°C.</p

Biophysical characterization of aggregates formed by MetSAA1.1 and hSAA1.1.

<p>AFM analysis of (A) MetSAA1.1, 3 h, 37°C; (B) MetSAA1.1, 72 h, 37°C; (C) hSAA1.1, 3 h, 37°C; (D) hSAA1.1, 200 h, 37°C; Immunoblot analysis of aggregates formed by MetSAA1.1 using (E) A11 antibody and (F) OC antibody; Immunoblot analysis of aggregates formed by hSAA1.1 using (G) A11 antibody and (H) OC antibody. All scale bars for AFM images represent 1 µm.</p

Cartoon representing the proposed pathway for oligomerization and fibrillation of MetSAA1.1 and hSAA1.1.

<p>Figures are not drawn to scale.</p

Characterization of aggregation of MetSAA1.1 and hSAA1.1 by the ThT Fluorescence assay, Congo red binding assay, far UV CD, and solubility assay.

<p>(A) ThT fluorescence intensity profile for MetSAA1.1 (black bars) and hSAA1.1 (red bars); (B) Congo red absorbance spectra for Congo red only (blue solid line); Congo red plus MetSAA1.1 sample (red solid line); MetSAA1.1 difference spectra (red dash line); Congo red plus hSAA1.1 sample (black solid line); hSAA1.1 difference spectra (black dash line); (C) Far UV CD spectra of MetSAA1.1 samples incubated at 37°C for 6 h (red solid line), 24 h (blue solid line), and 72 h (green solid line); (D) Far UV CD spectra of hSAA1.1 samples incubated at 37°C for 6 h (red solid line), 24 h (blue solid line), and 72 h (green solid line); (E) solubility profile for MetSAA1.1 (black solid line) and hSAA1.1 (red solid line). The starting concentration of protein was 20 µM. All assays were performed after the proteins were allowed to aggregate at 37°C.</p

Characterization of “seeding” properties of MetSAA1.1 and hSAA1.1 by ThT fluorescence assay.

<p>(A) ThT fluorescence intensity profile for freshly refolded MetSAA1.1 only (black bars) and MetSAA1.1+ MetSAA1.1 “seed” (gray bars); (B) ThT fluorescence intensity profile for freshly refolded hSAA1.1 only (black bars) and hSAA1.1+ hSAA1.1 “seed” (gray bars). The concentration of protein was 20 µM. ThT fluorescence intensities were recorded by incubating the samples at 37°C.</p