A retrospective study was carried out between]anuary 1990 to December 1992. One hundred and sixty patients were admitted with acute pneumonia to Trinity Hospital, a mission hospital in the South of Malawi, and the response to penicillin was evaluated. 31 % of the patients did not respond to penicillin and needed a broad spectrum antibiotic to be cured

Damoiseaux, RAMJ

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Malawi Medical Joumal. January 1994. Vol. 10. No 1 13 Acute Pneumonia In Adults: A Retrospective Clinical Study On The Response To Penicillin In Malawi RAM] Damoiseaux ABSTRACT: A retrospective study was carried out between]anuary 1990 to December 1992. One hundred and sixty patients were admitted with acute pneumonia to Trinity Hospital, a mission hospital in the South of Malawi, and the re-sponse to penicillin was evaluated. 31 % of the patients did not respond to penicillin and needed a broad spec-trum antibiotic to be cured. INTRODUCTION Pneumonia is a common reason for hospital admission and a major cause of death in Malawi and in tropical Africa as a whole1•2 • The most common aetiological agent is Streptococcus pneumonia!l-7. Other frequent causative organisms to be considered are Haemophilus influenzaes and Mycoplasma pneumonia6, In HIV-posi-tive patients the same pattern is seen. Pneumocystis Winii. pneumonia occasionally occurs in these patients in Africa, but with much less frequency compared with Europe and North Americas. Parenteral penicillin is commonly recommended as the first treatment of choice2.s.5.7.9. However, 10% or more of patients with acute pneumonia do not respond to penicillin2.S·5. Chloramphenicol or doxycycline are rec-ommended as second line drugs9.IO• This study was un-dertaken to determine the response to penicillin in acute pneumonia in a rural area in Malawi. PATIENTS AND METHODS The study was carried out in Trinity Hospital, a 200 bed mission hospital in the Lower Shire Valley in Malawi. A retrospective review was made of case notes of all adult patients admitted under the care of the author with acute pneumonia between]anuary 1990 and December 1992. The diagnosis of acute pneumonia was made on clinical grounds. Criteria required for the diagnosis were either an auscultatory finding of bronchial breath-ing or fine inspiratory crepitations, together with at least two of the following: 1. history of cough of recent onset; 2. history of/or clinically detectable fever (38 0 C); 3. history of pleuritic chest pain. The following patients were excluded: those with chronic cough (more than 2 weeks), tuberculosis (sputum positive and sputum nega-tive), chronic lung disease, cardiac disease and patients with pleural effusions. On admission to hospital, a history was taken and a physical examination performed. Haemoglobin was rou-tinely measured. A HIV-test was done only when a pa-Trinity Hospital, Lower Shire, Malawi. Correspondence to : Dr RAM] Damoiseaux tient showed symptoms of AIDS related complex (ARC) or AIDS. All patients were initially treated with ben-zylpenicillin 1 mega unit every 6 hours for 24 hours followed by procaine benzylpenicillin 900,000 units every 12 hours for 6 days. All patients routinely received anti-malarial chemotherapy. Treatment was given in hospital. Patients were reviewed twice a week anct treatment was changed to a broadspectrum antibiotic if there was no clinical improvement after a minimum of 72 hours on penicillin. Criteria for no improvement were: l. persist-ent fever; 2. persistent crepitations and/or bronchial breathing; 3. persistent chest pain; 4. persistent cough. (one or a combination of these criteria). Statistical analysis was carried out with the X2-test. RESULTS One hundred and eighty four patients with acute pneu-monia were admitted during the study period. Twenty-four of these patients were excluded because treatment was started with an antibiotic other than penicillin. The remain-ing 160 patients were included in the study. The average age of the patients was 36 years (range 13-70 years) and 65% were female. The main present-ing symptoms and signs are in Table 1. Haemoglobin was less than 10 gldl in 62% of patients (n=149). A HIV-test was carried out on 18 patients and 13 were HIV-seropositive. Table 1. Main presenting symptoms and signs in 160 patients with acute pneumonia. Symptoms Recent cough Chest Pain Fevel' Tachypnoea (30 rpm) Crepit.,tions Bronchial Breathing No(%) 144 (90) 134 (84) 121 (76) 91 (57) 153 (96) 49 (31) There were two deaths in the whole group, both of the palienls being HIV-seropositive. Fifty patients (31 %) did not respond to penicillin, and treatment was changed after a mean period of 5 days on penicillin. Thirty-eight of these received chlorampheni-col, 7 ampicillin and 5 co-trimoxazole. The reasons for changing to a broadspectrum antibiotic are given in Table 2. Thirty-five patients in this group (70%) had 2 or more reasons for changing treatment. No penicillin hypersen-sitivily reactions were observed. Six of the patients who were HIV-seropositive did not respond to penicillin, and two of these six patients died. Mean duration of hospital stay for the whole group was 9 days. Mean duration of hospital stay for patients who did not respond to penicillin and who needed another antibiotic was 14 days. Reproduced  by Sabinet Gateway under licence granted by the Publisher ( dated 2012)14 DISCUSSION This study shows that a high proportion of patients (31%) failed to respond to penicillin, and this is signifi-cantly different compared with other hospital based stud-ies (10%) (p, X2 - test)2.!.!i. In this study there was a higher proportion of female fatients (65%) compared with other studies (25%)u.!i .. However, there was no signifi-cant difference between the percentage of non respond-ers to penicillin in female (30%) and male (32%) patients (pO.I,X2-test), so the difference in sex-ratio did not influ-ence the results. It is suggested that a change of antibiotic treatment in acute pneumonia be considered after 48 h 'f th . cl"cal . 9 10 th th ours I ere IS no 1m Improvement', so e me -odological guidelines followed in thi~ study were appro-priate. The majority of those failing to respond to penicillin (70%) had at least 2 clinical signs of persisting infection, and this further justifies the change in antibi-otic treatment. There was no significant difference in the response to penicillin in the patients with ARC or AIDS compared with the other patients (pO. I, X2-test) The reasons for penicillin failure remain speculative. Apart from the two deaths, all non-responders had good results with chloramphenicol, ampicillin or co-trimoxa-zole. Further research should be carried out to deter-mine the reasons for penicillin failure. CONCLUSION The majority of adults with acute pneumonia can still be treated with penicillin. However the results of this study demonstrate that Sl% of patients admitted to our hospital do not respond to pel1icillin. This is a higher percentage compared with reports from other countries in Southern Mrica, and this places a question mark over the belief that penicillin is the drug of first choice. Malawi Medical Journal. January 1994. Vol. 10. No 1 Table 2. Reasons/ora change to broad spectrum antibiotics in 50 patUmts with acute pneumonia not responding to peniciUin Reason Persistent Crepitations and Consolidation Persistent Cough Persistent Fever Persistent Chest Pain REFERENCD No(%) 48 (96) 25 (50) 20 (40) 15 (30) 1. Harriel AD. Medical dilease patterns an analysis of medical admis-lions to Kamuzu Central Hospital. In Wirima J J. Common medical problems in Malawi. Lilongwe MOH, 1988: 17S 2. Allen SC. Lobar pneumonia in Northern Zambia: clinical study of 502 adult patients. TI10rax 1984; S9: 612-616 S. Douglal II M, Devitt K. Pneumonia in New Guinea: Bacteriological findings in 6S2 adults with panicular reference to Haemophilus inOuenzae. Med.J. Australia 1975; 1: 42-49 4. Tugwell p, Greenwood BM. Pneumococcal antigen in lobar pneu-monia. J.c1in.Path. 1975; 28: 118-12S 5. Slack RBC, StewartJD, Lewil CLH et al. Acute pneumonia in adults in Nairobi. Ease African Med.J. 1976; 5S: 48-48S 6. Macfar1aneJT, Adegboye D S, Warrell MJ. Mycoplasma pneumonia and the aetiology of lobal' pneumonia in Northern Nigeria. Thoro: 1979; S4: 7150719 7. Walill A, Corrah PT, Mabey DCW, Greenwood BM. The etiology of lobar pneumonia in the Gambia. Bulletin WHO 1986; 64: 5550558 8. McLeod DT, Neil P, Robertson V Jet al. Pulmonary diseases in patients infected with the human immunodeficiency virus in ~imbabwe, Central Afl'ica. Trans. R. Soc, Trop. Med. Hyg. 1989; 83: 694-697 9. Harries AD, Beeching NJ. Pneulllonia in adults: a guide to diagnosis and management in the district hospital. Tropical Doctor 1991; 21: 9-13 10. Enenkel S, Stille W. Antibiotics in the Tropics. Frankfurt/Main Springer Verlag 1988. Reproduced  by Sabinet Gateway under licence granted by the Publisher ( dated 2012)

Acute pneumonia in adults: a retrospective clinical study on the response to penicillin in Malawi

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Acute pneumonia in adults: a retrospective clinical study on the response to penicillin in Malawi

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