Bhutta, Zulfiqar A.

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EDITORIALSINDIAN  PEDIATRICS 538 VOLUME 45__JULY 17, 2008Pneumonia is now widely regarded as the dominantcause of child mortality in the developing worldwith over 150 million cases and almost 2.4 milliondeaths annually(1). Although there are remarkableadvances in preventive strategies including nutritioninterventions such as promotion of exclusive breast-feeding, environmental control such as reduction ofindoor air pollution and newer effective vaccines(2),antibiotic therapy remains the mainstay of manage-ment and treatment strategies(3).In this issue of Indian Pediatrics, Zhang, et al.(4)from the University of Rio Grande (Brazil) presenttheir evaluation of empiric antibiotic therapy basedon a retrospective evaluation of data from acohort of children (29 d - 12 yr of age) admitted withcommunity acquired pneumonia between 1991-2001.  Notwithstanding the relatively higher rates oftreatment failure observed from 1999-2001, theoverall treatment success rates were close to 95%,suggesting that their strategy of empiric therapyworked. However, these findings are difficult tointerpret and extrapolate to community settings, aspopulation denominators and cause specificmortality rates are not provided. Only 4% of caseswith either pleural effusion or more severe diseasehad cultures obtained and the relatively high rates ofpositive cultures (61%) in this group do suggest thatthese represented a subgroup of relatively severedisease. The choice of antibiotics and reasons fortherapeutic changes are also unclearly defined,indicating that a variety of management protocols, ifany, were in place over this time. It is thereforeunclear if the empiric therapy protocols wereinfluenced by adequate knowledge of the back-ground rates of antimicrobial resistance, other casemanagement strategies or therapeutic recommenda-tions in Rio Grande over this period of time. Asindicated by Graham, et al.(5), the greatest potentialfor reducing pneumonia-related deaths in healthfacilities is wider implementation of the currentTreating Childhood Pneumonia Empirically: Several Issues Still Remain!ZULFIQAR A BHUTTAHusein Lalji Dewraj Professor & Chairman, Department of Paediatrics & Child Health,The Aga Khan University, Karachi, Pakistan.E mail: zulfiqar.bhutta@aku.eduguidelines built around a few core activities such astraining of healthcare providers, appropriateantibiotics and availability of oxygen.Given the difficulties in obtaining appropriatemicrobiological information in a timely manneramong children with community-acquired pneu-monia, it is imperative that the choice of empiricalantibiotics is based on sound knowledge of commonbacterial pathogens and sensitivities in the region.There is strong evidence of emerging resistanceamong common organisms causing pneumonia froma variety of community settings(6,7), and theseshould inform policy for the choice of empiricaltherapy. In areas with special problems such asresistance of common respiratory bacterialpathogens such as Streptoccoccus pneumoniae andHemophilus influenzae to first line antibiotics(8) andemergence of methicillin-resistant Staphylococcusinfections(9) in community settings, antibioticchoices must be based on available local data.This approach does require adequate availabilityof surveillance information as well as systematiccollection of local and regional microbiologicalinformation. The fact that our current clinical criteriafor the diagnosis of pneumonia may also include asubstantial proportion with non-bacterial lowerrespiratory infections, criteria for recognizing andinstituting empirical antibiotic therapy must bedeveloped carefully and periodically reviewed.However, once developed, such evidence-basedprotocols for the recognition and treatment ofchildhood pneumonia must be implemented at scalein close coordination between community-basedoutreach services as well as referral facilities. Dataand facility-based case series such as the onereported by Zhang, et al.(4) are an extremelyimportant step in this direction and must be coupledwith triangulation from additional health systeminformation including periodic microbiologicalINDIAN  PEDIATRICS 539 VOLUME 45__JULY 17, 2008EDITORIALSsurveillance. This must lead to a careful strategy ofavoiding large scale carte blanche administration ofantibiotics on empirical grounds while ensuring thatthere is no inordinate delay in instituting appropriatetreatment. This balancing of "access and excess" iskey in ensuring that we save lives today and alsoavoid the specter of multi-drug resistant infectionstomorrow(10).Funding: None.Competing interests: None stated.REFERENCES1. World Health Organization. Global Action Plan forthe Prevention and Control of Pneumonia (GAPP).Report of an informal consultation, La Mainaz, Gex,France: March 5-7, 2007.2. Mulholland EK, Smith L, Carneiro I, Becher H,Lehmann D. Equity and child survival strate-gies. Bull World Health Organ 2008; 86: 399-407.3. Bhutta ZA. Managing severe pneumonia indeveloping countries. BMJ 2008; 336: 57-58.4. Zhang L, Lovatel R, Nicolete D, Sinzkel E, MatielloJ, Staszko K, et al. Empiric antibiotic therapy inchildren with community-acquired pneumonia.Indian Pediatr 2008; 45: 554-558.5. Graham SM, English M, Hazir T, Enarson P,Duke T. Challenges to improving case managementof childhood pneumonia at health facilities inresource-limited settings. Bull WHO 2008; 86: 349-355.6. Bhutta ZA. Dealing with childhood pneumonia indeveloping countries: how can we make adifference? Arch Dis Child 2007; 92: 286-288.7. Atkinson M, Lakhanpaul M, Smyth A, Vyas H,Weston V, Sithole J, et al. Comparison of oralamoxicillin and intravenous benzyl penicillin forcommunity acquired pneumonia in children(PIVOT trial): a multicentre pragmatic randomisedcontrolled equivalence trial. Thorax 2007; 62:1102-1106.8. Jeena P, Thea DM, MacLeod WB, Chisaka N, FoxMP, Coovadia HM, et al. Failure of standardantimicrobial therapy in children aged 3-59 monthswith mild or asymptomatic HIV infection and severepneumonia. Bull World Health Organ 2006; 84:269-275.9. Hageman JC, Uyeki TM, Francis JS, Jernigan DB,Wheeler JG, Bridges CB, et al.  Severe community-acquired pneumonia due to Staphylococcus aureus,2003-04 influenza season. Emerg Infect Dis2006;12: 894-889.10. Bhutta ZA. Drug resistant infections in developingcountries: a major burden on children. BMJ,doi:10.1136/bmj.39520.680718.94. Accessed 8April 2008.

Treating childhood pneumonia empirically: Several issues still remain!

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Treating childhood pneumonia empirically: Several issues still remain!

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