Abstract
BackgroundDespite significant progress, pneumonia is still the leading cause of infectious deaths in children under five years of age. Poor adherence to antibiotics has been associated with treatment failure in World Health Organisation (WHO) defined clinical pneumonia; therefore, improving adherence could improve outcomes in children with fast-breathing pneumonia. We examined clinical factors that may affect adherence to oral antibiotics in children in the community setting in Malawi.MethodsWe conducted a sub-analysis of a prospective cohort of children aged 2–59 months diagnosed by community health workers (CHW) in rural Malawi with WHO fast-breathing pneumonia. Clinical factors identified during CHW diagnosis were investigated using multivariate logistic regression for association with non-adherence, including concurrent diagnoses and treatments. Adherence was measured at both 80% and 100% completion of prescribed oral antibiotics.ResultsEight hundred thirty-four children were included in our analysis, of which 9.5% and 20.0% were non-adherent at 80% and 100% of treatment completion, respectively. A concurrent infectious diagnosis (OR: 1.76, 95% CI: 0.84–2.96/OR: 1.81, 95% CI: 1.21–2.71) and an illness duration of >24 h prior to diagnosis (OR: 2.14, 95% CI: 1.27–3.60/OR: 1.88, 95% CI: 1.29–2.73) had higher odds of non-adherence when measured at both 80% and 100%. Older age was associated with lower odds of non-adherence when measured at 80% (OR: 0.41, 95% CI: 0.21–0.78).ConclusionNon-adherence to oral antibiotics was not uncommon in this rural sub-Saharan African setting. As multiple diagnoses by the CHW and longer illness were important factors, this provides an opportunity for further investigation into targeted interventions and refinement of referral guidelines at the community level. Further research into the behavioural drivers of non-adherence within this setting is needed.
Highlights
Despite significant progress, pneumonia is still the leading cause of infectious deaths in children under five years of age
There is limited and conflicting evidence surrounding all these factors, in acute conditions such as pneumonia, with a synthesis of systematic reviews finding over 770 separate factors in 51 systematic reviews of long-term treatments, yet found no publication focusing on short-term treatments [13]. In light of this evidence gap, we aimed to investigate clinical and diagnostic factors associated with nonadherence to oral antibiotic treatment of fast-breathing pneumonia in children at the community level, using data from a prospective cohort in rural Malawi
Malaria was the most common concurrent diagnosis, occurring in 41.4% of children, and 61.8% of children received any medication in addition to oral cotrimoxazole
Summary
Pneumonia is still the leading cause of infectious deaths in children under five years of age. The World Health Organisation (WHO) recommends the use of integrated community case management (iCCM) at the community health worker (CHW) level [3] These guidelines categorise pneumonia into non-severe pneumonia or ‘fast-breathing pneumonia’ (presence of a cough and/or difficult breathing with a fast respiratory rate for age) and advise treatment with oral antibiotics in the community, or severe pneumonia (presence of cough and/ or difficult breathing with chest in-drawing or danger signs, irrespective of an increased respiratory rate for age), which requires referral to a hospital [4]. Approaches that aim to improve adherence to oral antibiotics should be considered
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