Gallagher Katherine E, Awori Juliet O, Knoll Maria D, Rhodes Julia, Higdon Melissa M, Hammitt Laura L, Prosperi Christine, Baggett Henry C, Brooks W Abdullah, Fancourt Nicholas, Feikin Daniel R, Howie Stephen R C, Kotloff Karen L, Tapia Milagritos D, Levine Orin S, Madhi Shabir A, Murdoch David R, O'Brien Katherine L, Thea Donald M, Baillie Vicky L, Ebruke Bernard E, Kamau Alice, Moore David P, Mwananyanda Lawrence, Olutunde Emmanuel O, Seidenberg Phil, Sow Samba O, Thamthitiwat Somsak, Scott J Anthony G
Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.
PLoS One. 2024 Mar 11;19(3):e0297159. doi: 10.1371/journal.pone.0297159. eCollection 2024.
In 2012, the World Health Organization revised treatment guidelines for childhood pneumonia with lower chest wall indrawing (LCWI) but no 'danger signs', to recommend home-based treatment. We analysed data from children hospitalized with LCWI pneumonia in the Pneumonia Etiology Research for Child Health (PERCH) study to identify sub-groups with high odds of mortality, who might continue to benefit from hospital management but may not be admitted by staff implementing the 2012 guidelines. We compare the proportion of deaths identified using the criteria in the 2012 guidelines, and the proportion of deaths identified using an alternative set of criteria from our model.
PERCH enrolled a cohort of 2189 HIV-negative children aged 2-59 months who were admitted to hospital with LCWI pneumonia (without obvious cyanosis, inability to feed, vomiting, convulsions, lethargy or head nodding) between 2011-2014 in Kenya, Zambia, South Africa, Mali, The Gambia, Bangladesh, and Thailand. We analysed risk factors for mortality among these cases using predictive logistic regression. Malnutrition was defined as mid-upper-arm circumference <125mm or weight-for-age z-score <-2.
Among 2189 cases, 76 (3·6%) died. Mortality was associated with oxygen saturation <92% (aOR 3·33, 1·99-5·99), HIV negative but exposed status (4·59, 1·81-11·7), moderate or severe malnutrition (6·85, 3·22-14·6) and younger age (infants compared to children 12-59 months old, OR 2·03, 95%CI 1·05-3·93). At least one of three risk factors: hypoxaemia, HIV exposure, or malnutrition identified 807 children in this population, 40% of LCWI pneumonia cases and identified 86% of the children who died in hospital (65/76). Risk factors identified using the 2012 WHO treatment guidelines identified 66% of the children who died in hospital (n = 50/76).
Although it focuses on treatment failure in hospital, this study supports the proposal for better risk stratification of children with LCWI pneumonia. Those who have hypoxaemia, any malnutrition or those who were born to HIV positive mothers, experience poorer outcomes than other children with LCWI pneumonia. Consistent identification of these risk factors should be prioritised and children with at least one of these risk factors should not be managed in the community.
2012年，世界卫生组织修订了针对伴有下胸壁凹陷（LCWI）但无“危险体征”的儿童肺炎的治疗指南，建议采用居家治疗。我们分析了儿童健康肺炎病因研究（PERCH）中因LCWI肺炎住院儿童的数据，以确定死亡率高的亚组，这些亚组儿童可能仍能从住院治疗中获益，但可能未被执行2012年指南的工作人员收治。我们比较了使用2012年指南中的标准确定的死亡比例，以及使用我们模型中的另一套标准确定的死亡比例。
PERCH纳入了2189名2至59个月大的HIV阴性儿童队列，这些儿童于2011年至2014年期间在肯尼亚、赞比亚、南非、马里、冈比亚、孟加拉国和泰国因LCWI肺炎住院（无明显紫绀、无法进食、呕吐、惊厥、嗜睡或点头）。我们使用预测逻辑回归分析了这些病例中的死亡风险因素。营养不良定义为上臂中部周长<125mm或年龄别体重Z评分<-2。
在2189例病例中，76例（3.6%）死亡。死亡率与氧饱和度<92%（调整后比值比3.33，1.99-5.99）、HIV阴性但有暴露史（4.59，1.81-11.7）、中度或重度营养不良（6.85，3.22-14.6）以及年龄较小（婴儿与12至59个月大的儿童相比，比值比2.03，95%置信区间1.05-3.93）相关。低氧血症、HIV暴露或营养不良这三个风险因素中至少有一个在该人群中识别出807名儿童，占LCWI肺炎病例的40%，并识别出86%在医院死亡的儿童（65/76）。使用2012年世卫组织治疗指南确定的风险因素识别出66%在医院死亡的儿童（n=50/76）。
尽管本研究侧重于医院内的治疗失败，但支持对LCWI肺炎儿童进行更好的风险分层的提议。那些有低氧血症、任何营养不良或母亲为HIV阳性的儿童，其预后比其他LCWI肺炎儿童更差。应优先持续识别这些风险因素，且至少有其中一个风险因素的儿童不应在社区进行管理。
