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ICIUM Conference, Thailand Shamim Qazi Department of Child and Adolescent Health Development

This case study explores the current recommendations for pneumonia therapy in children and the efficacy of short course antibiotic therapy. It discusses the benefits and implications for the health system.

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ICIUM Conference, Thailand Shamim Qazi Department of Child and Adolescent Health Development

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  1. Health System Implications of Short Course Antibiotic Treatment Case study: pneumonia therapy in children ICIUM Conference, Thailand Shamim Qazi Department of Child and Adolescent Health Development World Health Organization, Geneva

  2. Outline of presentation • Current recommendations for pneumonia therapy in children • Efficacy of various therapeutic regimens for pneumonia therapy in children • Benefits of short course antibiotic therapy • Implications for health system

  3. Current recommendations for pneumonia therapy in children • β-lactum / macrolides for community acquired pneumonia • Duration of therapy: • Most European and North American: for 7-10 days • Canadian experts recommended 7-14 days therapy • AAP refrain from recommending any specific duration of therapy • BTS recommended 7-10 days of therapy • WHO ARI case management guidelines: • Non severe pneumonia 5 days • Severe/very severe pneumonia 7-10 days • Sources: McIntosh K, 2002; Ruuskanen O, 1999; AAP Red Book 2000; McCracken GH, 2000; BTL. Thorax 2002;WHO 1990 WHO/ARI/90.5, Qazi et al 1996

  4. Different antibiotics Different antibiotics OR same antibiotic different dose Same antibiotic for Different duration Same duration Different duration Review of literature Definition: short course therapy < 5 days therapy

  5. Azithromycin vs. amox/clav & erythromycin (2 studies) Azithromycin vs. erythromycin Azithromycin vs. amoxicillin & erythromycin Different antibiotics - switch therapy Methods & Results Duration 3 - 14 days Follow-up 2-5 weeks 1 study used switch therapy Clinical efficacy 83 - 100% Treatment difference - none Limitations: - different antibiotics & duration - small sample sizes - variable pneumonia definitions Different antibiotics for different duration Source: Roord JJ et al 1996, Harris JA et al 1998, Wubbel L et al 1999, Al-Eiden FA et al 1999 & Kogan R et al 2003

  6. Cotrimoxazole vs. procaine penicillin Cotrimoxazole vs. ampicillin Cotrimoxazole vs. amoxicillin (2 studies) Cotrimoxazole standard dose vs. double dose Methods & Results Used WHO ARI guidelines Duration 5 days Follow-up up to 2 weeks Clinical efficacy 79 - 92% Treatment difference - none Limitations: - small sample size for 3 studies Different antibiotics OR same antibiotic same duration Source: Campbell H et al 1988, Keeley DJ et al 1990, Straus WL et al 1998, CATCHUP 2002, WHO/FCH/CAH/04.2

  7. Azythromycin Procaine penicillin and cefuroxime Cotrimoxazole Amoxicillin (2 studies) Methods & Results 3 studies used WHO ARI guidelines 4 studies compared 3 vs 5 days Follow-up 2-3 weeks Clinical efficacy 80 - 97% Treatment difference - none Less AMR with 3 days therapy Limitations: - small sample size for 2 studies Same antibiotic for different duration Source: Ficnar B et al 1997, Vouri-Holopainen E et al 2000, Peltola H et al 2001, MASCOT 2002, ISCAP 2004 (in press), WHO/FCH/CAH/04.02

  8. Conclusions of the review • Most episodes of pneumonia can be treated for a shorter duration • Hospitalized severe pneumonia can be treated with switch therapy • Ambulatory non-severe pneumonia can be treated with 3 days of oral antibiotics • Shorter course results in less prevalence of resistant organisms

  9. Benefits of short course antibiotic therapy

  10. Lower costs: Hospitalized patients • United Kingdom: patients cost estimates: • excess cost of 7-day vs. 5-day therapy £1.9 to £7.2 million (Harris CM, BMJ 1994) • Ireland: estimated saving of £ 58,000 for 45 hospitalised patients (Al-Eidan et al JAC 1999)

  11. Oral cotrimoxazole 0.081 $/ (400 mg SMZ, 80 mg TMP tab) 6-9 kg requires 1 tab/day 3-day course: 3 tab 18.2 m tab costing 0.15 m $ 5-day course: 5 tab 30.4 m tab costing 0.25 m $ Oral amoxicillin 0.0177 $/ (250 mg tab) 6-9 kg requires 1.5 tab/day 3-day course: 4.5 tab 27.3 m tab costing 4.8 m $ 5-day course: 7.5 tab 45.5 m tab costing 8.1 m $ Theoretical example: Cost and logistics of non-severe pneumonia therapy in children Pakistan Pakistan < 5 year old population: 22.5 million Episodes of pneumonia: 6.75 million (0.3/child/year) Ambulatory pneumonia: 90% - 6.075 million episodes Source: MSH, Campbell et al Bull WHO 2004, in press, UNICEF

  12. 5 vs 10 days(Schrag et al JAMA 2001) 3 vs 5 days(MASCOT Lancet 2002) 3 vs 5 days(ISCAP BMJ 2004) 82% vs 74% 98.2% vs 94.9% 94.2% vs 85.8% Improved adherence: amoxicillin Short course preferred by patients and caretakers (Pechere JC 2001 & Branthwaite A 1996)

  13. 5 vs 10 days cefuroxime(Gooch et al PIDJ 1996) 5 vs 10 days co-amoxiclav(Hoberman PIDJ) 3 day azithromycin vs 10 days co-amoxiclav(Schaad U JAC 1993) 5 days azithromycin vs 10 days co-amoxiclav(Khurana CM PIDJ 1996) 12% vs 17% 8.7% vs 9.6% 2.6% vs 16.9% 7.2% vs 17.2% Less adverse events

  14. 5 vs 10 days(Schrag et al JAMA 2001) 3 vs 5 days(ISCAP BMJ 2004) 3 vs 5 days(SCC WHO report 2003) S. pneumoniae 34% vs 44% H. influenzae 57% vs 61% S. pneumoniae 67% vs 78% H. influenzae 54% vs 62% S. pneumoniae 62% vs 64% Reduced antimicrobial resistance Carriage of cotrimoxazole non-susceptible organisms 2-4 weeks after antibiotic therapy

  15. Traditional Health System Framework: service provision functions per level of care Individual Local community First level health facility District health department and hospital Regional hospital Ministries Adapted from Amonoo-Lartson District Health Care, 1984

  16. Family and individual benefits • Improved adherence • Less antibiotic related adverse events • Lower costs • Direct and indirect • Less antimicrobial resistance

  17. Public health benefits • Lower costs • Less health service utilisation • Improved logistics • Less antimicrobial resistance

  18. Summary and recommendation • Lower costs • Less health service utilisation • Improved logistics • Less antimicrobial resistance • Improved adherence • Less antibiotic related adverse events Need for research to determine appropriate duration of antibiotic therapy for other infections

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