A Randomized Multicentre Double Blind Trial of Amoxicillin Compared With Placebo for Treatment of WHO Defined Non-Severe Pneumonia in Children Aged 2-59 Months: NARIMA Study Group

Pneumonia is one of the major cause of childhood morbidity and mortality in developing countries. Burden of acute respiratory infections (ARI) is high with an estimated 5-7 episodes in under 5 population every year resulting in 2 million deaths. However, most of these are due to severe bacterial pneumonia.

In order to reduce pneumonia related deaths in communities where qualified personnel and diagnostic facilities are often not available WHO developed management guidelines based on simple clinical signs followed by empirical treatment. All children with cough and fast breathing are classified into management categories: Children with fast breathing only are classified as having non-severe pneumonia requiring oral antibiotic at home, children who have lower chest indrawing and /or general danger signs (GDS) are classified as severe pneumonia, and very severe pneumonia respectively. Both these groups require referral to a hospital and injectible antibiotic therapy. These guidelines have shown to effectively reduce ARI related mortality by 34% (?) in communities where they have been successfully implemented.

However, there are certain concerns regarding these guidelines. It is felt that using the sign of fast breathing alone for prescribing antibiotic may not be the most judicious thing from a public health perspective as it may lead to the spread of antibiotic resistance. Fast breathing could be due to many other causes not related to pneumonia.

There are many factors affecting the respiratory rate I children. Children with fever will have elevated respiratory rates in any case. Although WHO guidelines recommend that respiratory rate must be counted when child is afebrile, calm and preferably sleeping. In real life such practice is not always possible.

Another issue is the children with cough and fast breathing who have wheezing. In many developing countries wheeze is commonly associated with fast and difficult breathing. Data from the developed countries shows that wheeze is more common in viral than bacterial infections. Likewise, data from the developing countries has shown that viruses, especially respiratory syncytial virus (RSV), are isolated more frequently than bacteria from children with episodes of acute lower respiratory tract infections. A randomized trial of infants with bronchiolitis and pneumonia found no difference in clinical outcome in children with antibiotics compared with placebo(ref?). Wheeze has long been unaddressed and is one of the major cause for overuse of antibiotics. Evidence shows that three cycles of inhaled bronchodilator was found to be associated with a significant decrease in respiratory rate leading to revised classification of "no pneumonia" in these children. It has convincingly shown that majority of these children continue to do well when sent home without an antibiotic.