Factors related to severity and outcome of pneumonia among children aged 2 - 59 months, in Dar es salaam, Tanzania.

Abstract

Background: Severe pneumonia among children less than five years old is a

major cause of morbidity and mortality throughout the developing world.

Children with certain risk factors in particular, can develop pneumonia or a more

severe disease that requires inpatient attention and is associated with increased

risk of death. Improved case management is the main strategy to reduce morbidity

and mortality. In developing world, with the risk of malnutrition, HIV-epidemic

and the development of antibiotic resistance, pneumonia pattern may have been

altered. Therefore there is a need to review management of pneumonia in children

in order to define appropriate local approaches to pneumonia management.

Objective: To establish the factors related to severity and outcome of pneumonia

among children aged 2-59 months.

Methodology: A cross sectional hospital based study was done prospectively in

children aged 2-59 months admitted with clinical symptoms and signs of

pneumonia at Muhimbili National Hospital, Ilala, Temeke and Mwananyamala

District Municipal Hospitals from March to September 2006. A structured

questionnaire was used to capture demographic information, presence of key

symptoms and signs of pneumonia, after obtaining a written informed consent

from the parent/guardian. Thorough physical examination including oxygen

saturation, weight and height were done. Double Rapid test and Polymerase Chain

Reaction for HIV, Full Blood Count, ESR and chest X-ray were done. BACTEC

machine was used to detect bacteraemia. Children were followed up while in the ward. The outcome recorded as recovery and discharged or death. Data analysis was done using EPI Info and SPSS (Statistical Package for Social Science)

programmes. A p - value of less than or equal to 0.05 was considered significant.

Results: Among the 352 children, 152 (43.2%) were females and 200 (56.8%)

were males with the mean age of 12 months. The prevalence of severe pneumonia

was 68.8%, significantly affecting younger age group less than I year of age. The

case fatality due to pneumonia was 22.4%. Mortality was significantly high in

children with severe pneumonia with most deaths occurring within 48 hours of

admission. The prevalence of hypoxaemia was 25%. Hypoxaemia was

significantly associated with severe pneumonia, HIV-infection and high mortality.

(p - value = 0.000) Bacteraemia was found in 27.8% of children with pneumonia.

Coagulase Negative Staphylococcus was the most predominant organism,

followed by Pseudomonas, S. aureus, Klebsiella and Streptococcus species. Most

of the bacteria isolated showed less resistance to gentamicin, vancomycin,

oxacillin, erythromycin and augumentin. HIV-infection was significantly

associated with bacteraemia. A quarter (25%) of children admitted with

pneumonia were malnourished based on weight for height Z-score of less than -

2SD. Mortality was significantly high among the malnourished chll~ dren compared

to normal nourished children (p - value = 0.012). The prevalence of HIV among

children hospitalized with pneumonia was 24.7010. HIV-infection was significantly

associated with severe pneumonia and high mortality. (p - value = 0.000)

Conclusions and Recommendations: Considering high mortality associated with

pneumonia, development of antibiotic resistance and the short interval between

admission and death, early diagnosis, prompt and effective treatment at all health

facility levels are required. In the current era of HIV, which is associated with high

prevalence of severe pneumonia requiring oxygen therapy, there is a need to improve monitoring and oxygen supply to children with severe pneumonia. Continued

surveillance of bacterial resistance pattern is required to monitor causative organisms

and their antibiotic sensitivity patterns in order to guide antimicrobial use.