Background:
Hiv-related pneumonia is the main cause of paediatric hospital admissions in southern africa. we aimed to measure predictors of treatment failure and the cause of non-responsive pneumonia in children admitted to hospital with severe pneumonia in durban, south africa.
Methods:
We investigated 358 children aged 1-59 months who presented with who-defined severe or very severe pneumonia. children were recruited irrespective of hiv status and started on a standard antimicrobial regimen of benzylpenicillin and gentamicin. all infants also received high-dose trimethoprim-sulfamethoxazole. the primary outcome measure was treatment failure at 48 h.
Findings:
242 (68%) children were hiv infected, 41 (12%) hiv exposed, uninfected, and 75 (21%) hiv uninfected. failure to respond by 48 h was predicted by age under 1 year (adjusted odds ratio 6.38, 95% ci 2.72-14.91, p<0.0001), very severe disease (2.47, 1.17-5.24, p=0.0181), hiv status (hiv infected 10.3, 3.26-32.51; hiv exposed, uninfected 6.02, 1.55-23.38; p=0.0003), and polymicrobial disease (one organism 2.06, 1.05-4.05; two organisms 10.75, 4.38-26.36; p<0.0001) on logistic regression analysis. all children with three organisms failed treatment. 72/110 treatment failures had at least two organisms isolated. three of nine hiv-exposed, uninfected infants, 29/74 hiv-infected, but no hiv-uninfected infants who failed study therapy had pneumocystis jirovecii pneumonia.
Interpretation:
For children younger than 1 year, the who guidelines are inadequate and need to be revised since both hiv-infected and hiv-exposed, uninfected infants had more treatment failures than did hiv-uninfected infants. polymicrobial disease is an important reason for treatment failure, and we need to identify rapid low-cost diagnostic methods to assist clinicians.