Disease spectrum, risk factors for and management of children admitted with pneumonia in central Vietnam

Abstract

Globally, pneumonia is the leading cause of disease and death among children under five, but key differences between the situation in sub-Saharan Africa and East-Asia are rarely appreciated. A particular dilemma in East-Asian countries, where health care access is good, is the balance of benefits and harms resulting from excessive antibiotic use. This thesis focused on central Vietnam, where challenges are broadly similar to East-Asia and pneumonia management practices are understudied, to address both local and regional knowledge gaps. A comprehensive literature review identified lack of exclusive breastfeeding, gaps in vaccination coverage, cigarette smoke and air pollution exposure, malnutrition, as well as co-morbid conditions such as congenital heart disease and prematurity, as major pneumonia risk factors. It also identified acute respiratory infections (ARIs) as a major driver of antibiotic use in East-Asia. A retrospective audit confirmed ARI as the most common reason for paediatric admission in Vietnam, but suggested ‘over admission’ for mild disease. This was followed by a survey of mothers in the postnatal care unit in Da Nang hospital, which revealed a low prevalence of modifiable pneumonia risk factors, except for paternal cigarette smoke exposure. It documented good health literacy and decision autonomy among mothers. A survey of paediatricians at the hospital identified an urgent need for antibiotic stewardship. Finally, a 12-month prospective study described the clinical characteristics of children admitted with ‘pneumonia’, showing that a large percentage did not meet revised WHO criteria. Pre-admission antibiotic use was common, with cephalosporins generally preferred as first-line treatment. Using a novel approach that focused on predictors of ‘unlikely bacterial pneumonia’ (and ‘adverse pneumonia outcome’) we developed a pragmatic management algorithm to limit unnecessary hospital admission and guide rational antibiotic use. We confirmed the huge burden that child pneumonia places on the health system in Vietnam, but demonstrated that it is compounded by the ‘over admission’ of mild cases and inappropriate antibiotic use. The proposed algorithm should help to address this challenge, but formal validation in a prospective study is required to confirm its utility and safety.