Childhood severe pneumonia in Mulago Hospital: Associated factors and bacterial etiology in the era of universal access to HIV drugs
Background: Pneumonia is the leading cause of mortality among children below 5 years. Several factors including not being breastfed, lack of immunisation and HIV exposure have played a role. HIV exposed children have been found to have a weak immunity with increased susceptibility to infections especially lower respiratory tract infections and mortality compared to their unexposed counterparts. The introduction of pneumococcal vaccine, improved access to ART and universal treatment of HIV has led to a decline in the prevalence of pneumonia and the trend of bacteriology may have changed current causative organisms. It was important to study the prevalence, factors associated and bacterial aetiology in children with severe pneumonia in order to modify their inpatient management. Objective: To determine the prevalence of severe pneumonia, factors associated, bacterial aetiology, anti-microbial resistance and outcome among children aged 2 to 59 months admitted to Mulago Hospital Methods: A cross-sectional study was carried out in Acute Care unit and the main paediatric wards of Mulago Hospital. The History, physical exam and investigations such as complete blood count, blood smear for malaria, HIV testing (DNA PCR for HIV exposed children below 18 months) and antibody testing for children above 18 months were done. Sputum induction for culture and sensitivity, DNA PCR and chest X-ray were carried out for children with severe pneumonia. Data was entered using EPI data version 3.1 and analysed using STATA version 14.0 Results; Five hundred and three patients were recruited, 58.5% were male with 50% of the patients being less than 15 months. The prevalence of severe pneumonia was 27% and the factors significantly associated were being HIV positive (OR 3.6, C.I 1.4-9.2), immunisation status that was not up to date (OR 4.4, C.I 1.6-12.3) and having a mother with a low level of education (OR 0.3, C.1 0.2-0.7). Fifty-two percent (52%) of the children had bacteria isolated from sputum and the commonest organisms were Klebsiella pneumoniae (23.2%), Hemophilus influenzae (21.4%) and Streptococcus pneumoniae (16.1%). Klebsiella pneumoniae species were resistant to ampicillin (54%), gentamycin (69%) and ceftriaxone (69%), Hemophilus influenzae was resistant to ceftriaxone (42%) while Streptococcus pneumoniae was sensitive to chloramphenicol (67%). The duration of hospitalisation of children with severe pneumonia was longer than that of children with other diagnoses (M.D -1.4, C.I -2.68,-0.09). The mortality of severe pneumonia was 5.8% and the factors associated with and prolonged duration of hospitalisation were being HIV positive (OR 3.1, C.I 1.1-8.9) and wasting (OR 6.1, C.I 3.5-10.6). The factors that were associated with mortality were being HIV positive (OR 10.9, C.I 3.5-34.4) and wasting (OR 4.85, C.I 1.58-14.82). Conclusion: The prevalence of severe pneumonia among children aged 2-59 months was 27%. The factors associated were being HIV positive, immunisation status and low level of education. The commonest organisms isolated were Klebsiella pneumoniae, Hemophilus influenzae and Streptococcus pneumoniae at 23.2%, 21.4% and 16.1%, respectively. Klebsiella pneumoniae species were sensitive to imipenem and amikacin and resistant to the recommended antibiotics for treatment of severe pneumonia (ampicillin, gentamycin and ceftriaxone) while Hemophilus influenzae and Streptococcus pneumoniae species were sensitive to ceftriaxone and chloramphenicol respectively. The high antibiotic resistance pattern is worrying especially with the current WHO recommendation. Recommendations: Health education should encourage mothers to complete immunisation and carry their immunisation cards at every visit. A study to determine the most efficacious antibiotic in treating severe pneumonia should be carried out.