O ut-patient drug treatment of pneumonia
among children under two years of age
in Fortaleza, Brazil
1Tratame nto amb ulato rial d as p ne umo nias
nas c rianç as me no re s d e d o is ano s
e m Fo rtale za, Brasil
11 Su p p orted w ith gran ts from t h e Toyot a Fou n d a t ion a n d t h e ARI p rogra m m e of t h e W orld Hea lt h Orga n iz a t ion . 2 M atern al an d Ch ild Ep id em iology Un it , Lon d on Sch ool of Hygien e a n d Trop ica l M ed icin e, Lon d on W C1E 7H T, U K. 3 Dep artam en to d e Saú d e Com u n it á ria , Un iv ersid a d e Fed era l d o Cea rá , Ru a Ba rb osa d e Freit a s, 650/402, Fort a lez a , CE, 60170- 020, Bra z il. Ch iz u ru M isa go 2 Tom F. M a rsh a ll 2 W a lt er Fon seca 3 Bet t y R. Kirk w ood 2
Resumo Est u d ou se a a d erên cia a o t ra t a m en t o d e p n eu m on ia em cria n ça s, em serv iço a m b u -la t oria l d e h osp it a l p ed iá t rico em Fort a lez a , Bra sil. Fora m in v est iga d a s 171 cria n ça s com d ia g-n óst ico d e p g-n eu m og-n ia . At ra v és d e q u est iog-n á rio fora m colet a d a s ig-n form a ções refereg-n t es à p re-scriçã o m éd ica e est im a d a a a d erên cia a o t ra t a m en t o d e 149 cria n ça s. Os a n t im icrobia n os m a is com u m en t e p rescrit os fora m p en icilin a p roca ín a (33%), p en icilin a ben z a t in a (31%), a m p icilin a ou a m ox a cilin a (12%) e cot rim ox a z ol (8%). Em b ora t en h a sid o freq ü en t e a a ssocia çã o d e a n -t im icrobian os com ou -t ros m ed icam en -t os, -t ra-t am en -t o ex clu siv o com p en icilin a p rocain a foi p re-scrit o p a ra 31 cria n ça s. A a d erên cia a o u so d e a n t im icrob ia n os foi d e 52%, t en d o sid o m a is ele-v a d a p a ra os p a cien t es t ra t a d os ex clu siele-v a m en t e com m ed ica çã o in jet á ele-vel. As p rescrições m éd i-ca s co m b i n a ra m , m u i t a s v ez es, d i f eren t es a n t i m i cro b i a n o s d u ra n t e o m esm o t ra t a m en t o. A a n á lise d a s d iferen t es a ssocia ções a n t im icrob ia n a s rev elou q u e a p en a s 81 (54%) cria n ça s rece-beram t rat am en t o ap rop riad o, p or p eríod o d e cin co ou m ais d ias. Con clu i-se qu e a id en t ificação d e a n t im icrob ia n os q u e p ossa m resu lt a r n a m a ior a d erên cia a o t ra t a m en t o p erm a n ece com o u m d o s p ri n ci p a i s d esa f i o s n o m a n ejo a m b u la t o ri a l d a s p n eu m o n i a s n a s cri a n ça s. Ou t ro s m ed icam en t os in clu íram os an algésicos e bron cod ilat ad ores.
Palavras-chave Pn eu m on ia; M orbid ad e; Saú d e d a Crian ça; Trat am en t o
Introduction
Trea tm en t of a cu te lower resp ira tory in fection s (ALRI) in d evelo p in g co u n tries is a n im p o rta n t h e a lt h issu e. ALRI a cco u n t s fo r a p p roxim a t e ly 80% o f t h e u n d e r- five m o r t a lit y d u e t o a c u t e re sp ira t o r y in fe ct io n s, a t h ird o f a ll t h e d e a t h s in th is a ge grou p (Sh a n n et a l., 1984), a n d u p to 60% o f h e a lt h fa c ilit y vis it s a n d 30% o f h o s p it a l a d m is s io n s ( WH O / U N ICEF, 1986). An -t im icro b ia l d ru gs a re cen -tra l -to re co m m e n d e d case m a n a ge m e n t ( WH O, 1991) a n d a re o ft e n p r e scr ib e d fo r h o m e u se, b u t t h e q u e st io n o f wh eth er th ey a re p rescrib ed a p p ro p ria tely a n d given at correct d oses an d freq u en cies h as b een little stu d ied (va n d er Geest, 1987). A recen t re-view (Ho m ed es & Uga ld e, 1993) q u o ted o n ly 37 d ru g u se st u d ie s in t h e d e ve lo p in g wo rld , cov-e r in g a ra n gcov-e o f d iscov-e a scov-e s a n d c irc u m st a n c cov-e s, b u t n o n e sp ecifica lly a b o u t severe ALRI.
We re p o r t re su lt s fr o m a q u e st io n n a ire b a sed stu d y o f p re scrip tio n p a tter n s a n d co m -p lia n ce in ch ild re n with -p n e u m o n ia tre a te d a s o u t-p a tien ts o f th e p rin cip a l p ed ia tric h o sp ita l in Fo rt a leza , Bra zil, in 1990. Th is h o sp it a l p ro -vid e s fre e m e d ica l se r vice s, in clu d in g fre e e s-se n t ia l d r u gs fro m t h e gove r n m e n t in st it u t io n CEM E (Ce n t ra l d e Me d ic a m e n t o s), a lt h o u gh CEME d r u gs a re o ft e n o u t o f st o ck so p a t ie n t s ca n n o t a lwa ys u se th is so u rce. Th e stu d y ga th -ered d a ta on th e d ru gs p rescrib ed , if a n d wh ere t h e y we re o b t a in e d , a n d h ow t h e y we re give n to th e ch ild ren .
M ethods
Th e st u d y wa s ca rr ie d o u t in t h e Gre a t e r Me t -r o p o lit a n A-re a o f Fo -r t a le za , a c it y o f t wo m il-lio n p e o p le in No r t h e a st e r n Bra zil, lo ca t e d a t 3oSo u th in a tro p ica l zo n e, o n e o f th e lea st d e
-velo p ed a rea s o f th e co u n tr y. At th e tim e o f th e stu d y th e in fa n t m or ta lity ra te wa s som e 90 p er t h o u sa n d . Re sp ira t o r y t ra ct in fe ct io n s a re t h e se co n d m o st im p o rta n t in fe ctio u s ca u se o f in -fa n t d e a t h , a cco u n t in g fo r 11% o f su ch d e a t h s (UNICEF, 1989).
Re cru itm e n t to o k p la ce d u rin g a ca se co n -t ro l s-t u d y o f c h ild re n a ge d 0- 23 m o n -t h s wi-t h p n e u m o n ia co n fir m e d b y X-ra y, a t t e n d in g t h e h o sp it a l o u t - p a t ie n t c lin ic. Fu ll d e t a ils o f t h e m e t h o d o lo gy e m p lo ye d h a ve b e e n p r ovid e d elsewh ere (Fon seca et a l., 1996).
Ove r a 6- m o n t h p e r io d , c h ild re n livin g in th e m etrop olita n a rea of th e city were sa m p led . An in terviewer visited th e h o m e a p p roxim a tely a we e k la t e r a n d in t e r vie we d t h e m o t h e r (o r ca re r ) u sin g a st r u ct u re d q u e st io n n a ire. Ch
il-d ren t re a te il-d a s o u t-p a tie n ts a re in clu il-d e il-d h e re. Th e re sp o n d e n t s we re re q u e st e d t o sh o w th e h osp ita l p rescrip tion s, a n d th e d ru gs wh ere p ossib le; th ey were a sked wh ere th ese were ob -t a in e d , h ow m u ch (if a n y-t h in g) wa s p a id , a n d d o sa ge s a n d fre q u e n c ie s a c t u a lly fo llo we d . Fu rt h e r q u e st io n s co n ce r n e d d r u gs a n d h o m e re m e d ie s u se d b e fo re a t t e n d in g t h e h o sp it a l a n d a ft e r u sin g t h e h o sp it a l-p re scr ib e d d r u gs, a n d o th er gen era l fa m ily in fo rm a tio n .
Co m p lia n c e is d e fin e d a s a gre e m e n t b e t we e n t h e p re sc r ip t io n a n d wh a t t h e re sp o n -d e n t st a t e -d h a -d b e e n give n t o t h e c h il-d , wit h fo u r c o m p o n e n t s o f a gre e m e n t ; t h e d r u g b y n a m e, t h e a m o u n t p e r d o se , t h e d a ily n u m b e r of d oses, a n d th e n u m b er of d a ys. Wh en th e re-p ly wa s n o t sre-p e cific e n o u gh , n o n - co m re-p lia n ce wa s a ssu m ed . So m etim es th e d ru g wa s still b e-in g give n , a n d so m e p re sc r ip t io n s e-in d ic a t e d u se “u n til fin ish e d ” o r “u n til we ll”; in th e se in -sta n ce s, with co m p lia n ce o th e rwise co m p le te, ove ra ll c o m p lia n c e wa s a ssu m e d . Tre a t m e n t a d e q u a cy is d e fin e d a s 5 d a ys wit h a n a n t im i-crob ia l oth er th a n b en za th in e p en icillin ( WHO, 1991). 95% c o n fid e n c e in t e r va ls a re give n fo r th e p rin cip a l p ercen ta ges, in p a ren th esis.
Results
Study population
Ca re r s o f 226 c h ild re n we re in t e r vie we d , a n d 171 were ou t-p a tien ts. Th e gen era l ch a ra cterist ic s o f cterist h e 171 a re sh own in Ta b le 1. In fo r m a -t io n wa s o b -t a in e d d ire c-t ly fro m p re scr ip -t io n s fo r 148, a n d b y m o t h e r’s re ca ll fo r o n e. Th e re -m ain in g 22 carers said th ey were n ot given p re-scrip tio n s a t th is h o sp ita l; so m e so u gh t ca re in o th er h o sp ita ls o r elsewh ere. Mo st h o u se h o ld s were large, 34% with eigh t or m ore p erson s, an d in com es were gen erally low. Most m oth ers (59%) h a d m o re th a n 3 ye a rs e d u ca t io n . Th e re sp o n -d e n t wa s a lm o st a lwa ys th e m o th e r.
Prescription Patterns, Compliance, and O verall Antimicrobial Cover
127 ch ild re n re ce ive d o n e p re scr ip t io n , 14 re ce ive d t wo, 5 re ce ive d t h re e, a n d 2 re ce ive d fo u r. Alm o st a ll m u ltip le p rescrip tio n s resu lted from m u ltip le visits, th e m a jority with in a week of ea ch oth er.
Pre scr ip t io n p a t t e r n s fo r t h e m a in a n t im crob ia ls a re sh own in Ta b le 3. Ben za th in e p en i-c illin wa s u su a lly p re si-c r ib e d fo r o n e d a y. Th e
p r in c ip a l o t h e r a n t im ic ro b ia l p re sc r ib e d fo r less th a n five d a ys wa s p ro ca in e p en icillin . Th e fo llowin g re su lt s a re fo r t h e 149 ch ild re n wit h p rescrip tion in form a tion .
Ta b le 4 sh ows n u m b e r s o f c h ild re n c la ssfied by overa ll p rescrip tion p a ttern s for a n tim ic ro b ia ls. 17 ic h ild re n we re p re sic r ib e d n o a n -tim icro b ia l, a n d 31 o n ly b en za th in e p en icillin .
Tab le 1
Basic c harac te ristic s o f the 171 o ut-p atie nt c hild re n.
n %
Sex
Male 104 61
Fe male 67 39
Age(mo nths)
0 – 1 5 15
2 – 5 17 30
6 – 11 55 32
12 – 17 50 29
18 – 23 41 24
24 – 29 3 2
W ith p re sc rip tio n o n d isc harg e 149 87
Received antimicrobial drug(s)
b e fo re p re sc rip tio n 65 38
with p re sc rip tio n 132 77
afte r p re sc rip tio n 43 25
M onthly household income (units o f natio nal minimum wag e : $US100 e q uivale nt)
b e lo w 1 41 26
1 to 1.99 50 31
2 to 4.99 55 35
5 o f mo re 13 8
no t state d 12 –
N umber of persons in household (all ag e s)
2 to 4 48 29
5 to 7 65 38
8 o r mo re 58 34
M other’s years of formal education
no ne 18 11
1 to 3 50 30
4 to 16 99 59
no t state d 4 –
Respondent
Mo the r 165 96
Fathe r o r aunt 4 2
O the r 2 1
Tab le 2
Patte rns o f p re sc rip tio n o f d rug s, with numb e rs o f time s and p e rc e ntag e s e ac h d rug
was p re sc rib e d , and numb e rs and p e rc e ntag e s o f c hild re n fo r who m e ac h d rug was
p re sc rib e d .
Drug * Prescriptions Children given
n % n %
Antimicrobials
Be nzathine p e nic illin 52 16 48 32
Pro c aine p e nic illin 57 17 55 37
Amp ic illin 10 3 10 7
Amo xic illin 10 3 10 7
Co trimo xaso l 13 4 13 9
O the r 28 8 27 18
To tal 170 51 132 89
Analgesics
Asp irin 6 2 6 4
Dip yro ne 44 13 43 29
O the r 11 3 10 7
To tal 61 18 55 37
O ther Drugs
for Respiratory Symptoms
Salb utamo l 42 13 40 27
O the r b ro nc ho d ilato rs 15 4 15 10
O the r 6 12 4 3
To tal 63 19 53 36
O ther drugs 38 11 28 19
O verall total 332 100 149 100
51 c h ild re n we re p re sc r ib e d a n o t h e r a n t im i-cro b ia l fo r b e twe e n five a n d se ve n d a ys; th is is t a ke n a s o p t im a l. 7 ch ild re n we re p re scrib e d a sin gle a n tim icrob ia l “u n til u sed ” or “u n til well”, st a r t e d b e fo re t h e h o sp it a l visit . 18 c h ild re n we re p re sc r ib e d m o re t h a n se ve n d a ys o f o n e a n t im icro b ia l. No t co u n t in g b e n za t h in e p e n i-cillin , a n d p re su m in g t h a t “u n t il u se d o r we ll” ga ve a d e q u a te cove ra ge, o n ly 10 ch ild re n we re p re scr ib e d a n t im icro b ia ls wh ich we re u n d e r-p re scr ib e d . Of t h e 17 t h a t we re r-p re scr ib e d n o a n t im icr o b ia l, 3 re ce ive d t h e m sh o r t ly b e fo re t h e h o sp it a l visit a n d 7 d ire ct ly a t t h e h o sp it a l (6 a s fre e sa m p le s). It a p p e a rs t h a t a n t im icro -b ia ls we re co m p le t e ly a -b se n t fo r o n ly 7 o f t h e 149 ch ild ren .
Exact com p lian ce with b en zath in e p en icillin wa s re p o rte d fo r 87% (78% to 96%) o f th e ch il-d re n p re sc r ib e il-d it . Ot h e r e xa c t c o m p lia n c e rates are as follows: p rocain e p en icillin 54% (44% to 64%), a m p icillin or a m oxicillin 50% (28% to 72%), co trim oxa zo le 38% (12% to 64%), a n d a ll a n t im ic r o b ia ls c o m b in e d 52% (43% t o 61%).
Ta b le 5 sh ows t h e d e t a ils o f n o n - c o m p lia n ce for th e m ore freq u en t lian tim icrob ilials. Non -co m p lia n ce wa s -co m m o n , b u t d id n o t a lwa ys resu lt in d eficien t a n tim icrob ia l covera ge.
Ten of th e 77 ch ild ren with in itia l p rescrip -tion s of a n tim icrob ia ls for five or m ore d a ys (Tab le 4, ad d ition of (a) an d (b )) were treated for less th an five days on accou n t of n on -com p lian ce. U lt im a t e ly, wh e t h e r a c h ild re c e ive d a n t im i-cro b ials ad eq u ately d ep en d ed on th e com b in a-tion of all h is/ h er p rescrip a-tion s an d com p lia n ce; five d a ys cove r wa s re a ch e d fo r 77 (a d ifferen t 77), 52% of th e 149 (44% to 60%), an d a m in im u m of th ree d ays for 60% of th e 149 (52% to 68%). In -clu d in g a n tim icrob ia ls sta rted b efore h osp ital co n su lta tio n , a n d co n tin u in g a t th e tim e, th ese p eriod s were rea ch ed by 4 m ore ch ild ren .
Bro n ch o d ila to rs were p rescrib ed to 55 ch il-d re n in a ra n ge o f il-d a ily il-d o se s with il-d a ys ge n e r-a lly n o t sp ecified . Co m p lir-a n ce wr-a s low r-a t 55%. Co m p lia n c e t o a n a lge sic s wa s lo we r a t 22%. Th e m o st co m m o n a n a lge sic wa s d ipyro n e. Tab le 3
Pre sc rip tio n p atte rns fo r the mo re fre q ue ntly p re sc rib e d antimic ro b ials. Numb e rs o f p re sc rip tio ns c lassifie d b y d rug ,
b y q uantity p e r d ay and b y numb e r o f d ays.
Drug and daily dosage N umbers of times the drug was prescribed
O ve rall By numb e r o f d ays
Be nzathine p e nic illin (IU) * 1 d ay 2,3 d ays no t state d
300 000 10 9 1 0
450 000 1 1 0 0
600 000 41 39 1 1
Pro c aine p e nic illin (mg ) 1 – 4 d ays 5 – 7 d ays 8 – 10 d ays
125 1 1 0 0
250 52 12 34 6
400/ 500 4 1 3 0
Amp ic illin (mg ) 6 – 7 d ays 8 d ays till finishe d till we ll
125 1 0 1 0 0
250 1 0 0 0 1
375/ 500 4 2 0 2 0
750/ 1000 4 2 1 1 0
Amo xic illin (mg ) 3 d ays 6,7 d ays 8 – 10 d ays till finishe d
375 4 0 2 0 2
600/ 750 5 1 1 2 1
1000 1 0 0 1 0
Co trimo xaso l(mg sulp hame to xaso l) 5 – 7 d ays 8 – 15 d ays till finishe d
200 4 1 3 0
400-600 9 7 1 1
Use of pharmaceutical drugs before hospital consultation
Du rin g th e fou r weeks p rior to h osp ita l con su l-t a l-t io n , 140 c h ild re n re c e ive d p h a r m a c e u l-t ic a l d r u gs, 65 a t le a st o n e a n t im icr o b ia l, t h e m o st c o m m o n b e in g c o t r im o xa zo le, e r yt h r o m yc in a n d b en za th in e o r p ro ca in e p en icillin . An tim i-c ro b ia ls we re re i-c o m m e n d e d b y a p h ysii-c ia n 70% o f t h e t im e, b y p h a r m a cy a t t e n d a n t s 5%, a n d c h o se n b y t h e c a re r 16%. Th e m o st c o m m o n o t h e r d r u gs we re a n a lge sic s a n d b r o n -ch od ila tors.
Discussion
Th e re wa s co n sid e ra b le va r ie t y in p re scr ib in g p ra ct ice, in a d d it io n t o fre q u e n t n o n - co m p la n ce. On ly 53% (90/ 170, Tla b le 2) o f th e la n tim i-c ro b ia l p re si-c r ip t io n s we re fo r re i-c o m m e n d e d d r u gs ( WH O, 1991); 31% we re fo r b e n za t h in e p en icillin a n d 16% for a va riety of oth er a n tim
i-c ro b ia ls. Tre a t m e n t wa s fre q u e n t ly so u gh t m o re t h a n o n c e a n d a n t im ic ro b ia ls o b t a in e d m o re th a n o n ce. Allowin g fo r th is a n d fo r n o n -co m p lia n ce, 52% o f t h e ch ild re n re ce ive d five o r m o re d a ys a n t im ic r o b ia l c ove r o t h e r t h a n b en za th in e p en icillin , (54% in clu d in g co n tin uin g trea tm en t b egu n p rior to h osp ita l con su lta -t io n ). Th e figu re s fo r -t h re e d a ys a re 60% a n d 63%. Th ese p ercen ta ges a re low, p a rtly b eca u se b e n za t h in e p e n icillin wa s t h e o n ly a n t im icro -b ia l for 31 ch ild ren .
Th e e st im a t e s o f co m p lia n ce d e p e n d o n stated u sage b ein g reason ab ly accu ra te. Gen er-a lly, th ere is su p p ort for m eer-a su rin g com p lier-a n ce b y in t e r vie w (Ho m e d e s & Uga ld e, 1993), b u t com p arison s with p ill cou n ts, u rin e an alysis, or o t h e r m e a su re s h a ve give n e vid e n ce o f ove r-st a t e m e n t ( Wr igh t , 1993; Go rd is, 1979), a l-th ou gh l-th ese ol-th er m el-th od s l-th em selves can al-so lack sen sitivity an d sp ecificity (Gord is, 1979). Man y com p lian ce stu d ies h ave b een con cern ed wit h p ro p h yla xis o r lo n g- t e r m ch ro n ic co n d i-tio n s (Ha yn es et a l., 1979); co m p lia n ce m a y b e Tab le 4
Numb e rs o f c hild re n with p re sc rip tio ns, c lassifie d b y (A) ab se nc e o f antimic ro b ials, (B) p re sc rip tio n o f b e nzathine
p e nic illin alo ne , and (C) d uratio n o f e xp o sure to antimic ro b ials o the r than b e nzathine p e nic illin.
n %
A) Child re n p re sc rib e d no antimic ro b ial 17 11
B) Child re n p re sc rib e d b e nzathine p e nic illin alo ne 31 21
C) Child re n p re sc rib e d antimic ro b ials o the r than b e nzathine p e nic illin
(with o r witho ut b e nzathine p e nic illin)
O ne antimic ro b ial o nc e
Fo r 5 to 7 d ays 51 34
Fo r 8 d ays o r mo re 17 11
Fo r 3 o r 4 d ays 9 6
Fo r le ss than 3 d ays 1 0.7
Ind e finite p e rio d 8 11
O ne antimic ro b ial twic e o r mo re o fte n
Initially fo r 8 d ays o r mo re 1 0.7
Initially fo r ind e finite p e rio d 1 0.7
Two o r mo re antimic ro b ials, to g e the r o r o ne fo llo we d b y ano the r.
First antimic ro b ial fo r 5 to 7 d ays 8 5
First antimic ro b ial fo r 3 o r 4 d ays 1(1) 0.7
First antimic ro b ial fo r le ss than 3 d ays 1(1) 0.7
First antimic ro b ial fo r ind e finite p e rio d 3 2
Sub -to tal 101 68
To tal with p re sc rip tio n 149 100
h igh er with sh orter term treatm en t for acu te ill-n e sse s p e rce ive d a s se r io u s (Gro b , 1992). Ou r estim ates of com p lian ce, excep t for b en zath in e p en icillin , are n ot h igh . Th e m oth ers were in ter-viewed in d ep en d en tly, a wa y fro m th e h o sp ita l, with th e q u estion s p u t in a n eu tral p h rasin g. We d o n o t b e lie ve ove rst a t e m e n t wa s a se r io u s p rob lem in th is stu d y.
Co m p lia n c e wa s h igh e st fo r b e n za t h in e p e n icillin , wh ich wa s re a d ily a va ila b le, u su a lly fre e o f c o st fr o m t h e h o sp it a l p h a r m a c y, a n d give n a s a fe a sib le o p t io n fo r m a n y m o t h e r s, q u it e o ft e n a t t h e h o sp it a l. It wa s p re sc r ib e d fa irly o ft e n wit h o t h e r a n t im icro b ia ls b u t wa s t h e o n ly a n t im icro b ia l fo r 31 ch ild re n . It s u se fo r ch ild h o o d p n e u m o n ia h a s b e e n co m m o n p ra ct ic e in Br a z il s in c e b e in g a d vo c a t e d in t h e Sã o Pa u lo St a t e ARI p ro gra m (Pio A, p e rs co m m ). Bu t it is sp ecifica lly n o t reco m m en d ed b y WH O ( WH O, 1991). Mo re re c e n t in fo r m a -t io n sh ows -t h a -t i-t s u s e h a s s in c e d e c lin e d a -t t h e stu d y site (Re y L. C., p e rs co m m ).
Co m p lia n ce is like ly t o b e h igh e r fo r t r e a t -m e n ts give n o n ce a d a y (Gro b, 1992). Pro ca in e p en icillin wa s u su a lly p rescrib ed on ce a d a y for a t le a st five d a ys. It is in je c t a b le . Fo llowin g a co u rse o f in jectio n s fro m th e h o m e is n o t d
iffi-c u lt in t h is iffi-c o m m u n it y. Mo t h e r s o b t a in t h e d ru g a t eith er th e h o sp ita l o r a lo ca l p h a rm a cy, a n d lo ca l p h a rm a cy a t t e n d a n t s o ft e n give fo llow u p in je c t io n s e ve n if t h e d r u g wa s o b -t a in e d e lse wh e re. Th e re is a n e cd o -t a l e vid e n ce th a t in jectio n s a re p referred b y m a n y m o th ers, so com p lia n ce m a y b e h igh er for in jecta b les on t h is co u n t a lso. Bu t a cle a r a rgu m e n t fa vo r in g o ra l d r u gs fo r o u t -p a t ie n t s is t h e p o ssib ilit y o f in fectio n th ro u gh in a d eq u a te steriliza tio n (Pio A, p ers com m ).
Th e m o st co m m o n n o n -a n t im icro b ia l wa s d ip yron e. Victora et al. (1982) rep orted h igh u s-a ge in So u t h e r n Brs-a zilis-a n h o sp it s-a ls s-a n d e x-p re sse d co n ce r n ove r sa fe t y, wh ich is a lso d is-cu ssed by Fu ch s (Fu ch s, 1988; IAAAS, 1986). Th e am ou n t of u se sh own h ere is cau se for con cern .
Lower co m p lia n ce ca n b e exp ected fo r p re-scrip tion s with m an y item s (Hom ed es & Ugald e, 1993; Hayn es, 1979), wh ich argu es for sim p licity in p re scr ib in g. Howe ve r, we we re n o t a b le t o sh ow su ch an effect, th ou gh ou r stu d y m ay h ave lacked th e p ower to d o so.
Ca re - p r ovid e r s fo r c h ild re n in t h is st u d y ch o se h o sp it a l ca re, so t h e y a re o n ly a p ro p o r-tion of ch ild ren with p n eu m on ia . Bu t a d eq u a te t re a t m e n t in t h is gro u p m a t t e r s gre a t ly; it is Tab le 5
De tails o f no n-c o mp lianc e with mo st c o mmo nly p re sc rib e d antimic ro b ials ap art fro m b e nzathine p e nic illin.
Numb e rs o f p re sc rip tio ns whe re no n-c o mp lianc e re sulte d in c hang e s are sho wn, with d e tails o f the c hang e s.
Procaine penicillin Ampicillin Amoxicillin Cotrimoxasol
Numb e r o f p re sc rip tio ns 57 10 10 13
Numb e r no t take n 1 1 0 2
Numb e r with o the r no n-c o mp lianc e 25 3 6 6
O the r no n-c o mp lianc e
Numb e r with c hang e s o f d rug 0 0 0 2
List o f c hang e s in d rug – – – to Sup hame tho xo so l to Trime tro p in & sulp had iazine
Numb e r with c hang e s o f amo unt p e r d o se 0 1 1 0
List o f c hang e s in amo unt(1) – 125 to 250mg – 200 to 125mg
Numb e r with c hang e s
o f numb e r o f d o se s p e r d ay 3 1 0 0
List o f c hang e s in d o se s p e r d ay 1 to 3 2 to 1 2 to 1 – – –
Numb e r with c hang e o f numb e r o f d ays; 23 2 5 4
Numb e r with inc re ase 12 1 2 2
Numb e r with d e c re ase 11 1 3 2
List o f d e c re ase s in d ays re sulting
in le ss than five d ays tre atme nt 7 to 1 4 to 1 6 to 2 – “ Till use d ” to 1 “ Till use d ” to 4
8 to 3 7 to 3 4 to 3
5 to 4 5 to 4 5 to 4
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Acknowledgements
We th a n k th e Alb ert Sa b in Hosp ita l, th e Hea lth Secre-ta ria t o f Cea rá SSecre-ta te, a ll th e ca rers wh o willin gly ga ve u s t im e a n d in fo r m a t io n , a n d t h e c h ild re n t h e m selves. We a re gra tefu l to Dr. Cesa r Victo ra o f th e Fed -e ra l Un iv-e rsit y o f P-e lo t a s fo r h is co n sid -e ra b l-e a ssis-t a n ce in ssis-t h e co n ce p ssis-t io n a n d in issis-t ia ssis-t io n o f ssis-t h is sssis-t u d y, a n d t o Dr. Ju lia n Lo b - Le vyt o f t h e Lo n d o n Sch o o l o f Hygie n e a n d Tro p ica l Me d icin e a n d Dr. Sa n d y Gove o f th e ARI Pro gra m o f th e Wo rld Hea lth Orga n iza tio n for con stru ctive a d vice.
SHANN, F.; GRATTEN, M.; GERNER, S.; LINNEMANN, V.; H AZLETT, D. & PAYN E, R., 1984. Ae t io lo gy o f p n eu m on ia in ch ild ren in Goroka Hosp ital, Pap u a New Gu in ea. Th e Lan cet, 2:537-541
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