Retrospective study on the usefulness of pulse oximetry for the identification of young children with severe illnesses and severe pneumonia in a rural outpatient clinic of Papua New Guinea

Pathogenic Role and Antibiotic Resistance of Methicillin-Resistant Staphylococcus aureus (MRSA) Strains Causing Severe Community-Acquired Pneumonia in Vietnamese Children

In recent years, the pathogenic role and antibiotic resistance of methicillin-resistant Staphylococcus aureus (MRSA) strains causing severe community-acquired pneumonia (CAP) have received increasing attention in clinical practice. The aim of this study was to determine the rate of isolates of MRSA strains causing severe CAP in children and to assess their level of antibiotic resistance. The study design was cross-sectional. Children with severe CAP were sampled by nasopharyngeal aspiration for the culture, isolation, and identification of MRSA. Antimicrobial susceptibility testing was performed using the gradient diffusion method to determine the minimum inhibitory concentration (MIC) of antibiotics. Results: MRSA was identified as the second leading cause of severe CAP in Vietnamese children. The rate of isolates of S. aureus was 41/239 (17.5%), of which most were MRSA, at 32/41 (78.0%). MRSA strains were completely non-susceptible to penicillin (100%), more resistant to clindamycin and erythromycin, less sensitive to ciprofloxacin and levofloxacin, and fully susceptible to vancomycin and linezolid, with a 32-fold decreased MIC90 for vancomycin (0.5 mg/L) and a 2-fold decreased MIC90 for linezolid (4 mg/L). Therefore, vancomycin and linezolid may be appropriate options for severe CAP identified by MRSA.

Prevalence of hypoxaemia in children with pneumonia in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Pneumonia accounts for around 15% of all deaths of children younger than 5 years globally. Most happen in resource-constrained settings and are potentially preventable. Hypoxaemia is one of the strongest predictors of these deaths. We present an updated estimate of hypoxaemia prevalence among children with pneumonia in low-income and middle-income countries.

METHODS

We conducted a systematic review using the following key concepts "children under five years of age" AND "pneumonia" AND "hypoxaemia" AND "low- and middle-income countries" by searching in 11 bibliographic databases and citation indices. We included all articles published between Nov 1, 2008, and Oct 8, 2021, based on observational studies and control arms of randomised and non-randomised controlled trials. We excluded protocol papers, articles reporting hypoxaemia prevalence based on less than 100 pneumonia cases, and articles published before 2008 from the review. Quality appraisal was done with the Joanna Briggs Institute tools. We reported pooled prevalence of hypoxaemia (SpO2 <90%) by classification of clinical severity and by clinical settings by use of the random-effects meta-analysis models. We combined our estimate of the pooled prevalence of pneumonia with a previously published estimate of the number of children admitted to hospital due to pneumonia annually to calculate the total annual number of children admitted to hospital with hypoxaemic pneumonia.

FINDINGS

We identified 2825 unique records from the databases, of which 57 studies met the eligibility criteria: 26 from Africa, 23 from Asia, five from South America, and four from multiple continents. The prevalence of hypoxaemia was 31% (95% CI 26-36; 101 775 children) among all children with WHO-classified pneumonia, 41% (33-49; 30 483 children) among those with very severe or severe pneumonia, and 8% (3-16; 2395 children) among those with non-severe pneumonia. The prevalence was much higher in studies conducted in emergency and inpatient settings than in studies conducted in outpatient settings. In 2019, we estimated that over 7 million children (95% CI 5-8 million) were admitted to hospital with hypoxaemic pneumonia. The studies included in this systematic review had high τ2 (ie, 0·17), indicating a high level of heterogeneity between studies, and a high I2 value (ie, 99·6%), indicating that the heterogeneity was not due to chance. This study is registered with PROSPERO, CRD42019126207.

INTERPRETATION

The high prevalence of hypoxaemia among children with severe pneumonia, particularly among children who have been admitted to hospital, emphasises the importance of overall oxygen security within the health systems of low-income and middle-income countries, particularly in the context of the COVID-19 pandemic. Even among children with non-severe pneumonia that is managed in outpatient and community settings, the high prevalence emphasises the importance of rapid identification of hypoxaemia at the first point of contact and referral for appropriate oxygen therapy.

FUNDING

UK National Institute for Health Research (Global Health Research Unit on Respiratory Health [RESPIRE]; 16/136/109).

Hypoxemia, hypoglycemia and IMCI danger signs in pediatric outpatients in Malawi

Hypoxemia and hypoglycemia are known risks for mortality in children in low-income settings. Routine screening with pulse oximetry and blood glucose assessments for outpatients could assist in early identification of high-risk children. We assessed the prevalence of hypoglycemia and hypoxemia, and the overlap with Integrated Management of Childhood Illness (IMCI) general danger signs, among children seeking outpatient care in Malawi. A cross-sectional study was conducted at 14 government primary care facilities, four rural hospitals and one district referral hospital in Mchinji district, Malawi from August 2019-April 2020. All children aged 0-12 years seeking care with an acute illness were assessed on one day per month in each facility. Study research assistants measured oxygen saturation using Lifebox LB-01 pulse oximeter and blood glucose was assessed with AccuCheck Aviva glucometers. World Health Organization definitions were used for severe hypoglycemia (<2.5mmol/l) and hypoxemia (SpO2 <90%). Moderate hypoglycemia (2.5-4.0mmol/l) and hypoxemia (SpO2 90-93%) were also calculated and prevalence levels compared between those with and without IMCI danger signs using chi2 tests. In total 2,943 children were enrolled, with a median age of 41 (range: 0-144) months. The prevalence of severe hypoxemia was 0.6% and moderate hypoxemia 5.4%. Severe hypoglycemia was present in 0.1% of children and moderate hypoglycemia in 11.1%. IMCI general danger signs were present in 29.3% of children. All severely hypoglycemic children presented with an IMCI danger sign (p <0.001), but only 23.5% of the severely hypoxemic and 31.7% of the moderately hypoxemic children. We conclude that while the prevalence of severe hypoxemia and hypoglycemia were low, moderate levels were not uncommon and could potentially be useful as an objective tool to determine referral needs. IMCI danger signs identified hypoglycemic children, but results highlight the challenge to detect hypoxemia. Future studies should explore case management strategies for moderate hypoxemia and hypoglycemia.

Hypoxaemia prevalence and management among children and adults presenting to primary care facilities in Uganda: A prospective cohort study

Hypoxaemia (low blood oxygen) is common among hospitalised patients, increasing the odds of death five-fold and requiring prompt detection and treatment. However, we know little about hypoxaemia prevalence in primary care and the role for pulse oximetry and oxygen therapy. This study assessed the prevalence and management of hypoxaemia at primary care facilities in Uganda. We conducted a cross sectional prevalence study and prospective cohort study of children with hypoxaemia in 30 primary care facilities in Uganda, Feb-Apr 2021. Clinical data collectors used handheld pulse oximeters to measure blood oxygen level (SpO2) of all acutely unwell children, adolescents, and adults. We followed up a cohort of children aged under 15 years with SpO2<93% by phone after 7 days to determine if the patient had attended another health facility, been admitted, or recovered. Primary outcome: proportion of children under 5 years of age with severe hypoxaemia (SpO2<90%). Secondary outcomes: severe (SpO2<90%) and moderate hypoxaemia (SpO2 90-93%) prevalence by age/sex/complaint; number of children with hypoxaemia referred, admitted and recovered. We included 1561 children U5, 935 children 5-14 years, and 3284 adolescents/adults 15+ years. Among children U5, the prevalence of severe hypoxaemia was 1.3% (95% CI 0.9 to 2.1); an additional 4.9% (3.9 to 6.1) had moderate hypoxaemia. Performing pulse oximetry according to World Health Organization guidelines exclusively on children with respiratory complaints would have missed 14% (3/21) of severe hypoxaemia and 11% (6/55) of moderate hypoxaemia. Hypoxaemia prevalence was low among children 5-14 years (0.3% severe, 1.1% moderate) and adolescents/adults 15+ years (0.1% severe, 0.5% moderate). A minority (12/27, 44%) of severely hypoxaemic patients were referred; 3 (12%) received oxygen. We followed 87 children aged under 15 years with SpO2<93%, with complete data for 61 (70%), finding low rates of referral (6/61, 10%), hospital attendance (10/61, 16%), and admission (6/61, 10%) with most (44/61, 72%) fully recovered at day 7. Barriers to referral included caregiver belief it was unnecessary (42/51, 82%), cost (8/51, 16%), and distance or lack of transport (3/51, 6%). Hypoxaemia is common among acutely unwell children under five years of age presenting to Ugandan primary care facilities. Routine pulse oximetry has potential to improve referral, management and clinical outcomes. Effectiveness, acceptability, and feasibility of pulse oximetry and oxygen therapy for primary care should be investigated in implementation trials, including economic analysis from health system and societal perspectives.

Experiences From an Implementation Model of ARI Diagnostic Device in Pneumonia Case Management Among Under-5 Children in Peripheral Healthcare Centers in India

OBJECTIVES

To address pneumonia, a major killer of under-5 children in India, a multimodal pulse oximeter was implemented in Health and Wellness Centers. Given the evidence of pulse oximetry in effective pneumonia management and taking into account the inadequate skills of front-line healthcare workers in case management, the device was introduced to help them readily diagnose and treat a child and to examine usability of the device.

DESIGN

The implementation was integrated with the routine OPD of primary health centers for 15 months after healthcare workers were provided with an abridged IMNCI training. Monthly facility data was collected to examine case management with the diagnostic device. Feedback on usefulness of the device was obtained.

SETTING

Health and Wellness Centers (19) of 7 states were selected in consultation with state National Health Mission based on patient footfall.

PARTICIPANTS

Under-5 children presenting with ARI symptoms at the OPD.

RESULTS

Of 4846 children, 0.1% were diagnosed with severe pneumonia and 23% were diagnosed with pneumonia. As per device readings, correct referrals were made of 77.6% of cases of severe pneumonia, and 81% of pneumonia cases were correctly given antibiotics. The Pulse oximeter was highly acceptable among health workers as it helped in timely classification and treatment of pneumonia. It had no maintenance issue and battery was long-lasting.

CONCLUSION

Pulse oximeter implementation was doable and acceptable among health workers. Together with IMNCI training, PO in primary care settings is a feasible approach to provide equitable care to under-5 children.

Right lateral position can improving oxygen saturation and respiratory rate on under-five children with pneumonia

Pediatric patients with pneumonia experience respiratory distress in the form of shortness of breath and rapid breathing, which affects oxygen saturation. Oxygen saturation and respiratory rate can be increased by providing the right lateral position. Fulfillment of oxygen will affect the healing of children and can reduce the length of stay in hospital. The purpose of this study was to identify the effect of right lateral positioning on oxygen saturation and respiratory rate in under-five children with pneumonia. The study design was a quasi-experimental pre-posttest with control group design. Respondents were 32 infants with pneumonia, (right lateral=16 and control group=16), selected by consecutive sampling. Univariate and bivariate analyzes were performed. There was a significant difference in oxygen saturation before and after right lateral position (p-value=0.000) and there was a significant difference in the respiratory rate before and after right lateral position (p-value=0.000). The results can be used to improve health services by promoting the right lateral position as a selftreatment intervention for increasing oxygen saturation and stabilizing respiratory rate in infants with pneumonia.

Experiences with use of a pulse oximeter multimodal device in outpatient management of children with Acute Respiratory Infection during Covid pandemic

Background:

While Covid-19 infection rate in children is low, respiratory symptoms are a common mode of presentation which calls for better management of such symptoms. However, ARI case managemnet in primary health settings settings has challenges as health workers lack skills to count respiratory rate and check chest indrawing. To address this multimodal pulse oximeters have been introduced in health and wellness centres of seven states to ease the work of front line health workers. A study was undertaken to understand the usability of the multimodal pulse oximeter during Covid times.

Methods:

A qualitative study was conducted with the aid of indepth interviews among a convenience sample of eleven health care workers from ten health and wellness centres. Interviews were conducted and recorded over phone, after obtaining consent. Transcribed interviews were coded and analysed on a qualitative analysis software. Content analysis was conducted.

Results:

Total children screened during covid lockdown period (April 1-May 31) is 571, those diagnosed with pneumonia and severe pneumonia is 68 and 2. Health care workers were satisfied with pulse oximeter as it helped in timely diagnosis and treatment, and offered protection from possible infection as it mitigated the need for physical contact.

Conclusion:

The multimodal pulse oximeter is well accepted among providers as it is easy to use aiding in timely management of ARI in children. It has an added protection as it's use reduces the need for physical contact. It can be adopted in other HWC and primary health facilities.

Repeat assessment of examination signs among children in Malawi with fast-breathing pneumonia

Background

As part of a randomised controlled trial of treatment with placebo versus 3 days of amoxicillin for nonsevere fast-breathing pneumonia among Malawian children aged 2–59 months, a subset of children was hospitalised for observation. We sought to characterise the progression of fast-breathing pneumonia among children undergoing repeat assessments to better understand which children do and do not deteriorate.

Methods

Vital signs and physical examination findings, including respiratory rate, arterial oxygen saturation measured by pulse oximetry (S_pO2), chest indrawing and temperature were assessed every 3 h for the duration of hospitalisation. Children were assessed for treatment failure during study visits on days 1, 2, 3 and 4.

Results

Hospital monitoring data from 436 children were included. While no children had S_pO2 90–93% at baseline, 7.4% (16 of 215) of children receiving amoxicillin and 9.5% (21 of 221) receiving placebo developed S_pO2 90–93% during monitoring. Similarly, no children had chest indrawing at enrolment, but 6.6% (14 of 215) in the amoxicillin group and 7.2% (16 of 221) in the placebo group went on to develop chest indrawing during hospitalisation.

Conclusion

Repeat monitoring of children with fast-breathing pneumonia identified vital and physical examination signs not present at baseline, including S_pO2 90–93% and chest indrawing. This information may support providers and policymakers in developing guidance for care of children with nonsevere pneumonia.

This study characterised the progression of fast-breathing pneumonia among children in Malawi. Repeat monitoring of children identified vital and physical exam signs not present at baseline, including oxygen saturation of 90–93% and chest indrawing.http://bit.ly/2vUlckS