Use of antibiotics within the IMCI guidelines in outpatient settings in Papua New Guinean children: an observational and effectiveness study

Abstract

Introduction: There is a need to investigate the effectiveness and appropriateness of antibiotics prescription within the Integrated Management of Childhood Illness (IMCI) strategy in the context of routine outpatient clinics.

Methods: Making use of a passive case detection system established for a malaria prevention trial in outpatient clinics in Papua New Guinea, the appropriateness and effectiveness of the use of antibiotics within the IMCI was assessed in 1605 young children. Main outcomes were prescription of antibiotics and re-attendances within 14 days for mild pneumonia, mild diarrhoea and uncomplicated malaria whether they were managed with or without antibiotics (proxy of effectiveness). Appropriateness was assessed for both mild and severe cases, while effectiveness was assessed only for mild diseases.

Results: A total of 6975 illness episodes out of 8944 fulfilled inclusion criteria (no previous attendance <14 days+full medical records). Clinical incidence rates (episodes/child/year; 95% CI) were 0.85 (0.81-0.90) for pneumonia, 0.62 (0.58-0.66) for malaria and 0.72 (0.65-0.93) for diarrhoea. Fifty three percent of 6975 sick children were treated with antibiotics, 11% were not treated with antibiotics when they should have been and in 29% antibiotics were prescribed when they should not have been. Re-attendance rates within 14 days following clinical diagnosis of mild pneumonia were 9% (126/1401) when managed with antibiotics compared to 8% (56/701) when managed without (adjusted Hazard Ratio (aHR) = 1.00 (0.57-1.76), p = 0.98). Rates for mild diarrhoea were 8% (73/874) and 9% (79/866) respectively (aHR = 0.8 (0.42-1.57), p = 0.53).

Conclusion: Non-adherence to IMCI recommendations for prescription of antibiotics is common in routine settings in Papua New Guinea. Although recommended, the use of antibiotics in young children with mild pneumonia as defined by IMCI criteria did not impact on their outcome. Better tools and new strategies for the identification of bacterial infections that require antibiotics are urgently needed.

Conflict of interest statement

Competing Interests: The authors can otherwise confirm that the fact that Ivo Mueller (co-author) is a PLOS ONE Editorial Board member does not alter our adherence to all the PLOS ONE policies on sharing data and materials, as detailed online in the guide for authors. http://www.PLOSone.org/static/editorial.action#competing

Figures

Figure 1. Appropriateness of antibiotics’ use according to the IMCI recommendations.

Figure 2. Re-attendance rates within 14 days and outcomes for the most common mild syndromes according to the prescription of antibiotics.

Figure 3. Kaplan–Meier estimates of the proportion of patients with mild pneumonia (3a), mild malaria (3b) or gastroenteritis (3c) re-attending the clinics within 14 days whether they received antibiotics (red line) or not (blue line).