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Antibiotic strategies for developing countries: experience with acute respiratory tract infections in Pakistan
1Federal ARI Cell, National ARI Control Programme, The Children's Hospital, Pakistan Institute of Medical Sciences, Islamabad.qazis@who.ch
Abstract:
The Pakistan program for control of acute respiratory tract infections (ARIs) adopted the standard ARI-case-management strategy of the World Health Organization and recommended co-trimoxazole for the management of nonsevere pneumonia. Reports in that country of high in vitro antimicrobial resistance of Streptococcus pneumoniae and Haemophilus influenzae to co-trimoxazole prompted the program to reevaluate its treatment policy. Two community-based studies during 1991-1993 showed in vivo efficacy of co-trimoxazole in 92% and 91% of children with nonsevere pneumonia. A third double-blind trial showed co-trimoxazole and oral amoxicillin to be equally effective in vivo in cases of nonsevere pneumonia, despite high in vitro resistance. Country-wide surveillance from 1991 to 1994 revealed 78.3%-79.9% in vitro resistance to co-trimoxazole among S. pneumoniae isolates and 59.5%-61.0% among H. influenzae isolates. Co-trimoxazole is still recommended by the Pakistan ARI control program. The fact that amoxicillin is three times more expensive and must be administered more frequently is a big impediment to recommending it as a first-line drug for nonsevere pneumonia.
Insights
Despite high in vitro resistance, co-trimoxazole remains effective for treating childhood nonsevere pneumonia in Pakistan. Amoxicillin is a viable alternative but faces cost and dosing challenges.
Area of Science:
- Pediatrics
- Infectious Diseases
- Pharmacology
Background:
- Pakistan's Acute Respiratory Tract Infections (ARIs) control program adopted WHO guidelines, recommending co-trimoxazole for nonsevere pneumonia.
- Concerns arose regarding high in vitro antimicrobial resistance of Streptococcus pneumoniae and Haemophilus influenzae to co-trimoxazole.
Purpose of the Study:
- To reevaluate the treatment policy for nonsevere pneumonia in Pakistan.
- To assess the in vivo efficacy of co-trimoxazole despite documented in vitro resistance.
Main Methods:
- Community-based studies and a double-blind trial were conducted between 1991-1993.
- In vitro antimicrobial resistance surveillance was performed from 1991 to 1994.
Main Results:
- Two studies showed co-trimoxazole efficacy in 91-92% of children with nonsevere pneumonia.
- A trial found co-trimoxazole and amoxicillin equally effective in vivo.
- High in vitro resistance rates persisted: 78.3%-79.9% for S. pneumoniae and 59.5%-61.0% for H. influenzae.
Conclusions:
- Co-trimoxazole remains effective in vivo for nonsevere pneumonia in Pakistan, despite high in vitro resistance.
- Co-trimoxazole is still recommended by the Pakistan ARI control program.
- Amoxicillin's higher cost and frequent dosing impede its recommendation as a first-line treatment.