The Uptake Of New Guidelines For The Treatment Of Pneumonia In Children Aged 2-59 Months Admitted At Kenyatta National Hospital

Abstract

Background Management of childhood pneumonia in Kenya is based on WHO case management guidelines. These guidelines were updated in 2013 by the WHO, adopted by the Kenyan Ministry of Health and disseminated in February 2016. Cases previously classified as severe pneumonia and treated with intravenous benzyl penicillin are now categorized as pneumonia and treated with an oral antibiotic. We aimed to establish the level of adherence to these guidelines at KNH. The primary objective was to determine the proportion of children whose antibiotic treatment prescribed by the admitting clinician is consistent with the national pneumonia guidelines. The adequacy of clinical assessment (documented in admission notes) and consistency of severity classification with national guidelines were assessed as secondary outcomes. The adoption of the revised WHO guidelines would result in reclassification of children with pneumonia and the clinical sign of lower chest wall indrawing as pneumonia and not severe pneumonia therefore decreasing the number of admissions and the cost of treatment per child. Methodology We carried out a retrospective cross-sectional study of patients between the ages of two and fifty nine months admitted to KNH with pneumonia between April 1, 2017 and November 30, 2017. Patients with pneumonia and co-morbid diagnoses for which there are additional guideline recommended treatments were excluded. These conditions include dehydration, meningitis, diabetic ketoacidosis, pulmonary tuberculosis and patients with a wheeze. Data were summarized using means, interquartile ranges and proportions. Adherence to four main domains (assessment, classification, antibiotic and supportive treatment was assessed using the MOH national pneumonia guidelines as the audit criteria. Cross tabulation were used to calculate consistency between clinician practice and guideline recommendations. Results We assessed 390 clinical records of patients admitted to the hospital in the course of the period of study. The level of adherence to the clinical pneumonia guidelines was assessed at three levels: assessment of all five essential clinical signs was 17.7%(95% CI 14.0 - 21.85%), classification of pneumonia severity consistent with the guidelines was 44.87%(95% CI 39.86 - 49.96%) while the prescription of appropriate antibiotic and dosage was at 18.06%(95% CI 13.39 to 23.55%) .Oxygen was prescribed at admission for 160/390 (50.16%, 95% CI 36.1 to 46.09%) children with severe pneumonia who had a danger sign present but no record of oxygen saturation >90% .Of the 96 patients with severe pneumonia who had either a reduced level of consciousness or inability to feed, 86.45% were prescribed enteral feeds /intravenous fluids at admission . Conclusion There was poor adherence to the clinical practice guidelines. Only 18.06% of the patients were properly classified and received the correct treatment according to the guidelines.