Academic journal article Bulletin of the World Health Organization

Randomized Trial of Sulfamethoxazole + Trimethoprim versus Procaine Penicillin for the Outpatient Treatment of Childhood Pneumonia in Zimbabwe

Academic journal article Bulletin of the World Health Organization

Randomized Trial of Sulfamethoxazole + Trimethoprim versus Procaine Penicillin for the Outpatient Treatment of Childhood Pneumonia in Zimbabwe

Article excerpt

Introduction

Acute respiratory infections (ARI) are estimated to be responsible for over a third of all deaths of children under 5 years of age in developing countries [1]. As a result, a worldwide campaign has been initiated by WHO to reduce child morbidity and mortality from such infections [2]. In Zimbabwe, a national ARI control programme was initialed in April 1987; the training materials that were distributed outline the criteria for case recognition and management by primary health care workers and closely follow WHO recommendations. Both the WHO and the Zimbabwe ARI programmes recommend sulfamethoxazole+trimethoprim (co-trimoxazole) or procaine penicillin as alternative therapies for children with ARI who require antibiotic treatment as outpatients. (a) We studied the effectiveness of this management policy in two busy urban municipal primary health care clinics in Zimbabwe, and in a randomized trial compared the outcome of treatment using sulfamethoxazole+trimethoprim with that using procaine penicillin.

Patients and methods

The study was carried out in Chitungwiza (estimated population, 350 000), a town situated 15 km south of Harare, the capital. Children under 5 years of age made up 19% of the population at the most recent census in 1982. The town consists largely of small brick or breeze-block houses, most of which have electricity, water, and mains sanitation, although there is a great deal of overcrowding. The population is entirely African. Some employment is provided by local industry but the town functions mainly as a high density dormitory suburb for people who work or are seeking work in Harare.

Chitungwiza is served by four municipal primary health care clinics and one 250-bed general hospital that opened in 1984. The study was carried out at the two busiest clinics (Seke North and Zengeza). During the period of the study neither clinic had a doctor and diagnosis and treatment were carried out entirely by nursing staff.

The study was conducted between mid-November 1987 and mid-March 1988. Before starting, staff at both clinics were carefully instructed in the case management guuidelines for children with ARI. (b) Children aged 3 months to 12 years who presented at the clinics and were diagnosed to have pneumonia that could be treated on an outpatient basis were entered into the study. Following ARI programme guidelines, the diagnosis was based primarily on a recent history of a cough and a respiratory rate of over 50 per minute. In the Zimbabwe programme, immediate referral to hospital is recommended, if, in addition, a child has chest indrawing without wheeze, is unable to drink, is malnourished, or aged under 3 months. Children who required immediate referral to hospital were excluded from the study. Also, children not resident in Chitungwiza or whose mothers indicated that they were unlikely to remain in the town for the following 2 weeks were excluded in order to minimize follow-up losses. All children entered into the study were seen at the two neighbourhood primary health care clinics; the likelihood that any of them might have received prior treatment with antibiotics from another source was very remote.

After the decision to treat with antibiotics had been made, allocation to the treatment modality was made by drawing the next in a numbered sequence of sealed envelopes. The enclosed proforma specified which drug to use according to a computer-generated randomization sequence. The patient's name, address, age, weight, and sex were recorded as well as the axillary temperature and the presence or absence of a respiratory rate of greater than 50 per minute and chest indrawing.

The mothers of children entered into the study were encourage to return to the clinic daily for 5 days, irrespective of whether sulfamethoxazole+trimethoprim or procaine penicillin had been prescribed, and then to come back 1 week after completion of treatment (12 days after entry) for a follow-up visit. …

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