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Improvements in Nutritional Management as a Determinant of Reduced Mortality From Community-Acquired Lower Respiratory Tract Infection in Hospitalized Children From Rural Central Africa

Bahwere, Paluku MD, PhD*||¶; De Mol, Patrick MD, PhD; Donnen, Philippe MD, PhD§¶; Dramaix-Wilmet, Michèle PhD||¶; Butzler, Jean Paul MD, PhD; Hennart, Philippe MD, PhD§¶; Levy, Jack MD, PhD

The Pediatric Infectious Disease Journal: August 2004 - Volume 23 - Issue 8 - p 739-747
doi: 10.1097/01.inf.0000135663.17018.51
Original Studies

Background: In-hospital mortality from lower respiratory tract infections (LTRI) is unacceptably high in developing countries where LTRI are still a leading cause of death.

Objective: To identify new approaches to reduce in-hospital mortality of LRTI through the improvement of its management.

Methods: The prospectively collected database of children admitted during an 11-year period with LRTI in a pediatric rural hospital in Central Africa was reviewed to determine the predictors of death and to evaluate the impact on mortality of 4 different protocols for the management of malnutrition.

Results: During the study period, 859 children were admitted with a nonmeasles severe LRTI. In the 3-year period during which blood cultures were obtained, 29.0% of the children with LRTI were bacteremic, and multiresistant Enterobacteriaceae were recovered in 81.4% of positive blood cultures. Independent predictors of death in children without edema were age <24 months, dehydration and hepatomegaly with adjusted odds ratios (numbers in parentheses, 95% confidence interval) of 3.47 (1.70–7.08), 4.24 (2.11–8.50) and 2.90 (1.43–5.85), respectively. In those with edema, a significantly increased risk of death was noted for girls [4.31 (1.71–10.90)], in children with z-score of weight to height ≤ −3 [5.45 (1.67–17.79)] and when the serum albumin was <16 g/l [2.58 (1.01–6.58)]. The improvement in the management of malnutrition was followed by a reduction of LRTI-related mortality in children with edema from 32.4 to 8.9% (P < 0.001). In children without edema, the LRTI-related mortality decreased from ~12% to 3.5% when their diet was supplemented with micronutrients.

Conclusion: This study indicates that the improvement of the management of underlying nutritional deficiencies is crucial for the reduction of the high in-hospital case fatality rate associated with severe nonmeasles LRTI. The empiric antibiotic regimen should be modified to cover for multiresistant Enterobacteriaceae.

From the *Centre de Recherche en Sciences Naturelles (CRSN), Lwiro, Democratic Republic of Congo); Services de †Microbiologie et ‡Pédiatrie, Centre Hospitalier Universitaire Saint Pierre, Université Libre de Bruxelles; the Departments of §Epidemiology and Preventive Medecine and ||Biostatistics, Ecole de Santé Publique (Université Libre de Bruxelles), Brussels, Belgium; ¶Cemubac (Centre Médical de l’Université Libre de Bruxelles pour ses Activités de Coopération) team; and Service de Microbiologie, Hôpital Universitaire Sart Tilman, Université de Liège, Liège, Belgium

Supported in part by grant 3.4532.86 from the Belgium Fund of Scientific and Medical Research, by the David and Alice Van Buuren Foundation and the Laboratory of Microbiology of Hôpital Saint Pierre of Brussels. Address for reprints: Paluku Bahwere, CEMUBAC and Department of Epidemiology and Preventive Medecine, School of Public Health, Université Libre de Bruxelles (ULB), Route de Lennik, 808, CP 595, 1070, Brussels, Belgium. Fax 003225554012; E-mail

Accepted for publication April 7, 2004.

© 2004 Lippincott Williams & Wilkins, Inc.