Thread by @ResusOne

Important paper in @NEJM coming out of #Pakistan

RCT of amoxicillin for pneumonia in #Pakistan - the world’s largest community-based assessment of the use or withholding of antibiotics in children with mild pneumonia

Fantastic to see @FyezahJehan as 1st author

#welldone

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.@WHO recommendations for pneumonia recommend amoxicillin, but this conflicts with trial data showing possibility noninferiority of using amoxicillin.

Overuse of course leads to antibiotic resistance

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In this RCT
Kids 2-59 months (all from #Pakistan) who met @WHO criteria for nonsevere pneumonia with tachypnea
Assigned to either amoxicillin for 3 days or placebo

4002 children enrolled

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Primary outcome was treatment failure
In intervention arm - 2.6%
In control arm - 4/9%
Between-group difference: 2.3 percentage points
95% confidence interval: 0.9 to 3.7

Results were similar in the intention-to-treat analysis.

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This meant a NNT of 44
95% CI 31-80

Of note <0.1% of patients died in each group

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Based on these results, the authors show the @WHO results are valid, but several important considerations need to be made especially in #LMIC populations.

This includes carefully selecting a high-risk subgroup who may benefit most from Abx rather than broad prescribing

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This trial also raises a question about revisiting clinical criteria for diagnosing non-severe pneumonia. Adding additional criteria like temperature and wheezing to respiratory rate may allow better identification of children who will most benefit from Abx

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Congratulations to the trial team for conducting a large, well-designed trial using a cohort solely based in #Pakistan, challenging established concepts, and addressing important issues such as antibiotic stewardship.