Severe pneumonia can be managed at home (Lancet 2008; 371: 49-56)

WHO case management guidelines for severe pneumonia involve referral to hospital for treatment with parenteral antibiotics. If equally as effective as parenteral treatment, home-based oral antibiotic treatment could reduce referral, admission, and\ treatment costs. This randomized, open-label equivalency trial was done at seven study sites in Pakistan. 2037 children aged 3-59 months with severe pneumonia were randomly allocated to either initial hospitalization and parenteral ampicillin (100 mg/kg per day in four doses) for 48 h, followed by 3 days of oral amoxicillin (80-90 mg/kg per day; n=1012) or to home-based treatment for 5 days with oral amoxicillin (80-90 mg/kg per day in two doses; n=1025). There were 87 (8.6%) treatment failures in the hospitalized group and 77 (7.5%) in the ambulatory group by day 6. Five children died within 14 days of enrolment, one in the ambulatory group and four in the hospitalized group.

Comments This large study which is relevant to most developing countries clearly indicates that home treatment with high-dose oral amoxicillin is equivalent to currently recommended hospitalization and parenteral ampicillin for treatment of severe pneumonia without underlying complications, suggesting that WHO recommendations for treatment of severe pneumonia need to be revised.

Relationship of H. pylori and idiopathic thrombocytopenic purpura (J Pediatr Hematol Oncol 2008; 30: 53)

Recent reports have suggested that Helicobacter pylori infection may be a causative agent of adult chronic idiopathic thrombocytopenic purpura (cITP) and antimicrobial treatment may increase platelet counts. As there is limited experience in pediatric age, the authors investigated the prevalence of H. pylori infection and the effects of H. pylori eradication therapy in a series of children with cITP. Twenty-four children with cITP were investigated for H. pylori infection using the C-urea breath test or H. pylori fecal antigen. In cases of H. pylori infection, antimicrobial treatment was given with amoxicillin, clarithromycin, and proton pump inhibitors. H. pylori infection was found in 8 patients (33%) and 3 of them showed a response after eradication therapy, but 2 of them relapsed later on. Two patients had a spontaneous increase in platelet count in the group of H. pylori-negative patients. The authors were unable to demonstrate that H. pylori plays a major role in pediatric cITP.

Comments Given the difficulty in managing cases of cITP, it maybe worthwhile to try and conduct larger multicentric trials to find if H. pylori is indeed responsible for another human disease.

Arginine-vasopressin and terlipressin in refractory shock (Anaesthesia 2007; Dec 13. Epub ahead of print)

Severe septic and cardiogenic shock is associated with a high mortality. Common therapies include the administration of fluids and the use of conventional inotropes. However, in severe forms of shock, cardio

circulatory failure may be secondary to profound vasoparalysis and unresponsive to conventional therapies. The authors identified 17 reports (11 case series, 6 case reports) on a total of 109 patients for use of arginine-vasopressin (AVP) and terlipressin (TP) as a rescue therapy in neonates, children and adolescents with catecholamine-refractory shock or circulatory arrest. Administration of AVP/TP resulted in a rapid increase in systemic arterial blood pressure, an increase in urine output, and a decrease in serum lactate. AVP and TP had a significant impact on the required dose of inotropes which could be reduced. Despite the use of AVP/TP, mortality was high (52/109). There is a need for larger prospective trials assessing the efficacy and safety profiles of these drugs in a defined setting.

Comments Refractory shock is a major killer in pediatrics, and if the positive results with AVP/TP in adults are replicated in pediatric trials they would be a worthwhile addition to our armamentarium.