Table 4

GRADE evidence profile 1: Cotrimoxazole versus amoxicillin for non-severe pneumonia

Quality assessment

Summary of findings


Number of patients

Effect

Quality of evidence


No of studies/Design

Limitations

Inconsistency

Indirectness

Imprecision

Amoxicillin

Cotrimoxazole

Odds ratio

(95% CI)


Outcome 1: Treatment failure based on clinical signs. Follow-up 2 - 5 days.

Importance: Critical


2 RCTs [22,23]

no serious limitations

no serious inconsistency

serious1

no serious imprecision3

147/922 (15.9%)

231/1132 (20.4%)

0.83 (0.65 - 1.07)

Moderate


Outcome 2: Treatment failure based on clinical signs. Follow-up 4-6 days.

Importance: Critical


1 cluster randomised trial [24]

no serious limitations

no serious inconsistency

serious2

no serious imprecision3

137/993 (13.8%)

97/1016 (9.5%)

1.52 (0.73 - 3.17)

Moderate


Outcome 3: Mortality

Importance: Critical


No studies

-

-

-

-

-

-

-

-


Outcome 4: Cost

Importance: Important


No studies

-

-

-

-

-

-

-

-


Overall quality of evidence: Moderate quality evidence suggests no difference between standard and proposed treatments for outcomes assessed


Benefits or desired effects:

Amoxicillin may be also effective for treatment of severe pneumonia, potentially simplifying treatment by reducing severity classes to two.


Risks or undesired effects

Potential for increased bacterial resistance to amoxicillin with widespread use. Reduced options for second line treatment in case of treatment failure - a whole new class of antibiotic might have to be provided as second line treatment.


Values and preferences:

Cotrimoxazole is formulated as a commonly used tablet in adults too that can be divided for children if pediatric formulations are missing - the same is not true for amoxicillin that is often distributed as capsules if syrups are not available


Costs:

Amoxicillin is more costly than cotrimoxazole (US$ 0.12 and US$ 0.21 for cotrimoxazole and amoxicillin syrups respectively for a course appropriate for a child weighing approximately 10 kg [KEMSA* July 2009])


Feasibility

Both drugs are widely available and in use


Clinical question: For Kenyan children aged 2 - 59 months who meet WHO criteria for non-severe pneumonia, should cotrimoxazole be replaced by amoxicillin?

1 Indirectness of population (studies conducted in Pakistan)

2 Indirectness of population (study conducted in India)

3 Although studies failed to show a difference between the two treatments, narrow confidence intervals and power calculation described by authors supported decision against downgrading the quality for imprecision.

KEMSA - Kenya Medical Supplies Agency

Agweyu et al. BMC Pediatrics 2012 12:1   doi:10.1186/1471-2431-12-1

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