Table 6

GRADE evidence profile 3: Benzyl penicillin plus gentamicin versus ceftriaxone for very severe pneumonia

Quality assessment

Summary of findings


Number of patients

Effect

Quality of evidence


No of studies/Design

Limitations

Inconsistency

Indirectness

Imprecision

ceftriaxone

benzyl penicillin and gentamicin

(P value)


Outcome 1: Time to resolution of signs and symptoms of pneumonia

Importance: Critical


1 RCT [32]

serious1

no serious inconsistency

very serious2

serious3

51

46

(P > 0.05)

Very low


Outcome 2: Treatment failure/time to resolution of clinical signs of pneumonia

Importance: Critical


1 RCT [33]

no serious limitations

no serious inconsistency

very serious4

Serious5

33

38

(P > 0.1)

Very low


Outcome 3: Mortality

Importance: Critical


No studies

-

-

-

-

-

-

-

-


Outcome 4: Cost

Importance: Important


No studies

-

-

-

-

-

-

-

-


Overall quality of evidence: Very low quality evidence suggests no advantage of ceftriaxone over benzyl penicillin/ampicillin and gentamicin


Benefits or desired effects

Lower risks, less discomfort associated with single injection


Risks or undesired effects

Potential emergence of extended spectrum beta-lactamase (ESBL)-producing organisms; concern of 'overuse' of important second line drug and what next if it doesn't work?


Values and preferences

Favourable once-daily dosing schedule


Costs

Ceftriaxone more costly than penicillin/gentamicin. However availability of cheap generic preparations and additional costs (consumables and human resource) associated with multiple injections may outweigh apparent cost disadvantage of ceftriaxone.


Feasibility

Ceftriaxone already widely available and in use


Clinical question: For HIV-unexposed Kenyan children aged 2 - 59 months without clinical signs of severe malnutrition who meet WHO criteria for very severe pneumonia, should benzyl penicillin/ampicillin plus gentamicin be replaced by ceftriaxone?

1 Limitation due to failure to lack of description of randomisation/allocation concealment

2 Indirectness of comparison (compared penicillin chloramphenicol versus ceftriaxone) and population (Conducted in Turkey),

3 Imprecision due to small sample size

4 Indirectness of: 1) comparison (compared benzyl penicillin gentamicin versus amoxicillin/clavulanate), 2) population (India),

5 Imprecision due to small sample size

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

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