Assessment of childhood pneumonia management and outcomes at primary healthcare centres in Islamabad and Rawalpindi: an observational cohort study from Pakistan

Background: Pneumonia remains a leading cause of under-five mortality in Pakistan. The Government of Pakistan adopted the revised World Health Organization guidelines, which recommend outpatient management of chest indrawing pneumonia using oral amoxicillin in children aged 2-59 months. We evaluated the management and outcomes of the guidelines at the primary healthcare (PHC) settings in Islamabad and Rawalpindi, Pakistan. Methods: We conducted a prospective observational cohort study (January 2024-February 2025) across seven PHCs. Children aged 2-59 months with cough and/or difficult breathing and chest indrawing without general danger signs, who lived in the catchment area, were enrolled following caregiver consent and followed up on day 15. The primary outcome was the case fatality rate (CFR), with secondary outcomes being caregiver-reported cure, hospitalisation, and antibiotic adherence in follow-up children. Results: Of 3358 children screened, 373 (11.1%) were diagnosed with chest indrawing pneumonia. Median age was 11 months, and 57.1% (n = 213) were male. By day 15, 366 children were successfully followed up. The CFR was 0.6% (n = 2; 95% confidence interval (CI) = 0.1-2.1), with both deaths in infants (aged 2-11 months). Caregivers reported that 89.3% (n = 327) were cured, 9.0% (n = 33) remained unchanged, and 1.1% (n = 4) worsened. Further, 12 children (3.3%) were hospitalised. At enrolment, 93.8% (n/N = 350/373) were prescribed oral antibiotics, predominantly amoxicillin (n = 322, 92.0%). Moreover, of these 350 children, 307 (87.7%) initiated treatment at home. Within this subgroup, 90.2% (n = 277) completed the prescribed course, and 89.9% (n = 249) of those completing treatment were cured. Among those who did not complete treatment, one child worsened, and another died. Conclusions: Outpatient treatment of chest indrawing pneumonia with oral amoxicillin at the PHC level is safe and effective, with low mortality and high cure rates. Strengthening Integrated Management of Childhood Illnesses protocols and supervision can reduce hospital referrals, while timely care-seeking and caregiver adherence can further improve outcomes in Pakistan and similar low-resource settings.