Outpatient management of children with chest indrawing pneumonia in primary healthcare settings in Punjab, Pakistan: a prospective cohort study

Background: Pneumonia remains a leading cause of mortality among children under five years of age in Pakistan. The government of Pakistan revised the national Integrated Management of Childhood Illness (IMCI) protocol in 2019, recommending outpatient treatment of pneumonia, characterised by fast breathing and/or chest indrawing, with oral amoxicillin in children aged 2-59 months. We aimed to evaluate parents/caregivers-reported outcomes in children presenting with chest indrawing pneumonia at primary healthcare (PHC) facilities of Lahore, Punjab, Pakistan. Methods: We conducted a prospective observational cohort study from 3 January 2024 to 28 February 2025 at five PHC facilities in the peri-urban areas of Lahore. We enrolled children aged 2-59 months with chest indrawing pneumonia and followed them up on day 15 post-enrolment. The primary outcome was the case-fatality rate (CFR), and the secondary outcomes included antibiotic use, treatment adherence, and hospitalisation. Two physicians conducted verbal autopsies independently for children who died during the period of follow-up to determine the cause of death. We calculated CFRs with 95% confidence intervals (95% CI). Results: We enrolled 360 children aged 2-59 months, of whom 356 (98.8%) completed the 15-day follow-up. The CFR for chest indrawing pneumonia was 0.6% (n/N = 2/356; 95% CI = 0.1-2.2). At follow-up, parents/caregivers reported that 336/356 (94.4%) children were cured, while 18/356 (5.0%) showed no improvement or had worsened health. Healthcare workers prescribed oral amoxicillin to 192/356 (53.9%) children, of whom 160/192 (83.3%) adhered to the specified duration of four or more days. On day 15 of follow-up, 26/356 (7.3%) parents/caregivers reported that they had switched to other antibiotics during treatment. Among these, 7/26 (26.9%) were hospitalised and received injectable antibiotics, 5/26 (19.2%) were managed as outpatients with injectable antibiotics, and 14/26 (53.8%) were treated with different oral antibiotics on an outpatient basis. Conclusions: The low CFR and high cure rate among children with chest indrawing pneumonia treated on an outpatient basis with oral antibiotics at the PHC settings in Lahore support the IMCI protocol. Management of chest indrawing pneumonia on an outpatient basis at the primary care level is feasible, with the potential to reduce unnecessary hospital referrals, reduce antimicrobial resistance, lower healthcare costs, and decrease mortality, particularly in resource-constrained settings. Registration: ISRCTN: ISRCTN12687253.