Level 2: Mid-level evidence

Home-based treatment of severe pneumonia with high-dose oral amoxicillin was evaluated in a randomized trial conducted in Pakistan (Lancet. 2008;371:49-56). Children with severe pneumonia (N=2,100) were randomized to home-based treatment vs. initial hospitalization. Children were excluded if they had asthma or very severe pneumonia, defined as inability to drink, convulsions, central cyanosis, abnormal sleepiness or difficultly in waking, clinically severe malnutrition, or stridor in a calm child.

The home-based treatment group was given oral amoxicillin 80-90 mg/kg/day in two divided doses for five days. The initial hospitalization group was given parenteral ampicillin 100 mg/kg/day in four divided doses for 48 hours, then oral amoxicillin 80-90 mg/kg/day for three days. Follow-up assessments were completed at one, three, six, and 14 days after study enrollment. Treatment failure was defined as any of the following: inability to take oral medication due to persistent vomiting, development of a comorbid condition requiring antibiotic treatment, persistence of fever >100.4°F with lower chest indrawing from day 3-6, fever or lower chest indrawing alone, hospitalization due to pneumonia, any serious adverse event, leaving against medical advice or being lost to follow-up, voluntary withdrawal of consent, or death.

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Comparing home-based vs. hospital-based treatment in an intention-to-treat analysis, 4.5% vs. 7% had treatment failure by three days (NNT 40) and 8.5% vs. 10% had treatment failure by six days (not a significant difference). Within 14 days, there was one death in the home-based treatment group compared with four deaths in the hospital-based group.