Characteristics of children readmitted with severe pneumonia in Kenyan hospitals

Background: Pneumonia is a leading cause of childhood morbidity and mortality. Hospital re-admission may signify missed opportunities for care or undiagnosed comorbidities. Methods: We conducted a retrospective cohort study including children aged ≥2 months to 14 years hospitalised with severe pneumonia between 2013 and 2021 in a network of 22 primary referral hospitals in Kenya. Severe pneumonia was defined using the World Health Organization criteria, and re-admission was based on clinical documentation from individual patient case notes. We estimated the prevalence of re-admission, described clinical management practices, and modelled risk factors for re-admission and inpatient mortality. Results: Among 20,603 children diagnosed with severe pneumonia, 2,274 (11.0%, 95% confidence interval (CI) 10.62 to 11.47) were readmitted. Re-admission was independently associated with age (12-59 months vs 2-11 months: adjusted odds ratio (aOR) 1.70, 95% confidence interval (CI) 1.55 to 1.88; >5 years vs 2-11 months: aOR 1.86, 95% CI 1.55 to 2.23), malnutrition (weight for age z-score (WAZ) <-3SD vs WAZ> -2SD: aOR 2.03, 95%1.83 to 2.28); WAZ -2 to -3 SD vs WAZ> -2SD: aOR 1.37, 95% CI 1.20 to 1.56) and presence of a concurrent neurological disorder (aOR 4.04, 95% CI 1.57 to 10.42) . Chest radiography was ordered more frequently among those readmitted (540/2,274 vs 3,102/18,329, p<0.001). Readmitted patients were more likely to receive second-line antibiotics (808/2,256 vs 5,538/18,173 p<0.001), TB medication (69/2,256 vs 298/18,173 p<0.001), salbutamol (530/2,256 vs 3,707/18,173 p=0.003), and prednisolone (157/2,256 vs 764/18,173 p<0.001). Inpatient mortality was 2,354/18,329 (12.8%) among children admitted with a first episode of severe pneumonia and 269/2,274 (11.8%) among those who were readmitted (adjusted hazard ratio (aHR) 0.94, 95% CI 0.82-1.07). Age (12-59 months vs 2-11 months: aHR 0.62, 95% 0.57 to 0.67), female sex (aHR 1.23, 95% 1.14 to 1.33), malnutrition (WAZ <-3SD vs WAZ> -2SD: aHR 1.90 95% CI 1.74 to 2.08); WAZ -2 to -3 SD vs WAZ> -2SD: aHR 1.48, 95% CI 1.32 to 1.65), incomplete vaccination (aHR 1.43, 95% CI 1.16 to 1.75), and anaemia (aHR 2.16, 95% CI 1.90 to 2.45) were independently associated with mortality. Conclusions: Children readmitted with severe pneumonia account for a substantial proportion of pneumonia hospitalisations and deaths. Further research is required to develop evidence-based approaches to screening, case management, and follow-up of children with severe pneumonia, prioritising those with underlying risk factors for readmission and mortality. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The research reported is funded by a Joint Global Health Trials Award (MR/R006083/1) from the Department of Health and Social Care (DHSC), the Foreign, Commonwealth & Development Office (FCDO), the Medical Research Council (MRC) and the Wellcome Trust. This UK funded award is part of the EDCTP2 programme supported by the European Union. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Kenya Medical Research Institute (KEMRI) Scientific and Ethics Review Unit approved the collection of the deidentified data analysed in this study. The CIN is run in collaboration with the Ministry of Health and participating hospitals with the aim to improve the quality of routine paediatric hospital data for use in audits, observational and interventional research. Individual consent for access to deidentified patient data was not required. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data utilized in this work was made available to the research team by the participating hospitals and the Ministry of Health, and thus we are not the primary data owners; our use for these routine hospital data is approved as part of a specific ethical review process. Further access to the data can be sought through a request to KEMRI Wellcome Trust Research Programmes's Data Governance Committee through email: dgc@kemri-wellcome.org.