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Effective case management is an important strategy to reduce pneumonia-related morbidity and mortality in children. Guidelines based on sound evidence are avallable but are used variably. This review outlines current guidelines for childhood pneumonia management in the setting where most child pneumonia deaths occur and identifies challenges for improved management in a variety of settings and different "at-risk" groups. These include appropriate choice of antibiotic, clinical overlap with other conditions, prompt and appropriate referral for inpatient care, and management of treatment failure. Management of neonates, and of HIV-infected or severely malnourished children is more complicated. The influence of co-morbidities on pneumonia outcome means that pneumonia case management must be integrated within strategies to improve overall paediatric care. The greatest potential for reducing pneumonia-related deaths in health facilities is wider implementation of the current guidelines built around a few core activities: training, antibiotics and oxygen. This requires investment in human resources and in equipment for the optimal management of hypoxaemia. It is important to provide data from a variety of epidemiological settings for formal cost-effectiveness analyses. Improvements in the quality of case management of pneumonia can be a vehicle for overall improvements in child healthcare practices. La prise en charge efficace des cas joue un role important dans la reduction de la morbidite et de la mortalite dues a la pneumonie. Des recommandations reposant sur des elements factuels solides sont disponibles, mais sont appliquees diversement. Le present article expose dans leurs grandes lignes les recommandations actuelles pour la prise en charge de la pneumonie chez l&apos;enfant dans les pays ou interviennent la plupart des deces d&apos;enfants par pneumonie et identifie les difficultes pour ameliorer cette prise en charge dans divers pays et chez differents groupes << a risque >>. Ces recommandations concernent notamment le choix d&apos;un antibiotique adapte, le recouvrement clinique avec d&apos;autres pathologies, l&apos;orientation rapide et appropriee vers des soins hospitaliers et la prise en charge des echecs therapeutiques. La prise en charge des nouveau-nes et des enfants infectes par le VIH ou gravement denutris est plus complexe. L&apos;influence des comorbidites sur l&apos;issue de la pneumonie implique que la prise en charge de cette maladie doit s&apos;integrer dans des strategies d&apos;amelioration des soins pediatriques en general. Le plus fort potentiel de reduction de la mortalite par pneumonie dans les etablissements de soins reside dans l&apos;elargissement de l&apos;application des recommandations actuelles, elaborees autour de quelques interventions centrales : formation, antibiotiques et oxygene. Cet elargissement necessite des investissements en ressources humaines et en equipements pour une prise en charge optimale de l&apos;hypoxemie. Il est important de fournir des donnees provenant de divers contextes epidemiologiques pour etablir des analyses cout/efficacite formelles. L&apos;amelioration en termes de qualite de la prise en charge de la pneumonie pourrait servir de moteur a des ameliorations globales des pratiques de soins pediatriques. Un manejo de casos eficaz constituye una estrategia importante para reducir la morbilidad y la mortalidad por neumonia en la ninez. Las directrices basadas en la evidencia de que se dispone se utilizan en diversa medida. En el presente analisis se describen las directrices actuales para el tratamiento de la neumonia en la ninez en las circunstancias que rodean la mayoria de las muertes por neumonia en la infancia y se senalan les retos que deben superarse para mejorar el tratamiento en diversos contextos y diferentes grupos en riesgo. Entre ellos cabe citar la eleccion apropiada del antibiotico, el solapamiento clinico con otras dolencias, la derivacion rapida y apropiada para dispensar atencion hospitalaria, y el manejo de les casos de fracaso terapeutico. El tratamiento de les recien nacidos y de les ninos infectados por el VIH o malnutridos es mis complicado. Dada la influencia de posibles comorbilidades en la evolucion de la neumonia, el tratamiento de les casos de esa enfermedad debe integrarse en estrategias orientadas a mejorar la atencion pediatrica en general. Las mayores posibilidades de reducir las defunciones relacionadas con la neumonia en les centros de salud son las que se derivan de una mis amplia aplicacion de las directrices actuales centradas en unas cuantas actividades basicas: capacitacion, antibioticos y oxigeno. Eso exige invertir en recursos humanos y en equipo para manejar optimamente la hipoxemia. Es importante aportar datos procedentes de diverses entornos epidemiologicos para poder realizar analisis formales de costo-eficacia. Las mejoras de la calidad del tratamiento de casos de neumonia pueden brindar la ocasion para introducir otras mejoras mas generales en las practicas de salud infantil. [TEXT NOT REPRODUCIBLE IN ASCII], Introduction Pneumonia is the leading cause of death in children worldwide and the great majority of these deaths occur in resource-limited settings. (1) WHO developed a case-management strategy in the [...]

Nontyphoidal strains of Salmonella (NTS) are a common cause of bacteremia among African children. Cell-mediated immune responses control intracellular infection, but they do not protect against extracellular growth of NTS in the blood. We investigated whether antibody protects against NTS bacteremia in Malawian children, because we found this condition mainly occurs before 2 years of age, with relative sparing of infants younger than 4 months old. Sera from all healthy Malawian children tested aged more than 16 months contained anti-Salmonella antibody and successfully killed NTS. Killing was mediated by complement membrane attack complex and not augmented in the presence of blood leukocytes. Sera from most healthy children less than 16 months old lacked NTS-specific antibody, and sera lacking antibody did not kill NTS despite normal complement function. Addition of Salmonella-specific antibody, but not mannose-binding lectin, enabled NTS killing. All NTS strains tested had long-chain lipopolysaccharide and the rck gene, features that resist direct complement-mediated killing. Disruption of lipopolysaccharide biosynthesis enabled killing of NTS by serum lacking Salmonella-specific antibody. We conclude that Salmonella-specific antibody that overcomes the complement resistance of NTS develops by 2 years of life in Malawian children. This finding and the age-incidence of NTS bacteremia suggest that antibody protects against NTS bacteremia and support the development of vaccines against NTS that induce protective antibody., Introduction Nontyphoidal strains of Salmonella (NTS), principally Salmonella enterica serovars Typhimurium and Enteritidis, are a major but neglected cause of invasive disease in Africa and the commonest cause of bacteremia [...]