Amoxicillin for Severe Acute Malnutrition

Posted by • February 5th, 2016

1Severe acute malnutrition affects approximately 19 million children under 5 years of age worldwide and contributes substantially to mortality and the disease burden among children. Only one previous randomized trial has examined the routine use of antibiotics in the community-based treatment of severe acute malnutrition. Isanaka et al. conducted a randomized, double-blind, placebo-controlled trial in Niger that assessed the effect of routine amoxicillin use on nutritional recovery in children with severe acute malnutrition.

The role of routine antibiotic use in the treatment of severe acute malnutrition is unclear. In this randomized, placebo-controlled trial in Niger, amoxicillin did not significantly improve nutritional recovery in children with severe acute malnutrition. A new Original Article summarizes.

Clinical Pearl

• What is the historical reason for the routine use of antibiotics when treating children with acute severe malnutrition?

Bacterial infection can complicate advanced cases of severe acute malnutrition, and the risk of nosocomial infection in inpatient settings can be high. Therefore, in 1999, when all children with severe acute malnutrition were treated as inpatients, the World Health Organization (WHO) recommended routine use of broad-spectrum antibiotics for the management of severe acute malnutrition, irrespective of clinical indications.

Clinical Pearl

• Are children with severe acute malnutrition still routinely treated as inpatients?

In 2007, the WHO and the United Nations endorsed a community-based model for the management of malnutrition, in which children with uncomplicated severe acute malnutrition are treated at home with ready-to-use therapeutic food (RUTF). Community-based treatment emphasizes community mobilization and the finding of active cases, with the goal of reaching greater numbers of malnourished children before clinical complications arise.

Morning Report Questions

Q: Is the routine use of amoxicillin superior to placebo for nutritional recovery in children with uncomplicated severe acute malnutrition?

A: In the study by Isanaka et al., overall, 64% of the children enrolled in the study (1542 of 2399) recovered from severe acute malnutrition. There was no significant between-group difference in the likelihood of nutritional recovery (risk ratio with amoxicillin vs. placebo, 1.05; 95% confidence interval [CI], 0.99 to 1.12). Among children who recovered, the time to recovery was significantly shorter with amoxicillin than with placebo, with a mean treatment duration of 28 days versus 30 days. Amoxicillin had no significant effect among children with a confirmed bacterial infection at admission to the nutritional program and the effect did not vary significantly according to age or sex.

Table 2. Treatment Outcomes According to Study Group.

Q: How do the results of the study by Isanaka et al. compare with those of the only other randomized trial?

A: One other randomized study, from Malawi, evaluated the effect of routine antibiotic therapy for uncomplicated severe acute malnutrition. In that study, amoxicillin significantly reduced the risk of treatment failure (by 24%) and death (by 36%), as compared with placebo. The authors concluded that antibiotics should continue to be used routinely in areas where kwashiorkor and HIV infection are prevalent. Children with HIV infection, however, were not assessed separately, and it was not possible to confirm a benefit among children without HIV infection. In the Isanaka study in Niger, malnutrition was predominantly due to marasmus, and the prevalence of HIV infection was low. Differences in study findings may therefore be due to differences in study populations, as well as in the level of ancillary care and in the frequency of follow-up.

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