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Risks here is now growing concern about increasing frequency of MDR strains of
S. Typhi and S. Paratyphi with reduced susceptibility to irst line antibiotics and old luoroquinolones. Resistance to nalidixic acid has been used to identify these strains.
here is, therefore, a risk of treatment failure, if the current irst line antibiotics are used for treatment.
he review identiied only three instances of adverse events: severe leucopenia in the chloramphenicol group; anaphylaxis in the cetriaxone group, and a rash in the
ciproloxacin group. Side efectstoxicity of recommended antibiotics as outlined in section 6.2, WHO Model Formulary for Children [WHO 2010].
8.6.3 Acceptability and feasibility:
Value was placed on the beneits of recommended antibiotics in hastening recovery, improving symptoms, and preventing complications of poorly treated disease.
Although the current irst line antibiotics may be cheap, the cost of a shorter course of ciproloxacin may be comparable to a 14-day chloramphenicol regimen [Phongmany
2005]. In addition, the increasing numbers of clinical failures with the current irst line treatment suggest there is a cost advantage of using more eicacious medicines
in the rising levels of resistance.
Although luoroquinolones are efective and safe, there are still unfounded con- cerns of ciproloxacin safety in children that may still afect its uptake by physicians.
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9. Evidence for recommendation on use of antibiotics in SAM
9.1 Antibiotics use in the management of severe acute malnutrition
a In children with severe acute malnutrition SAM without complications, manage according to the current community case management guidelines.
Weak Recommendation, expert opinion
b In children with severe acute malnutrition with complications, give parenteral antibiotics as follows:
— Benzyl penicillin: 50 000 Ukg IMIV every 6 hours, or ampicillin 50 mgkg IMIV every 6 hours for 2 days, then oral amoxicillin: 15 mgkgdose every
8 hours for 5 days AND
— Gentamicin: 7.5 mgkg IMIV once daily for 7 days.
Weak recommendation, low quality evidence
he recommendation was based on the current WHO deinition of complicated Severe Acute Malnutrition SAM. he panel emphasized that where a child with
SAM has complications of very severe pneumonia or meningitis, treatment should be based on the speciic guidelines for these conditions.
he panel had concern that the recommendation to give antibiotic to all children with SAM, even those with no complications, would apply to a substantial number of
children in the Indian subcontinent. It was observed that there should be a distinction between the acute form of SAM, which is common in Africa and chronic SAM, which
is common in Asia. he panel made a decision not to make a recommendation to give antibiotics in SAM with no complications, but to follow community case management
recommendations for consistency.
9.1.1 Evidence and summary of findings
A systematic review [Lazzerini, 2010] identiied three studies of antibiotic efectiveness in treating children with SAM. he use of broad-spectrum antibiotics in
children hospitalized with SAM is supported by strong epidemiological data and low quality clinical studies. However, there is insuicient data from RCTs to determine
the most efective antibiotic regimen. he role of antibiotics in home treatment of ‘uncomplicated’ malnutrition is not clear, and there is very low quality evidence that
antibiotics may not be of beneit in this group
see GRADE table A7.27
.
