Benefits and risks Head or whole body cooling in management of hypoxic ischaemic

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5.7 Antibiotics for treatment of necrotizing enterocolitis

Young neonates with suspected necrotizing enterocolitis NEC should be treated with IV or IM ampicillin or penicillin and gentamicin as a irst line antibiotic treatment for 10 days. Standard recommendation, low quality evidence Remarks he panel noted that it has been common practice to add metronidazole to the treatment of NEC. Although there is no evidence to judge its beneits, metronidazole covers gastrointestinal tract anaerobic bacteria such as Bacteroides fragilus. It also noted that while a combination of vancomycin and cetriaxone is a suitable alternative, the only evidence is from tertiary western intensive care units. Vancomycin and 3rd generation cephalosporins are expensive, and would not be feasible to use as a irst line antibiotic treatment for NEC in low-resource settings.

5.7.1 Evidence and summary of findings

NEC is a serious disease characterized by varying degrees of mucosal necrosis, seen predominantly in premature infants. he underlying pathogenesis remains unclear and pathogenic organisms are not isolated in many cases. Clustering of cases and outbreaks in nurseries suggest an infective component to its aetiology. Four studies were found directly comparing antibiotic regimens in NEC. One non-concurrent cohort study from Belgium was excluded as the efect of the addition of metronidazole to an existing antibiotic regimen could not be separated from other simultaneous modiications to an existing management protocol e.g. earlier and diferent surgical approaches, changes in anaesthesia, and modiication of intensive care management routines. One study included 46 cases of NEC in 1982–3 treated with ampicillin and gentamicin, and 44 cases in 1984–5 treated with vancomycin and cetriaxone [Scheifele, 1987]. here were no statistical diferences in any measured outcomes for infants of birth weight 2200g and complications were infrequent in both groups. For infants 2200g, those treated with Vancomycin demonstrated statistically lower rates of death p = 0.048, need for surgery p = 0.04, culture positive peritonitis p = 0.01, and major complications p = 0.004: these included peritonitis, strictures, feed intolerance, and recurrent NEC and thrombocytopenia. he quality of evidence was graded as very low. One RCT allocated 42 premature infants with radiographically conirmed NEC to receive IV ampicillin and gentamicin or to receive ampicillin, gentamicin, and clindamycin [Faix, 1998]. his study found an increased rate of complicating strictures in the clindamycin group NNT harm 3, 95 CI 2 to 13 with a consequently longer time needed to restart feeds 8.4 days versus 22.3. here were no signiicant diferences in rates of death or in incidence of gangreneperforation. he study was terminated early due to signiicantly higher rates of strictures in the clindamycin group. he quality of evidence was graded as low see GRADE table A7.5 .