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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
.
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Wilkinson et al. 1996, used a pre-post design to compare mortality rates of 300 children admitted with SAM in South Africa over two time periods: a 6-month period
before introduction of a speciic antibiotic protocol compared with the following 6-month period, when standardized guidelines for antibiotics and management of
hypoglycemia were introduced. he recommended antibiotics were ampicillin 7 days and gentamicin 5 days. In the pre-protocol period, there were 32 deaths in 162
admissions case rate fatality [CFR] 20. In the post-protocol period, there were 8 deaths in 138 admissions CFR 6. his translates to a risk ratio of 0.25 95 CI 0.14
to 0.62, or a 75 95 CI 38-86 reduction in the risk of mortality.
In a cohort of children with uncomplicated SAM treated at home, Amthor et al 2009 retrospectively analyzed the recovery at 12 weeks Weight for Height 2
Standared Deviation and no oedema between a group treated with oral amoxicillin for 7 days n = 514 with a group not receiving antibiotics n = 1850. he chance
of recovery was 29 95 CI 7–46 higher in the group not receiving antibiotics. However, the two studied populations difered, in that children in the antibiotic
group were more likely to be wasted and less likely to have oedema.
In an open, randomized, controlled trial in a therapeutic feeding centre in Sudan, Dubray et al 2008 compared cetriaxone 75 mgkgday once daily for 2 days with
oral amoxicillin 80 mgkgday, twice daily for 5 days for uncomplicated malnutrition. Two hundred and thirty 230 children were randomized to the amoxillin group, and
228 to the cetriaxone group. Randomization was adequate, with intention-to-treat analysis. here was no signiicant diference between the two groups in weight gain
RR 0.96, 95 CI 0.81 to 1.31, recovery rate RR 0.94, 95 CI 0.84 to 1.05, mortality RR 1.27, 95 CI 0.48 to 3.36 or antibiotic-related adverse events RR 3.9, 95 CI
0.85 to 18.5. he cost of treatment with amoxicillin was signiicantly lower than cetriaxone US 1.60 versus US 0.20 for a 10 kg child.
Indirect evidence
Uncomplicated SAM
here are no data on the prevalence or aetiology of bacteraemia in children with ‘uncomplicated malnutrition’, and the role of antibiotics for ‘treatment’ of an occult
infection is therefore not clear. SAM in children is a cause of immunosuppression [Beisel 1996; Chandra 1991; Chandra 1999]. Cotrimoxazole prophylaxis reduces
mortality and morbidity in children with HIVAIDS and is currently recommended [WHO 2006]. Cotrimoxazole prophylaxis may have similar beneits in children with
malnutrition given the associated immunosuppression.
Complicated SAM
here is a high incidence of bacterial infections in children with SAM, with bacteraemia reported in 9–29 of children seven studies, UTI in 17–31 three
studies and pneumonia in 28. In 162 severely malnourished children in Tanzania, 92 had at least one bacterial infection, and 49 acquired an infection during
hospitalization [Isaack, 1992].
Frequently isolated pathogens include pneumococcus, staph. aureus, Klebsiella,
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