Date Published: 8 February 2016

Study reveals no significant benefit from routine use of antibiotics for malnourished children

According to a study by the international aid organisation Médecins Sans Frontières (MSF), the routine use of antibiotics is not of significant benefit for nutritional recovery among children with uncomplicated severe acute malnutrition.

This is a significant revelation because severe acute malnutrition is widely considered to be the most dangerous form of malnutrition. The MSF has investigated the use of antibiotics for uncomplicated severe acute malnutrition in young children who did not have medical complications requiring hospitalization.

More about the trial in Madarounfa, Niger:

This double-blind, placebo-controlled trial led to analysis of data from 2,399 children with uncomplicated severe acute malnutrition of a total 2412 children who participated in the study, 16,241 children having been assessed for eligibility. The data was gathered in Madarounfa, Niger, between October 2012 and November 2013. During the trial researchers randomly assigned children aged between 6 and 59 months who had been diagnosed as having uncomplicated severe acute malnutrition to either receive amoxicillin antibiotics or a placebo for seven days. Approximately half of the children (1202 individuals) received the antibiotics while the rest of the initial total of 2412 children received a placebo. After a small number of exclusions for reasons of protocol violation, i.e. discrepancies in how particular children were treated relative to the precise 'rules' of the scientific trial, the data analysed included information from 1200 children who received antibiotics and 1199 children who received a placebo instead.

Nutritional recovery occurred in 65.9% of children in the group that received amoxicillin and in 62.7% of the children in the placebo group.

" There was no significant difference in likelihood of nutritional recovery with amoxicillin versus placebo," said Myrto Schaefer, MSF deputy medical director.

She went on to explain that the finding that amoxicillin did not have significantly better effects than the placebo challenges the so-far generally accepted idea that routine antibiotic therapy is always at least beneficial, if not absolutely necessary, for the treatment of malnutrition. To clarify and illustrate such use of antibiotics to date, MSF stated that in 1999 children with severe acute malnutrition were treated as inpatients and the World Health Organization (WHO) recommended routine use of broad-spectrum antibiotics for the management of severe acute malnutrition. More recently international organisations such as the WHO and the United Nations (UN) have supported other approaches to the management of malnutrition, such that children with uncomplicated severe acute malnutrition are often looked after at home with ready-to-use therapeutic food and also broad use of antibiotics, which is still recommended. However, according to the 2012-13 MSF study, there is little evidence to support use of antibiotics for uncomplicated severe acute malnutrition for children.

Are there any arguments for the continued use of broad-spectrum antibiotics for severe acute malnutrition ?

In the recent article on its website1 the MSF cites only one other randomized trial that investigated the use of antibiotics in non hospital-based treatment of severe acute malnutrition. That study, which took place in Malawi in 2013 and did advocate the general use of antibiotics to treat severe malnutrition, involved children who were considered 'high-risk', many of whom had the undernutrition disease kwashiorkor (a form of protein energy malnutrition) and some of whom had HIV. In the case of that study it was not possible to confirm a benefit among children without HIV infection because the Malawian children with HIV were not assessed separately. Therefore the authors of the study in Niger were not satisfied that application of the recommendations from the Malawian trial to a more general population was scientifically valid.

Why not use antibiotics unnecessarily ?

Concerns about the use of unneccesary antibiotics are not driven merely by considerations of cost but are also about the possible long-term implications of widespread use of antibiotics. This could lead to bacteria developing resistance to antibiotics, which could then result in some infections becoming very difficult and expensive to treat. Unnecessary, and therefore inappropriate, prescription of antibiotics - such as in cases of common colds, has often been mentioned in the UK media in recent years and is therefore becoming a well-known issue. However, according to MSF, the routine use of antibiotics for the treatment of severe acute malnutrition amounts to about 15% of all antibiotic use among children younger than five in the area in which the 2012-13 trial took place.

" Given the cost and public health consequences of emerging antibiotic resistance associated with routine antibiotic use, current practices in the treatment of malnutrition should be questioned and studied further," said Rebecca Grais, director of research at Epicentre, the research arm of MSF.

" This study shows that in certain settings we can omit antibiotics from standardized treatment without compromising a child's ability to recover. In fact, in places where the medical infrastructure is adequate, public health authorities could consider eliminating the routine use of antibiotics in malnutrition treatment."

This study has resulted in some interesting and important data in addition to generating another opportunity to raise awareness about the risks of resistance to antibiotics; risks that are real and important globally. For further details about this study see the resulting paper which has been published in the New England Journal of Medicine, ref. below.

Source(s): Médecins Sans Frontières (MSF), http://www.msf.org1.

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