Malnourished children in Malawi, Africa, who were treated with antibiotics in addition to a peanut-based spread were more likely to survive than children who received only the spread, according to results of a randomized trial published in the New England Journal of Medicine today.
Severe malnutrition affects more than 20 million children around the world and leads to countless deaths. Until recently, as many as half of children who were hospitalized for malnutrition died, but improvements in the treatment of these children have boosted survival rates. For all but the sickest children, an outpatient treatment regimen is now recommended that includes a ready-to-use therapeutic food made of peanut paste, powdered milk, oil, sugar, and vitamins, but even with this treatment, as many as 10% to 15% of children who receive it do not survive, according to the authors of the study.
Some evidence has suggested that infection may contribute to some of these deaths, leading to suggestions that antibiotics also be used as part of outpatient treatment for malnutrition. But concerns about the development of antibiotic resistance, as well as results from a previous uncontrolled retrospective study that showed no benefit of amoxicillin treatment, raised doubts about this practice. To better assess whether antibiotics were useful in this population, a multi-institution team of researchers randomly assigned a group of 2767 malnourished Malawian children to receive standard outpatient treatment (the nutritional supplement) plus amoxicillin, cefdinir, or placebo.
Treatment was successful for 88.7% of the children taking amoxicillin, 90.0% of those taking cefdinir, and 85.1% of those taking a placebo. Fewer children receiving antibiotics died during the trial as well, with a 4.8% mortality rate among those in the amoxicillin group and 4.1% in the cefdinir group compared with 7.4% in the placebo group. Patients in the cefdinir group also recovered more quickly and gained more weight than the other groups.
The authors note that although the possibility of antimicrobial resistance must be weighed, “we believe that the routine use of antibiotics is worth serious consideration because of the observed benefits of nutritional recovery and reduced risk of death in this specific high-risk population.”
The article is a “major contribution” to the development of treatment strategies, said Myrto Schaefer, MD, deputy medical director of Doctors Without Borders, in a statement. But she also noted that certain characteristics of the study population may limit the transferability of the results to other populations. She noted, for example, that 20% of the children in the study who were tested for HIV were infected with the virus, and these children had a form of malnutrition called kwashiorkor that is common in Malawi. Most severely malnourished children, however, have the more common marasmic malnutrition.
“Improved recovery among children with kwashiorkor given antibiotics from a region where HIV is highly prevalent is insufficient evidence to confirm that systematic antibiotics should be given to all severely malnourished children everywhere,” Schaefer said. “Antibiotic prescription on the scale of 20 million children per year is not without consequences.”
Another study published in Science this week suggests a connection between kwashiorkor and gut bacteria.