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Amoxicillin first line antibiotic

This question was posted the Management of wasting/acute malnutrition forum area and has 6 replies.

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Syed Raza Shah

HSS Supervisor

Normal user

17 Oct 2015, 12:20

Hi dear All,
1. I need the information regarding why the first line of antibiotic amoxicillin medication is needed for SAM child.
2. What will be we do with SAM child in the absence of amoxicillin antibiotic medication unavailable.
3. Why do we need to only focus on MAM PLWs mother in the second and third trimester only, rather than any pregnant mother.

Rosemary

MOH

Normal user

22 Oct 2015, 07:55

Amoxicillin as a first line antibiotic is a broad spectrum antibiotic and it helps in covering the child against any "hidden" infection since you know that children with SAM do not exhibit the normal immune response like fever due to impaired immune response as a result of reductive adaptation. Treatment options are amoxyllin (chloramphenical)+ gentamicin or Benzyl Penicillin plus Gentamicin or you can do blind treatment with ceftriaxon especially useful in inpatient. But the underlying thing it is important to cover the child with an antibiotic I don't think you need to only focus on MAM PLW since all pregnant mother with HIV qualify to be at risk group its important that all these mothers be assisted through diet counseling and follow up of weight gain in every clinic visit so that they do not end up being undernourished

Mark Myatt

Frequent user

22 Oct 2015, 09:28

Three things ... (1) We focus on T2/T3 for a number of reasons. Energy requirements of pregnancy are high in T2/T3. There are many spontaneous (and induced) abortions in T1. Pregnancy may not easy to detect / verify in T1. We focus on lactating women because lactation requires energy and because we know that breastfeeding is best in the first 4 to 6 months of life. Lactation failure is dangerous to the child. We focus on MAM because this is demonstrable need. We also focus on young mothers regardless of MAM / SAM status as these women have their own growth needs. (2) Be careful with drugs and PLWs. Be sure to consult datasheets for contraindication in pregnancy and during lactation. (2) Antibiotics are growth promoters. In animal trials, > 15% increases in weight using 7% less feed (i.e. vs. control groups) have been reported. These experiments are controlled and performed at clean and disease-free research facilities. Antibiotics are, therefore, predicted to be more beneficial when used in the "wild". The mechanism of action (apart from the antimicrobial effect on the nutrition-infection cycle) is obscure. Hypotheses related to reduced energy requirements to maintaining immune response in the GI tract have some currency. Routine antibiotic treatment is needede for the reasons that Rosemary gives above and because of the growth-promotion effect.

Paul

Technical expert

29 Oct 2015, 11:41

Just some add on information to the previous posts.

In addition to the reasons previously posted, antimicrobials are recommended for the treatment in outpatients with SAM due to a reduction in mortality from 7.48% to 6.43%. The WHO guideline update (2013) recommends antimicrobials to be given even at the risk of increasing antimicrobial resistance at community level. See the update for full details.

In some contexts it has been suggested to use Co-Amoxiclav (Amoxicillin-Clavulanic Acid) where there is a problem of resistance to amoxicillin. Cefotaxime or Cefexime may be useful alternatives in the inpatient setting for complicated cases. The choice of 1st line antimicrobial should be consistent with other national guidelines (e.g. IMCI). Any decision to change the 1st line should only be done at Ministry level following review of the local evidence for resistance.

Where supply issues are the problem other antimicrobials have been used and may include co-trimoxazole, however it is suggested that this is not effective against the small bowel flora seen in SAM cases and therefore is unsuitable. Given that this action against small bowel flora is thought to be the mechanism underlying the reduction in mortality it is not to be recommended. There may also be problems with resistance to this antimicrobial too. If it is given it should be a temporary solution of last resort and should not be considered the preferred therapy. All possible efforts should be made to correct the logistical problems preventing the appropriate antibiotic from being available.

As Mark has said, during T2 and T3 the pregnancy is more easily visible, however nutritional support can be given one the pregnancy has been diagnosed by a physician or midwife even if it before this period. The addition requirements during each trimester are:
1st Trimester 85 kcal / day
2nd Trimester 285 kcal / day
3rd Trimester 475 kcal

For breastfeeding mothers the additional energy requirement for the first 6 months is:
If well nourished 500 kcal / day
If malnourished 675 kcal /day
(source: FAO / WHO, 2004)

I hope this helps.

Namesius

Clinical nutritionist/ dietitician. MOH

Normal user

30 Oct 2015, 15:46

It is advisable to give anticlbiotics to SAM children outpatients under care .

Sameh Al-Awlaqi

Public Health and Nutrition Consultant

Normal user

30 Oct 2015, 20:50

As our colleagues stated above, antibiotics are important for children with SAM admitted in OTP centers to improve the recovery and to reduce mortality rate. Moreover, Amoxicillin has a broad spectrum antimicrobial effect against against most enteric microorganisms.

In a recent randomized placebo-controlled trial published in 2014 and implemented between 2009-2011 in Malawi, 2767 SAM children enrolled into the OTP programme and categorized into 3 groups: The first one was given RUTF+Amoxicillin, Second on RUTF+Cefdinir(third generation Cephalosporin) and the third on RUTF+Placebo for the first week of admission for each group.
They have found that 88.7%, 90.0% and 85% of the children recovered respectively, we can notice the better recovery outcomes for children with Amoxcillin and Cefdinir, but at the same time children with placebo has 85% recovery rate which is close to that of Amoxicillin category. However, the mortality rate found to be higher in these patients (with placebo) with 7.4% mortality rate compared to 4.8% and 4.1% for each Amoxicillin and Cefdinir group.

Please have a look here for more details :
http://www.nejm.org/doi/full/10.1056/NEJMoa1202851(full article)
and also here :http://www.fantaproject.org/sites/default/files/resources/FANTA-Impact-CMAM-Antibiotics-May2014_0.pdf

Thanks,

Sameh

Sara Belleni

ICRC

Normal user

31 Oct 2015, 13:58

I would like to thank all the repliers to the first post. I do have a very similar request: anyone can give me some reference on the use of antibiotic for adult SAM? Not for PWL, but for adult male/women

Thank you in advance

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