Menu ENN Search

Antibiotics as part of the management of severe acute malnutrition

Summary of published research1

Mothers receive instruction on how to adminster antibiotics

Location: Malawi

What we know already: There is a high prevalence of clinically significant infections among children hospitalised for severe malnutrition (complicated cases).

What this article adds: Routine inclusion of antibiotics as part of the outpatient management of children with uncomplicated severe acute malnutrition at high infection risk (HIV prevalent) is warranted. Further investigation of longer term outcomes and high risk groups is needed.

International consensus guidelines now recommend the use of ready-to-use therapeutic food (RUTF) in outpatient settings as the preferred management for uncomplicated cases of severe acute malnutrition (SAM). Despite the markedly better outcomes observed with this revised outpatient regimen, 10-15% of children still do not recover, even in the context of rigorously controlled clinical trials. Even modest improvements in recovery and mortality rates could mean thousands of lives saved annually. Many studies, but not all, have shown a high prevalence of clinically significant infections among children hospitalised for severe malnutrition. This observation has led to treatment guidelines recommending the use of routine antibiotic agents even for children treated as outpatients, although outpatients are presumably much less likely to have a systemic infection than are patients with complicated cases that require inpatient care. This recommendation for the use of routine antibiotics is based on expert opinion and has not been directly tested in a clinical trial.

Mothers receive instruction on how to adminster antibiotics

A paper has recently been published on a prospective clinical trial to determine whether the routine administration of oral antibiotics as part of the outpatient management of SAM in children in Malawi was associated with improved outcomes.

The study enrolled children from December 2009 through January 2011 at 18 feeding clinics in rural Malawi. Each child’s weight, length, and mid-upper arm circumference (MUAC) were measured. Children who were 6 to 59 months of age, with oedema (indicative of kwashiorkor), a weight-for-height z score of less than -3 (indicative of marasmus) or both (marasmic kwashiorkor), were eligible for enrolment. Each eligible child was given a 30g test feeding of RUTF under the supervision of a nurse to verify that the child was an appropriate candidate for outpatient therapy. Children who were too ill to consume the test dose in the clinic were hospitalised for inpatient management.

The study was a randomised, double-blind, placebo-controlled clinical trial which compared nutritional and mortality outcomes among children with uncomplicated SAM who received treatment as outpatients with or without antibiotics. One intervention group received 80 to 90 mg of amoxicillin suspension per kg per day, divided into two daily doses; a second intervention group received approximately 14 mg of cefdinir suspension per kg per day, divided into two daily doses. The dose to be given to each child was based on a rounded amount that could be given by the field research pharmacist using the markings on a plastic syringe. The control group received placebo twice daily. Caregivers were instructed to administer the study drug in addition to RUTF during the initial seven days of therapy. Baseline characteristics of the enrolled children were similar among the three groups.

Mothers receive instruction on how to adminster antibiotics

A total of 924 children were randomly assigned to the amoxicillin group, 923 to the cefdinir group, and 920 to the placebo group. Caregivers for more than 98% of the children reported that the child completed the entire 7- day course of the study regimen.


Overall, 88.3% of the children enrolled in the study recovered from SAM. Children with marasmic kwashiorkor recovered less frequently and had higher mortality rates than children with either kwashiorkor or marasmus. The proportion of children who recovered was significantly lower among those who received placebo than among those who received either amoxicillin (3.6 percentage points lower; 95% confidence interval [CI], 0.6 to 6.7) or cefdinir (5.8 percentage points lower; 95% CI, 2.8 to 8.7). Deaths accounted for the largest proportion of children who did not recover in each study group and for each type of SAM. The overall mortality rate was 5.4%, but the rate was significantly higher among children who received placebo than among those who received either amoxicillin (relative risk, 1.55; 95% CI, 1.07 to 2.24) or cefdinir (relative risk, 1.80; 95% CI, 1.22 to 2.64). No significant differences in the causes of death, as reported by verbal autopsy (i.e. a structured investigation of events leading to the death), were identified among the three study groups. Although the point estimates for nutritional recovery were higher and those for death were lower among children who received cefdinir than among those who received amoxicillin, these differences were not significant (P = 0.22 for recovery and P = 0.53 for death, for the comparison of amoxicillin and cefdinir by logistic regression).

Kaplan–Meier survival analysis for all children in the study showed that the time to recovery was shorter in the cefdinir group than in the amoxicillin group or the placebo group and was shorter in the amoxicillin group than in the placebo group. Similarly, children who received an antibiotic agent survived longer than those who received placebo.

Weight gain from enrolment until the second follow-up visit (or until the one follow-up visit for children with only one) was significantly higher among children who received cefdinir than among those who received placebo. Children who received either antibiotic agent also had greater increases in MUAC than did those who received placebo.

As compared with children who did not recover, those who recovered were significantly older and were more likely to have their father alive and still in the home. Among children with marasmus or marasmic kwashiorkor, those with the MUAC and the lowest weight-forheight z score at enrolment were most likely to have treatment failure or to die. Children with the lowest height-for age z score were least likely to recover. Although only 874 of 2765 children (31.6%) were tested for HIV, those who were known to be HIV-seropositive, especially if not receiving antiretroviral therapy, had the highest risks of treatment failure and death. Acute infectious symptoms and poor appetite both at enrolment and at the first follow-up visit were also associated with an increased risk of treatment failure.

The amoxicillin used in this study cost an average of $2.67 per child. The cost of cefdinir was $7.85 but presumably would be lower if it were used on a large scale.

The results suggest that children with uncomplicated SAM who qualify for outpatient therapy remain at risk for severe bacterial infection and that the routine inclusion of antibiotics as part of their nutritional therapy is warranted. Further studies are needed to evaluate long-term outcomes of routine antibiotic use in children with uncomplicated SAM and to determine whether a specific high risk target population can be better defined.

Show footnotes

1Trehan. I et al (2013). Antibiotics as part of the management of severe acute malnutrition. New England Journal of Medicine, 368;5 January 31, 2013, pp 425-35

More like this

FEX: Routine amoxicillin use in treatment of uncomplicated SAM in children

Summary of research1 Location: Niger What we know: Routine use of broad-spectrum antibiotics is recommended in uncomplicated SAM case management; there is a lack of evidence...

en-net: Amoxicillin first line antibiotic

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...

FEX: Do children with uncomplicated severe acute malnutrition need antibiotics?

Summary of review1 Location: Multi-country review What we know already: Current WHO guidelines recommend routine antibiotics for all children with severe acute malnutrition...

en-net: CMAM and routine medicine

Based on WHO guideline, all severe acute malnourished children admitted to therapeutic programme are supposed to receive antibiotic whether or not they show any sign and...

FEX: Cotrimoxazole as a Prophylaxis for HIV Positive Malnourished Children

Summary of review1 By Susan Thurstans, AAH Susan Thurstans is the HIV adviser with Action Against Hunger (AAH), based in Malawi Thanks to Amador Gomez, Technical Advisor,...

en-net: Routine antibiotics in community management of SAM

Buenas tardes. ¿Además de los estudios de Niger y Malawi, respecto al uso rutinario de antibióticos en el manejo de la desnutrición aguda severa,...

en-net: Treatment of SAM children without Routine medicine

There are many occasions where CMAM program run out of routine medicines mainly Amoxicillin yet the provision of Plumpy Nut continues. Is there any study done so far to see the...

en-net: Routine antibiotics in SAM children

Dear all, As per protocol we have to administer routine antibiotics (amox) for all SAM children including those without apparent signs of infection. I would like to know...

FEX: Antioxidant Role in Preventing Kwashiorkor

Summary of published research1 A village of mothers waiting to enroll their children in Chipalonga A recent study set out to evaluate the efficacy of antioxidant...

FEX: Simplified approaches to treat acute malnutrition: Insights and reflections from MSF and lessons from experiences in NE Nigeria

View this article as a pdf Lisez cet article en français ici By Kerstin Hanson Kerstin Hanson has a background in paediatrics and public health. She most recently...

FEX: Malaria Treatment in Severe Malnutrition in Angola

By Amador Gomez and Elisa Dominguez Amador Gomez is Technical Director of Acción Contra el Hambre (ACH). Previously he spent several years working on nutrition and medical...

FEX: Routine antibiotics for infant growth failure: A systematic review

View this article as a pdf This is a summary of the following paper: Imdad A, Chen F, François M et al. (2023) Routine antibiotics for infants less than 6 months of age...

FEX: Treating high-risk moderate acute malnutrition using therapeutic food compared with nutrition counselling

View this article as a pdf This is a summary of the following paper: Lelijveld N, Godbout C, Krietemeyer D, Los A, Wegner D, Hendrixson D et al (2021) Treating high-risk...

en-net: Traitement de cas grave de Kwashiorkor

Dear all, Colleagues of mine had the following case this morning: Three years old neglected girl. Kwashiorkor case: Bilateral oedema hands and feet, gut oedema, does not...

FEX: Scaling up the treatment of acute childhood malnutrition in Niger

Milton Tectonidis By Isabelle Defourny, Emmanuel Drouhin, Mego Terzian, Mercedes Tatay, Johanne Sekkenes and Milton Tectonidis Emmanuel Drouhin is the Niger Desk Officer,...

FEX: Integrated protocol for severe and moderate acute malnutrition in Sierra Leone

Summary of research1 Location: Sierra Leone What we know: Impliementing separate protocols for MAM and SAM treatment can be administratively cumbersome in emergency...

FEX: Follow-up of post-discharge growth and mortality after treatment for SAM in Malawi

Summary of research1 Location: Malawi What we know: There are limited data on long term outcomes following discharge from SAM treatment; what exists is largely pre-HIV....

FEX: NOMA: a neglected disease!

News By GESNOMA, Winds of Hope, Sentinelles, and Médecins sans Frontières NOMA (cancrum oris and fusospirochetal gangrene or Necrotising Ulcerative Stomatitis),...

FEX: Review of WHO guidelines for the inpatient management of severe acute malnutrition

Summary of research1 Location: Global What we know: Optimising SAM management is an important strategy for reducing malnutrition-related mortality. What this article adds: A...

FEX: Community-based Therapeutic Care (CTC)

Malnourished Child being fed with ready-touse therapeutic food (RUTF) Summary of published research1 Bedawacho Woreda is a district in Ethiopia, 350 km south of Addis Ababa,...


Reference this page

Antibiotics as part of the management of severe acute malnutrition. Field Exchange 45, May 2013. p12.



Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.