Antibiotics could cut deaths from malnutrition

[NAIROBI] Including antibiotics in emergency treatment for malnutrition could help save more children from dying than food alone, two recent studies suggest.

A study on 2,800 children in Malawi found that fewer children died when they were fed ready-to-use therapeutic food (RUTF) for 30 days and received antibiotics (amoxicillin or cefdinir) for the first seven, although the antibiotics did not have an effect on how quickly children recovered.

The findings were published in the New England Journal of Medicine (31 January) and presented to the WHO Nutrition Guidance Expert Advisory Group at a meeting in February, says Indi Trehan, the lead author of the study from the Washington University in St. Louis, United States.

"The WHO accepted the results of our study … they will include our recommendations in the upcoming 2013 version of the guidelines for management of acutely malnourished [children]," he says.

"Using antibiotics in addition to RUTF will decrease deaths and improve recovery rates. Thousands of lives may be saved — malnutrition kills around one million children around the world each year," Trehan adds.

A quarter of children worldwide is affected by malnutrition, and up to 15 per cent of them do not respond to RUTF treatment. There is also a lack of evidence on how best to allocate such food aid.

Another study, published in Science last month (1 February), looked at 317 pairs of twins from Malawi, some with a severe acute malnutrition known as kwashiorkor.

People harbour around one kilogram of microbes in their gut, which help them digest food and are known as gut microbiota.

The study found that children with kwashiorkor have different microbial communities in their gut. They have more of a type of bacteria known as actinobacteria as well as "immature" microbiota.

RUTF treatment helped change the malnourished children's microbiota, but the effect did not last after the treatment was stopped.

To test if the gut microbes were a risk factor for developing acute malnutrition, or simply a consequence of it, the researchers introduced the healthy and immature microbiotas to mice and fed them the typical, nutrient-poor Malawi diet.

Mice with microbes from malnourished children lost weight. They recovered with RUTF, but lost weight again when they went back to the Malawi diet.

"Although the [two] papers … indicate that intentional manipulation of the gut microbiota could eventually form part of the treatment for RUTF-unresponsive, malnourished children, antibiotics are a blunt tool for altering the composition of the microbiota, as their effects can differ substantially between individuals," Ruth Ley, a professor at Cornell University, wrote in Nature last month (28 February).

"A more feasible approach might be bacteriotherapy, which involves infusing a healthy microbiota directly into the patient's gut," she said.

This approach has been successful in treating Clostridium difficile infections, but it is intensive and costly as it requires a clinical procedure, according to Ley. More practical may be a probiotic-like formulation, in which select microbes are taken orally as a supplement.

"The best preventive treatment, of course, is to provide proper nourishment throughout childhood," Ley concludes.

Caroline Owange, a nutritionist with Kenya's Ministry of Public Health and Sanitation, says children suffering malnutrition often have infections because of their weakened immune systems, and medical workers must go beyond simply administering antibiotics.

"While treating outpatient children for malnutrition, antimalarials, vitamin A and deworming treatments are recommended to treat infections and boost the immune system," she says, adding that routine immunisation is also important.

But Ley writes that the risks of the widespread use of antibiotics must be considered.

Trehan disagrees, dismissing potential fears that administering antibiotics on a large scale would lead to complications, including resistance.

"Antibiotic resistance is a real problem but a small concern here, as they are given for such a brief period. The risk in this context is vastly outweighed by the benefits," he says.

Link to full paper in the New England Journal of Medicine

Link to full paper in Science

Link to article in Nature