Therapeutic feeding centres - Routine Antibiotics ?

Dear Editor,

Routine prescription of antibiotics to all TFC admissions regardless of clinical presentation (as recommended by WHO protocol ) seems rather extreme. What are the benefits and risks involved?

Terry Andrews MD, World Vision.

Edited from Jean Long's response for the ENN.

To date, there is no published study indicating the precise comparative benefit/risk in giving routine antibiotics to severely malnourished children - indeed the ethics of such a study would be questionable. However, a vast body of research, and experience-based evidence supports the routine administration of a broad based antibiotic on admission to TFCs. In support of this, recent expert contributions to the NGOnut network cited worse results when treating patients on the basis of specific sensitivities. Patients who died while on narrow spectrum antibiotics were autopsied within the hour and found to have mixed and multiple site infections.

The advantages and disadvantages of standardised versus non-standardised regimes are summarised below:

Non standardised regimes (i.e. waiting for onset of symptoms before antibiotic treatment)

Advantages:

- Provision of clinical care tailored to individual needs

Disadvantages:

- Increased risk of delayed recovery and excessive mortality
- Labour intensive - requires more experienced staff to diagnose, prescribe and administer individual regimes
- Increased risk of dispensing errors adversely affecting health outcomes and cost effectiveness of programme
- The depression of the inflammatory response in severe malnutrition makes all the clinical signs of infection late and
unreliable, so that it becomes almost impossible to clinically judge which child is infected and which is not - even for very experienced paediatricians

Standardised regimes (e.g. WHO protocol)

Advantages:

- Effective use of scarce staff resources - attendants can dispense routine drugs allowing nurses to focus on non responders requiring individual treatments
- Operationally less time consuming
- Utilises essential drugs
- Reduces risk of dispensing errors - MOH and their health staff are familiar with it

Disadvantages:

- Staff must be able to give IM or IV injections
- Gentamicin and chloramphenicol have long term side effects; this however must be weighed against the risk of imminent mortality

In summary , this is a question of maximising resources for optimum outcome, and so for the moment the message is that routine broad based antibiotics on TFC admission are the way to go!