Metronidazole-sensitive organisms in children with severe acute malnutrition: an evaluation of the indication for empiric metronidazole treatment

Abstract Objectives Children with severe acute malnutrition (SAM) are treated with empiric amoxicillin or penicillin and gentamicin due to high risk of severe infections. Experts have suggested, based on available evidence, adding metronidazole to cover anaerobic bacteraemia and diarrhoea caused by Giardia duodenalis or Clostridium difficile . The objective of this study was to assess the importance of these infections in children with SAM. Methods Children from six months to 15 years with SAM were enrolled and followed clinically. Aerobic and, when patient weight permitted, anaerobic blood cultures were done using Bactec® system, and isolates identified with MALDI-TOF. Stool samples were tested for C. difficile, G. duodenalis and Entamoeba histolytica by PCR. Results 334 children were enrolled and 174/331 (53%) for which data on this was available had diarrhoea. Of 273 patients tested by blood culture, 11 had bacteraemia (4.0%, 95% CI 2.3%; 7.1%) but none with strict anaerobic bacteria(0/153, 0%; 2.4%). There was no difference in the prevalence of C. difficile between children with (5/128, 4%) and without (7/87, 8%) diarrhoea (OR 0.47, 0.14; 1.53), and no difference in the prevalence of Giardia between these groups (78/138, 60% vs. 46/87, 53%; OR 1.34, 0.77; 2.32). Children with C. difficile had higher mortality than those without this infection (3/11, 27% vs. 7/186, 4%; OR 43, 3.9; 483). Conclusion Our results do not provide support for empiric metronidazole to cover for anaerobic bacteraemia. Trials evaluating the effect of empiric treatment and its effect on G. duodenalis and C. difficile are warranted.