1 research outputs found
Safety and effi cacy of alternative antibiotic regimens compared with 7 day injectable procaine benzylpenicillin and gentamicin for outpatient treatment of neonates and young infants with clinical signs of severe infection when referral is not possible: a randomised, open-label, equivalence trial
Background Severe infections remain one of the main causes of neonatal deaths worldwide. Possible severe infection
is diagnosed in young infants (aged 0–59 days) according to the presence of one or more clinical signs. The
recommended treatment is hospital admission with 7–10 days of injectable antibiotic therapy. In low-income and
middle-income countries, barriers to hospital care lead to delayed, inadequate, or no treatment for many young
infants. We aimed to identify eff ective alternative antibiotic regimens to expand treatment options for situations
where hospital admission is not possible.
Methods We did this randomised, open-label, equivalence trial in four urban hospitals and one rural fi eld site in
Bangladesh to determine whether two alternative antibiotic regimens with reduced numbers of injectable antibiotics
combined with oral antibiotics had similar effi cacy and safety to the standard regimen, which was also used as outpatient
treatment. We randomly assigned infants who showed at least one clinical sign of severe, but not critical, infection (except
fast breathing alone), whose parents refused hospital admission, to one of the three treatment regimens. We stratifi ed
randomisation by study site and age (<7 days or 7–59 days) using computer-generated randomisation sequences. The
standard treatment was intramuscular procaine benzylpenicillin and gentamicin once per day for 7 days (group A). The
alternative regimens were intramuscular gentamicin once per day and oral amoxicillin twice per day for 7 days (group B)
or intramuscular procaine benzylpenicillin and gentamicin once per day for 2 days, then oral amoxicillin twice per day for
5 days (group C). The primary outcome was treatment failure within 7 days after enrolment. Assessors of treatment
failure were masked to treatment allocation. Primary analysis was per protocol. We used a prespecifi ed similarity margin
of 5% to assess equivalence between regimens. This study is registered with ClinicalTrials.gov, number NCT00844337.
Findings Between July 1, 2009, and June 30, 2013, we recruited 2490 young infants into the trial. We assigned
830 infants to group A, 831 infants to group B, and 829 infants to group C. 2367 (95%) infants fulfi lled per-protocol
criteria. 78 (10%) of 795 per-protocol infants had treatment failure in group A compared with 65 (8%) of 782 infants
in group B (risk diff erence –1·5%, 95% CI –4·3 to 1·3) and 64 (8%) of 790 infants in group C (–1·7%, –4·5 to 1·1). In
group A, 14 (2%) infants died before day 15, compared with 12 (2%) infants in group B and 12 (2%) infants in group C.
Non-fatal relapse rates were similar in all three groups (12 [2%] infants in group A vs 13 [2%] infants in group B
and 10 [1%] infants in group C).
Interpretation Our results suggest that the two alternative antibiotic regimens for outpatient treatment of clinical signs of
severe infection in young infants whose parents refused hospital admission are as effi cacious as the standard regimen.
This fi nding could increase treatment options in resource-poor settings when referral care is not available or acceptable