Amoxicillin for Severe Acute Malnutrition in Children

n engl j med 375;2 nejm.org July 14, 2016 190 with HIV. However, granulomatous reactions, lymphocytic infiltration, and elevated levels of CSF proinflammatory cytokines have been described.1,2 The degree of inflammation in patients who are receiving HAART is unknown but is probably higher than in patients who are not receiving HAART. Our trial was designed to aid decision making at the point of diagnosis. A total of 40% of the patients in our trial were receiving HAART at trial entry. However, we found no benefit of dexamethasone, even in this predefined subgroup analysis. As Miller notes, IRIS occurred infrequently in both trial groups by 6 months (in 6 of 226 patients in the placebo group and in 7 of 224 patients in the dexamethasone group). The low rate of IRIS is interesting; we speculate that it was due to the use of higher doses of antifungal agents (particularly fluconazole) than were typically used in previous cohorts. Brandt questions the appropriateness of the regimen chosen. We chose the lowest dexamethasone dose used in the trial involving patients with tuberculous meningitis reported on by Thwaites et al. because in that trial patients who received active drug had fewer serious adverse events than patients who received placebo.3 Among the patients in the trial by Thwaites et al., 18% were infected with HIV and most had profound immunosuppression; no evidence of harm was seen. Survival in relation to the Glasgow Coma Scale score at admission is provided in Table 2 of our article, and survival in relation to raised intracranial pressure is described in Section 10 of the Supplementary Appendix (available with the full text of our article at NEJM.org). We think that allcause mortality is the most clinically meaningful end point and that our conclusions are robust.