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Prescribing Pattern in Acute Diarrhoea in Three Districts in Bangladesh
Abstract
PIP
Since the irrational administration of drugs in diarrhea cases is a serious problem, a prescribing survey was made among 10 government health facilities (GHF) and private dispensaries (PD) in the Dhaka, Tangail, and Serajgong districts of Bangladesh. Using standard indicators on prescribing, patient care, and drug supply developed by the International Network for the Rational Use of Drugs, 12 prescriptions written for children under 5 years old with acute diarrhea were studied from each center (total = 120). It was found that the average number of drugs administered per encounter was 1.82 and 2.30 in the GHFs and PDs, respectively. Almost every prescription (0.79 and 0.96 in the GHFs and PDs, respectively) had an antimicrobial component, with metronidazole used in most cases despite the fact that it is not indicated in acute diarrhea and treatment guidelines advise against its use in children under age 5 years in Bangladesh. Oral rehydration salt solution was used in each facility in about 80% of cases (vs. 11% of cases in the community). Because of the inclusion of the antimicrobial, standard treatment guidelines were followed in only 17 and 23% of cases in the GHFs and PDs, respectively. Patient care indicators revealed that 1.8% of patients were examined in the GHFs vs. 65% in the PDs. 50% of patients in both facilities could report the correct dosing schedule for the drugs they were given. The GHFs do not label prescriptions, but all the drugs administered by the PDs remain in manufacturer-labeled containers. The existence of an essential drugs list and the distribution of standard treatment guidelines have not ensured good prescribing habits among health professionals for this common disease. Additional efforts are required to improve this situation.
... On the basis of the rigorous WHO guidelines for the treatment of diarrhea, 72.6% of children received inappropriate antimicrobials. The high level of antimicrobial prescriptions in this study were similar to the studies reported from Bangladesh (99%), Indonesia (94%), Mexico (79%), Pakistan (65%), India (64%) and Peru (58%) (Gani et al, 1991; Aguila and Brown, 1993; Chowdhury et al, 1993; Gutierrez et al, 1994; Singh et al, 1995; Nazami et al, 1996). The 27.4% prevalence of appropriate use of antimicrobials in our study was lower than the 73.8% figure reported by Osatakul and Tangadullart (1999), who reviewed the medical records of 529 children with 749 acute diarrheal episodes at Songklanagarind Hospital, a teaching hospital in Southern Thailand. ...
... Countries differ in the most commonly prescribed antimicrobials and employ different drugs as first-line treatments (Gani et al, 1991; Aguila and Brown, 1993; Chowdhury et al, 1993; Gutierrez et al, 1994; Singh et al, 1995; Nazami et al, 1996 ). This might depend on drug resistance features which differ between countries and also on the guidelines provided by the government . ...
... Moreover, the physicians may prescribe antimicrobials to prevent secondary infection and because of uncertainly about the diagnosis of the child's underlying condition [Howteerakul et al (2003) analysis of physicians rationales of adhering and not adhering to treatment guidelines for childhood diarrhea]. In Thailand, metronidazole is used little, (1%), but its use is markedly higher in Bangladesh (65%), Mexico (28%), and Pakistan (15%) (Chowdhury, 1993; Gutierrez et al, 1994; Nazami et al, 1996). Since amebiasis and giardiasis are uncommon in Thailand, few doctors prescribe metronidazole [the study in Mexico (Gutierrez et al, 1994 ) defined metronidazole as an antiparasitic ; in Pakistan (Nazami et al, 1996 ) it is defined as an antiamebics]. ...
This cross-sectional study aimed to estimate the prevalence of appropriate antimicrobial prescribing for treating childhood diarrhea within the public hospital system in a central region province, Thailand. Reported are findings of a prospective clinical audit of 424 cases treated by 38 physicians. Appropriate use of antimicrobials was defined as prescribing antimicrobials for managing an invasive bacterial-type, bloody diarrhea or not prescribing antimicrobials for managing a watery-type or non-bloody diarrhea. Among 424 cases with diarrhea, 12.5% were invasive bacterial-type. Of the 66 diarrheal episodes in which stool samples were cultured, 7 stool specimens were positive, two with Shigella sonnei, two with Vibrio cholerae Ogawa and three with E. coli. Based on the presence of mucus and blood in stools, 27.4% of 424 cases received appropriate antimicrobial drugs. Cotrimoxazole was the most commonly prescribed drug (51%), followed by colistin sulfate (15.3%), norfloxacin (11%), and nalidixic acid (0.5%). The average number of antimicrobials per case of inpatients was higher than outpatients (1.15 vs 0.84, p < 0.001). There was a trend toward prescribing norfloxacin in childhood diarrhea. The Ministry of Public Health should continue providing effective interventions aimed at improving physicians' knowledge of diarrhea treatment. Similar efforts should be directed toward improving caretakers' knowledge about home care for childhood diarrhea and encouraging widespread correct use of oral rehydration therapy (ORT) in the community. Hopefully, such activities will help reduce the inappropriate use of antimicrobial agents in treating diarrheal disease.
... In many cases, antibiotics are taken in diarrhea at home without having any prescription from a licensed physician. As a result, the risk of antibiotic resistance has increased among the children, and complete cure of diseases takes a longer time resulting in elevated hospital stay with increased treatment cost (26)(27)(28)(29). The persisted diarrheal cases with late hospitalization results in more antibiotic use in children. ...
Background: Childhood diarrheal diseases are common with mild-to-severe mortality rate worldwide. Lower-middle-income countries (LMICs), including Bangladesh in South Asia, are still unable to save their under-5 lives due to diarrheal conditions.
Objectives: The main aim of this study was to evaluate the duration of hospital stay and use of antibiotics in under-2 children with moderate diarrhea in Bangladesh.
Methods: This study was done on hospitalized 6 months to 2 years old pediatric patients (n=212) with an uncontrolled moderate type of diarrhea in 3 districts of Bangladesh. Based on the history of diarrhea onset, 133 and 79 patients were allocated in the early hospitalization (EH) and delayed hospitalization (DH) groups, respectively.
Results: To treat uncontrolled diarrhea at home, antibiotic therapy was initiated in 36.7% of patients in the DH group without any valid prescription, whereas only 7.5% of patients in the EH group received antibiotics (P
... al. and Nizami et. al. in children diagnosed with AGE reported that the average number of drug prescribed were found to be between 1.5 and 2.3[18][19][20][21]. ...
... As a consequence, doctors initiate the antimicrobial therapy empirically, very often aware of the risk for the bacterial flora of the intestines and the development of bacterial resistance (6). In some paper the prescription rate has arrived to unbelievable percentage of 99% (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). This phenomenon is global and has been reporter to very close to these figures to be present in Europe and United States (18)(19)(20)(21)(22)(23)(24). ...
Aim:
The aim of this study is to assess the sensitivity and specificity of procalcitonin to determine bacterial etiology of diarrhea.
The examinees and methods:
For this purpose we conducted the study comprising 115 children aged 1 to 60 months admitted at the Department of Pediatric Gastroenterology, Pediatric Clinic, divided in three groups based on etiology of the diarrhea that has been confirmed with respective tests during the hospitalization. Each group has equal number of patients – 35. The first group was confirmed to have bacterial diarrhea, the second viral diarrhea and the third extra intestinal diarrhea. The determination of procalcitonin has been established with the ELFA methods of producer B.R.A.H.M.S Diagnostica GmbH, Berlin, (Germany).
Results:
From the total number of 1130 patient with acute diarrhea procalcitonin was assessed in 105. 67 (63.8%) of these patient were male. More than one third (38.14%) of the children in our study were younger then 12 months. Approximately the same was the number of children 13-24 months (33 patients or 31.43%) and 25-60 months (32 patients or 30.43%). The mean value of PRC in children with viral diarrhea was 0.13±0.5 ng/mL in children with bacterial diarrhea was 5.3±4.9 ng/m Land in children with extra intestinal diarrhea was 1.7±2.8 ng/mL. When measured using ANOVA and Turkey HSD tests, results have shown the statistical significance when comparing viral with bacterial and extra intestinal diarrhea but were statistically insignificant when comparing bacterial and extra intestinal diarrhea.
Conclusion:
Procalcitonin is an important but not conclusive marker of bacterial etiology of acute diarrhea in children younger than 5 years.
... Although the use of population-based chemoprophylaxis in epidemic cholera has been associated with the acquisition of antibiotic resistance in the past, recent studies suggest that targeted chemoprophylaxis in household contacts of patients may reduce incidence of V. cholerae infection [52][53][54]. In areas of epidemic and endemic cholera, casual use of antibiotics is prevalent due to the heavily-utilized informal drug sector [55,56]. Thus, focused prophylaxis in household contacts represents a potential tool for disease prevention and further study should be evaluated. ...
Cholera is an acute, severe diarrheal disease caused by Vibrio cholerae that affects millions of people each year. Without prompt rehydration, death can occur within hours of the onset of symptoms. In October 2010, cholera emerged in Haiti, and the resulting large epidemic continues today. As of August 29, 2011, more than 439,000 cases have been reported in Haiti, with over 6,200 deaths. This review covers important features of epidemiology, pathogenesis, treatment and prevention of cholera, with a focus on the ongoing epidemic in Haiti.
A study of urban pharmacies in Guatemala and in Chiapas, southern Mexico, was undertaken to analyse the scale of the inadequate drug advice provided, and to identify the contributing factors. The estimate of the scale of the problem was based on the results of 969 approaches to 191 pharmacies by ‘magic clients’ (i.e. researchers pretending to be looking for treatment for relatives who had one of three ‘tracer’ diseases), interviews with 4469 pharmacy users as they left the same 191 pharmacies, and a comparison of the quality of advice offered by public and private pharmacies in Guatemala (based on exit interviews with 150 users). The contributing factors were explored using a provider survey (interviews with 166 pharmacy supervisors and 371 drug vendors), an in-depth study analysing large-chain and independent Mexican pharmacies, and a review of the national drug policies in both countries.
Although only about 11% of all drug treatments were recommended in pharmacies (the rest being prescribed by physicians or recommended by kin-groups), this still represents large numbers of treatments. Overall, 501 individuals who visited the 191 study pharmacies over 2 days of observation received drugs recommended by pharmacy staff. Much of the pharmacy advice was revealed to be poor: > 80% of the treatments recommended to the ‘magic clients’ for diarrhoeal disease or acute respiratory infection included unnecessary or dangerous drugs. Few of those who worked in the pharmacies based their advice on careful case histories. Drug advice in pharmacies was much more likely to be of poor quality than that from physicians or even kin-groups. The factors behind this poor advice were identified as a lack of knowledge about standard treatments and legal regulations, incompetence among pharmacy staff, commercial pressures (particularly in the large-chain pharmacies of Mexico), and a failure to implement the existing regulations covering the drug market and its retail practices.
It is recommended that: (1) pharmacy owners and drug vendors be made more aware that the selling of drugs should involve provision of healthcare (as well as reasonable profit-making); (2) existing drug-related legislation be reinforced (through consensus-building rather than coercion); and (3) mass training of pharmacy supervisors and drug vendors, in the standard treatment of common diseases, be undertaken. This process will be challenging and slow.
Objective: To look into the treatment given to children with acute watery diarrhea by Trainee Medical Officers at the time of admission and to compare it with the standard treatment protocol as recommended by World Health Organization for the treatment of acute watery diarrhoea. Material and Methods: This was a retrospective study conducted in Department of Pediatric Postgraduate Medical Institute, Hayatabad Medical Complex, Peshawar from June 15 to August 15, 2008. Treatment charts of children admitted with acute watery diarrhoea were studied for demographical findings, degree of dehydration and other clinical findings and treatment given at the time of admission. The data was statistically analyzed by SPSS version 10. Results: Eighty children were included in the study. The age range was from one month to five years with mean age of 25.5 months. The majority were in the range of 1 to 3 years with male to female ratio of 1.4:1. Majority (68.75%) had bowel movements more than 6 times/24 hours. Blood in the stool was present in only five cases (6.25%). Thirty-five (44%) and 12 (28%) were presented with some and severe dehydration respectively at the time of admission. Analysis of drug treatment (antibiotics, anti-protozoal, anti-emetics, stool hardeners, probiotics) showed that 65 (81.25%) children received appropriate treatment as per recommendations of World Heath Organization. All children were discharged uneventfully. Conclusion: Continuous training and supervision of the Trainee Medical Officers is required to implement standard treatment of acute watery diarrhoea according to laid down World Heath Organization guidelines. Such activities will help to reduce inappropriate use of drugs and wrong treatment for diarrhea.
Infant and child mortality in Bangladesh has declined in recent years but early death rates remain high among Bangladesh’s urban poor, even in comparison to rates in rural Bangladesh. Although they live close to the country’s leading public hospitals and private health clinics, the urban poor continue to rely heavily on services and advice provided by the informal health sector. This paper examines the use of the informal health sector by urban poor children’s main caregivers, their mothers, and the key role performed by pharmacists in treating these children. It explores the nature of the relationship between the mothers and the health providers and the implications for the broader health system. The study combines in-depth interviews with survey data.
Injection use problem in the hospitals of upazilla health complexes (UHCs) of Dhaka and Noakhali districts was studied though small group discussion with the health personnel of each the UHCs' The group discussion revealed that in the hospitals of UHCs of Dhaka, the antibiotic injections were used in 70% to 100% encounters in ARl/pneumonia. In dehydration, IV fluid and Antimicrobial injections were used in 60% to 100% of the encounters. Similarly 60% to 70 % of the encounters received analgesic and antibiotic injections in injury. Injections were used in >30% of the encounters in pyrexia of unknown origin. The use of injections in the hospitals of the UHCs of Noakhali was comparatively less than that of Dhaka, but was still too high. In ARl/pneumonia antibiotic injections were used in 60% to 80% of the encounters. In dehydration IV fluid and antimicrobial injections and in injury, analgesic and antibiotic injections were used in 60% to 80% of the encounters in each of the health conditions. In weakness IV fluids and amino acid injections were used in 100% and 50% of the encounters respectively. In undiagnosed fever antibiotic injections were use in 60% of the encounters. The findings of the retrospective prescribing survey in those health complexes of the two districts corroborated the findings of the small group
Discussion. ln the UHCs of Dhaka districts excessive injections were used in (i) ARl/pneumonia, (ii) dehydration and (iii) in injury. In ARl /pneumonia antibiotic injections were used in 100%, 94% and 74% of the encounters in Dohar, Savar and Nawabgonj UHCs respectively. In dehydration lV fluid was used in 100% and 89% of the encounters in Dhamrai and Keranigonj UHCs respectively. The IV fluid was also used in 76% encounters of injury. ln the UHCs of Noakhal the injection use was some what less than that of Dhaka. Ceftriaxone injection was used in 87% and 77% of the encounters in ARI /pneumonia in Cornpanligonj and Sonaimuri UHCs respectively. In the other three UHCs analgesic injections were used in 80%, 67% and 67% of the encounters in Subarnochar, Chatkhil and Senbagh respectively.
Multiple Vibrio cholerae infections in the same household are common. The objective of this study was to examine the incidence of V. cholerae infection and associated clinical symptoms in household contacts of patients with cholera and to identify risk factors for development of severe dehydration in this cohort.
Household contacts of hospitalized patients with cholera were observed with frequent clinical assessments and collection of serum and rectal swab samples for culture for a period of 21 days after presentation of the index case.
One-half (460 of 944) of all contacts reported diarrhea during the study period, and symptoms most frequently began 2 days after presentation of the index case. Antibiotics were used by 199 (43%) of 460 contacts with diarrhea. Results of rectal swab cultures for V. cholerae were positive for 202 (21%) of 944 contacts, and 148 (73%) infected contacts experienced diarrhea. Significant dehydration developed in 26 contacts; predictors of dehydration included vomiting, each additional day of diarrhea, and blood group O status.
In urban Bangladesh, the burden of diarrheal illness among household contacts of patients with cholera is higher than was previously estimated, and prophylactic intervention is feasible, because the majority of symptomatic cases of V. cholerae infection in contacts begin soon after presentation of the index case. Re-evaluation of targeted chemoprophylaxis for household contacts of patients with cholera may be warranted.
This prospective follow-up study was carried out during 1996 to identify the outcome of children rehydrated in the ORT Corner of the Chittagong Medical College Hospital. In total, 269 children, aged less than five years, who attended the ORT Corner, accompanied by their mothers, for treatment of uncomplicated acute watery diarrhoea with 'no signs of dehydration' and 'some dehydration,' were selected for the study. Mothers of the children were interviewed at the ORT Corner, and children were followed-up at home on the 5th post-ORT Corner visit day. The follow-up was completed for 260 cases (96.7%). At follow-up, 227 cases (87.3%) were found to be cured, and 33 cases (12.7%) still had diarrhoea. Of the cured, the mean duration of the episode was 5.84 +/- 2.34 days (95% CI.5.55-6.13 days). All the cases received oral rehydration therapy (ORT) after attending the ORT Corner. Eighty-one cases (31.2%), however, reconsulted the private doctors. Of those who reconsulted, only 3 (3.7%) received WHO-recommended treatment of acute watery diarrhoea, and the rest 78 (96.3%) received medication. The medication prolonged the episode of diarrhoea significantly (6.22 days vs 5.48 days, p < 0.001). None of the cases, who reconsulted the private doctors, revisited the ORT Corner. Treatment by 'ORS only' was mentioned by 64% of the mothers as the reason for non-revisit of the ORT Corner, and 20% of the mothers denied the receipt of any advice about when to revisit the ORT Corner which calls for further strengthening of communication activities of the ORT Corner.
A study of urban pharmacies in Guatemala and in Chiapas, southern Mexico, was undertaken to analyse the scale of the inadequate drug advice provided, and to identify the contributing factors. The estimate of the scale of the problem was based on the results of 969 approaches to 191 pharmacies by 'magic clients' (i.e. researchers pretending to be looking for treatment for relatives who had one of three 'tracer' diseases), interviews with 4469 pharmacy users as they left the same 191 pharmacies, and a comparison of the quality of advice offered by public and private pharmacies in Guatemala (based on exit interviews with 150 users). The contributing factors were explored using a provider survey (interviews with 166 pharmacy supervisors and 371 drug vendors), an in-depth study analysing large-chain and independent Mexican pharmacies, and a review of the national drug policies in both countries. Although only about 11% of all drug treatments were recommended in pharmacies (the rest being prescribed by physicians or recommended by kin-groups), this still represents large numbers of treatments. Overall, 501 individuals who visited the 191 study pharmacies over 2 days of observation received drugs recommended by pharmacy staff. Much of the pharmacy advice was revealed to be poor: > 80% of the treatments recommended to the 'magic clients' for diarrhoeal disease or acute respiratory infection included unnecessary or dangerous drugs. Few of those who worked in the pharmacies based their advice on careful case histories. Drug advice in pharmacies was much more likely to be of poor quality than that from physicians or even kin-groups. The factors behind this poor advice were identified as a lack of knowledge about standard treatments and legal regulations, incompetence among pharmacy staff, commercial pressures (particularly in the large-chain pharmacies of Mexico), and a failure to implement the existing regulations covering the drug market and its retail practices. It is recommended that: (1) pharmacy owners and drug vendors be made more aware that the selling of drugs should involve provision of healthcare (as well as reasonable profit-making); (2) existing drug-related legislation be reinforced (through consensus-building rather than coercion); and (3) mass training of pharmacy supervisors and drug vendors, in the standard treatment of common diseases, be undertaken. This process will be challenging and slow.
To analyze the patterns of prescriptions and drug dispensing using World Health Organization core drug use indicators and some additional indices.
Data were collected prospectively by scrutinizing the prescriptions written by pediatric resident doctors and by interviewing parents of 500 outpatient children.
The average number of drugs per encounter was 2.9 and 73.4% drugs were prescribed by generic name. Majority of drugs prescribed were in the form of syrups (60.8%). Use of antibiotics (39.6% of encounters) was frequent, but injection use (0.2% of encounters) was very low. A high number of drugs prescribed (90.3%) conformed to a model list of essential drugs and were dispensed (76.9%) by the hospital pharmacy. Certain drugs (5.7%) prescribed as syrups were not dispensed, although they were available in tablet form. Most parents (80.8%) knew the correct dosages, but only 18.5% of drugs were adequately labeled. No copy of an essential drugs list was available. The availability of key drugs was 85%.
Interventions to rectify over prescription of antibiotics and syrup formulations, inadequate labeling of drugs and lack of access to an essential drugs list are necessary to further improve rational drug use in our facility.
Dispensing limits, which ration prescriptions to 30-day supplies when filled at community pharmacies, is a strategy commonly used to control prescription drug costs. Yet, little is known about drug dispensing patterns. Prescription dispensing patterns may have important influences on adherence, therapeutic and preventive health outcomes, and costs. This study examined dispensing patterns for five drug classes commonly prescribed for chronic conditions.
Monitoring for disparities in health and services received based upon gender, income, and geography should continue as renewed efforts to reduce under-five mortality are made in response to millennium development goal #4. The purpose of this survey was to provide a nationally representative description of current childhood diarrhoea management practices and disparities in Bangladesh.
A nationally representative, cross-sectional, cluster-sample survey was carried out in randomly selected rural and urban populations across Bangladesh. The survey was completed over an 8 month period between November 2003 and June 2004.
A total of 7308 children with a prevalent diarrhoeal illness episode within 560 clusters were identified and enrolled in the survey. In 61% of the cases help was sought from a health care provider, with over 90% practicing in the private sector. Caretaker practice disparities favouring males and higher income households were identified. Significant trends (P < 0.001) favouring higher income households were found for having sought help from any provider or a licensed doctor and for treating their child with oral rehydration solution or an antibiotic. Female children in urban households were less likely to be seen by a licensed allopath, adj OR 0.73 (95% CI 0.57, 0.94). Among rural households gender disparities were limited to females being less likely to receive an antibiotic, adj OR 0.74 (95% CI 0.65, 0.86).
Households seeking help from a health provider overwhelmingly utilize the private sector in Bangladesh. Gender inequities in the utilization of licensed providers and purchase of antibiotics, favouring males were identified. Findings suggest that higher income, urban households tend to practice greater gender discrimination. In order to better understand health dynamics in urban populations, in particular slum-dwellers, there is a need to disaggregate survey data by household location.
Larson and colleagues make an important contribution to the literature on inequities in child health in Asia by providing evidence of marked gender and socioeconomic bias in diarrhoea management in Bangladesh. Their findings speak for themselves. Oral rehydration (ORS) a low-cost intervention that could prevent ~13% of all under-five deaths in the world was significantly more likely to be administered to boys than to girls and to the least poor than to the poorest. Antibiotics that are only indicated in a small proportion of diarrhoea episodes but are nevertheless widely used were also more likely to be used by boys and by the least poor. This commentary will concentrate on the issue of social inequities rather than on the deplorable preference for treating male children. These findings must be interpreted in light of the marked progress Bangladesh has achieved in terms of child survival in recent years. Under-five mortality dropped from 149 in 1990 to 77 in 2004. The country is currently one of seven-among the 60 countries with the highest burden of under-five deaths-to be on target for reaching the corresponding Millennium Development Goal. Nevertheless as shown by Larson et al. and Bryce et al. a large proportion of Bangladeshi children who have diarrhoea still fail to receive ORS. Scaling up the use of this simple solution can make a major contribution to the further reduction of mortality levels at low cost. (excerpt)
Inappropriate prescribing for ARI and diarrhoea is a serious health problem in many developing countries including Bangladesh. A baseline retrospective prescribing survey for ARI and diarrhoea have been conducted in randomly selected 60 thana health complexes (THCs) of Dhaka division of Bangladesh. In the 38 of 60 THCs, the prescribers did not comply with the standard treatment guidelines (STG) for ARI. They are marked as 'unsatisfactory performers'. In these THCs unnecessary antibiotics were prescribed in more than 50% of the encounters. The study further revealed that in 26 THCs, comprising 41.6% of the 38 THCs, the situation was even worse regarding the indiscriminate use of antibiotics. In these THCs antibiotics were prescribed in > or =72% of the encounters. For diarrhoea, only in 8.3% of the THCs antibiotics were prescribed in > or =50% of the encounters. Encouragingly, most of the prescribers prescribed ORS. So the diarrhoea cases were dropped from the intervention. The 24 out of 26 worse performing THCs for ARI management, were grouped into three groups: Group-I (implementing STG+ Audit), Group-II (STG) and Group-III (no intervention, control). The prescribers of the THCs belonging to Group-I and Group-II received STG+Audit and STG only respectively as intervention(s). On the contrary, the prescribers of the THCs of Group-III (control) did not receive any intervention. It was observed that after the implementation of interventions the use of the unnecessary antibiotics to treat ARI was significantly reduced (p<0.01) compared to pre-intervention period in Group-I (STG+Audit). In this group highly significant (p<0.000) reduction in antibiotics use was achieved in 6 out of 8 THCs. The average reduction in antibiotic use in terms of encounters was 23.7 and 15.2% in the Group-I and Group-II respectively owing to the intervention(s). Significant reduction in antibiotic use in terms of THCs was 3 (out of 8 THCs) and 2 (out of 8 THCs) belonging to the Group-II and Group-III respectively. When compensated for the change in the control group, the reduction of antibiotic use in terms of encounters was 15.2 and 6.9% in the THCs of the Group-I and Group-II respectively due to introduction of the interventions. The study concludes that STG supported by prescription audit are highly effective interventions to change the prescribing behaviour of the prescribers for ARI in the THCs.
To develop guidelines for community health workers in the treatment of patients with diarrhoea, diarrhoea prevalence was actively surveyed for a year in a remote rural community of 915,000 persons, and the enteric pathogens and clinical features associated with diarrhoeal illness were determined in a sample of 300 patients. Bloody diarrhoea accounted for 39% of all diarrhoea episodes and 62% of diarrhoea-associated deaths. 51 (50%) of 101 patients with a history of bloody diarrhoea had Shigella infection, compared with 31 (16%) of 199 patients with other types of diarrhoea. A history of bloody diarrhoea was as predictive of the presence of shigella infection (positive predictive value 50%, negative predictive value 86%) as more complex prediction schemes incorporating other clinical features or stool microscopic examination. In the area of Bangladesh where the study was done reduction of diarrhoea-related morbidity and mortality will depend on control and treatment of shigellosis, and community health workers have been instructed to provide antibiotics for patients with a history of bloody dysentery.
Drugs and childhood diarrhoea
- K Elliot
- W Cutting
- K Attawel
How to investigate drug use in health facilities
- Chowdhury Bimo
- A Das
Self prescribing by way of pharmacies in three Asian developing countries
- G Tomson
- G Terkey