Pharmacy approach to a case of acute diarrhoea with dehydration in Antalya, Turkey

A study examining the approach of pharmacies to diarrhoeal disease in childhood was carried out in Antalya, Turkey.A fictitious case history of a 10 month infant with an acute diarrhoea of three days duration, which was clinically identical with viral diarrhoea and accompanied by moderate dehydration was hypothesised. Following this, final semester students of the medical faculty posed as relatives of the infant and sought the advice of pharmacy attendants.The approach, to this hypothesised case, of all 214 pharmacies in the Antalya municipality district was examined. Most of the pharmacy attendants (57.7%) did not ask any questions to determine a differential diagnosis or establish the degree of dehydration. Only 21.6% of the pharmacy attendants recommended consulting a doctor or health centre, 6.5% recommended Oral Rehydration Solution (ORS) without giving an explanation about the amount needed or for how long it should be administered, 44.4% only dispensed a drug, 23.8% dispensed a drug with ORS and 3.7% recommended infant formula. Antidiarrhoeals were dispensed by 67.2% of the pharmacies and 14% gave antibiotics. Also 5.6% of the pharmacy attendants advised a reduction in the infant's fluid intake, 17.3% said that they could not give an opinion regarding breast feeding 19.2% advised stopping breast feeding and 7.0% did not know. All the pharmacies except the ones with the appropriate recommendation ‘consult a doctor or a health centre’ responded with advice given without hesitation although they did not intend to inspect or examine the infant.The approaches for acute diarrhoea of the pharmacies were determined as inappropriate and harmful.     

Carob bean juice: a powerful adjunct to oral rehydration solution treatment in diarrhoea

In children, the treatment of acute diarrhoea with the World Health Organization (WHO) standard oral rehydration solution (ORS) provides effective rehydration but does not reduce the severity of diarrhoea. In community practice, carob bean has been used to treat diarrhoeal diseases in Anatolia since ancient times. In order to test clinical antidiarrhoeal effects of carob bean juice (CBJ), 80 children, aged 4–48 months, who were admitted to SSK Tepecik Teaching Hospital with acute diarrhoea and mild or moderate dehydration, were randomly assigned to receive treatment with either standard WHO ORS alone or a combination of standard WHO ORS and CBJ. Three patients were excluded from the study because of excessive vomiting. In the children receiving ORS + CBJ the duration of diarrhoea was shortened by 45%, stool output was reduced by 44% and ORS requirement was decreased by 38% compared with children receiving ORS alone. Weight gain was similar in the two groups at 24 Êh after the initiation of the study. Hypernatraemia was detected in three patients in the ORS group but in none of those in the ORS + CBJ group. The use of CBJ in combination with ORS did not lead to any clinical metabolic problem. We therefore conclude that CBJ may have a role in the treatment of children's diarrhoea after it has been technologically processed, and that further studies would be justified.     

The impact of face-to-face educational outreach on diarrhoea treatment in pharmacies

Private pharmacies are an important source of health care in developing countries. A number of studies have documented deficiencies in treatment, but little has been done to improve practices. We conducted two controlled trials to determine the efficacy of face-to-face educational outreach in improving communication and product sales for cases of diarrhoea in children in 194 private pharmacies in two developing countries. A training guide was developed to enable a national diarrhoea control programme to identify problems and their causes in pharmacies, using quantitative and qualitative research methods. The guide also facilitates the design, implementation, and evaluation of an educational intervention, which includes brief one-on-one meetings between diarrhoea programme educators and pharmacists/owners, followed by one small group training session with all counter attendants working in the pharmacies. We evaluated the short-term impact of this intervention using a before-and-after comparison group design in Kenya, and a randomized controlled design in Indonesia, with the pharmacy as unit of analysis in both countries (n = 107 pharmacies in Kenya; n = 87 in Indonesia). Using trained surrogate patients posing as mothers of a child under five with diarrhoea, we measured sales of oral rehydration salts (ORS); sales of antidiarrhoeal agents; and history-taking and advice to continue fluids and food. We also measured knowledge about dehydration and drugs to treat diarrhoea among Kenyan pharmacy employees after training. Major discrepancies were found at baseline between reported and observed behaviour. For example, 66% of pharmacy attendants in Kenya, and 53% in Indonesia, reported selling ORS for the previous case of child diarrhoea, but in only 33% and 5% of surrogate patient visits was ORS actually sold for such cases. After training, there was a significant increase in knowledge about diarrhoea and its treatment among counter attendants in Kenya, where these changes were measured. Sales of ORS in intervention pharmacies increased by an average of 30% in Kenya (almost a two-fold increase) and 21% in Indonesia compared to controls (p < 0.05); antidiarrhoeal sales declined by an average of 15% in Kenya and 20% in Indonesia compared to controls (p < 0.05). There was a trend toward increased communication in both countries, and in Kenya we observed significant increases in discussion of dehydration during pharmacy visits (p < 0.05). We conclude that face-to-face training of pharmacy attendants which targets deficits in knowledge and specific problem behaviours can result in significant short-term improvements in product sales and communication with customers. The positive effects and cost-effectiveness of such programmes need to be tested over a longer period for other health problems and in other countries.     

Evaluating the potential of an intervention aimed at promoting oral rehydration therapy (ORT) by educating pharmacy employees

Diarrhea is a major cause of morbidity and mortality in childhood, and Brazilians rely heavily on pharmacies for the resolution of this and other health problems. To promote the rational use of both pharmaceuticals and oral rehydration therapy (ORT), an intervention study was performed in pharmacies in Southwestern Brazil. Semi-structured interviews showed oral rehydration solution, or ORS (50%), antidiarrheals (39%), trimethoprim-sulfamethoxazole (27%), and yeast (22%) to be the most frequently suggested drugs, whereas questionnaire responses were ORS (75%), trimethoprim-sulfamethoxazole (25%), and yeast (25%), thus revealing that more than one methodology is needed if reliable data are to be obtained. An educational intervention was applied to 86.7% of pharmacies, but acquisition of knowledge on management of diarrhea did not prevent pharmacy workers from suggesting antidiarrheal drugs instead of ORS alone. In order to have pharmacy workers comply with official protocols for episodes of diarrhea, interventions should include regulatory measures on drugs that are contraindicated for children, and the role of pharmacies and pharmacists should be reviewed.     

The status of ORT (oral rehydration therapy) in Bangladesh: how widely is it used?

During 1980-1990 BRAC, a Bangladeshi non-governmental organization, taught over 12 million mothers how to prepare oral rehydration therapy (ORT) at home with lobon (common salt) and gur (unrefined brown sugar). This was followed by a strong promotion and distribution of prepackaged ORS by various agencies including the government. In 1993 we assessed knowledge of ORT preparation, its local availability and its use for the management of diarrhoea. Over 9000 households in 90 villages were revisited; 306 government outreach health workers, 296 drug sellers, and 237 village doctors were interviewed; 152 government facilities and 495 pharmacies/shops were visited. ORT prepared by mothers in a sub-sample of the households was analyzed for chloride content and interviewers collected information on use of ORT for diarrhoeal episodes occurring in the preceding two weeks. The data quality was assessed through a resurvey of sample respondents within two weeks of the first interview. Over 70% of the mothers could prepare a chemically 'safe and effective' ORS. A significant proportion of these mothers were very young at the time of the mass campaigns using house to house teaching, implying an intergenerational transfer of the knowledge on ORT. ORT was found to be used in 60% of all diarrhoeal episodes, but the rate varied with the type of diarrhoea, being highest for daeria (severe watery diarrhoea) and lowest for amasha (dysentery). Drug sellers and village doctors now recommend ORT much more frequently than before. Members of the medical profession (qualified and unqualified) still lag behind in prescribing the use of ORT. The availability of pre-packaged ORS in rural pharmacies has improved enormously. There is convincing evidence that the widescale promotion in the past of ORS for dehydration in diarrhoea has led to this marked improvement today. Nevertheless the use of rice-based ORS, culturally appropriate messages and the promotion of ORS with food offer opportunities to further improve the utilization of ORT.     

Factors associated with carriage of penicillin-resistant Streptococcus pneumoniae among Vietnamese children: a rural-urban divide

This study examined the relationship between antimicrobial resistance in Streptococcus pneumoniae and patterns of antimicrobial usage and over-the-counter dispensing by pharmacies in urban and rural districts of Vietnam. The antimicrobial susceptibility of S. pneumoniae carried by healthy urban and rural school children was determined. Questionnaires were distributed to parents to describe their healthcare-seeking behaviour. Mock parents presented standardized cases of mild respiratory infection and acute watery diarrhoea to pharmacies in the district surrounding each school. Penicillin resistance was significantly more common in S. pneumoniae carried by urban children compared to rural children as was recent antibiotic usage. Both urban and rural pharmacies showed high rates of dispensing inadequate antimicrobial regimens. The high level of antimicrobial resistance in S. pneumoniae may be related to greater antimicrobial usage. This may result from the much easier access to healthcare providers in urban areas and may suggest that relying solely on education without limiting access to outlets may have only limited impact. The results suggest a greater understanding of the subtleties of healthcare-seeking behaviour, and access to healthcare is needed to help refine and guide rationale suggestions to reduce the continued spread of drug resistance.     

Clinical trials of improved oral rehydration salt formulations: a review.

Reviewed are all the published clinical trials of glycine-based oral rehydration salts (ORS), L-alanine-based ORS, L-glutamine-based ORS, maltodextrin-based ORS, and rice-based ORS, as well as the results of several recently completed, but unpublished, studies of these formulations that were supported by WHO. All experimental ORS formulations contained the same concentrations of salts as citrate-based WHO-ORS; all trials were randomized comparisons with WHO-ORS, and all except those with rice-based ORS were double-blind studies. The rate of stool loss and, less frequently, the duration of diarrhoea were used as indicators of clinical performance to compare ORS formulations. The following conclusions were reached concerning the efficacy and use of modified ORS formulations. Rice-based ORS (50 g/l) is superior to WHO-ORS for patients with cholera, and for such patients it can be recommended in any situation where its preparation and use are practical. Rice-based (50 g/l) and WHO-ORS solutions are equally effective for treating children with acute non-cholera diarrhoea, when feeding is resumed promptly following initial rehydration, as has been consistently recommended by WHO. Since rice-based ORS is not superior to WHO-ORS for such children, there is no apparent reason to advise a change from glucose to pre-cooked rice in the recommended formulation for WHO-ORS. Maltodextrin-based ORS formulations (50 g/l) and WHO-ORS appear to be equally effective for treating children with acute non-cholera diarrhoea; there is no reason to advise a change from glucose to maltodextrin in the recommended formulation for WHO-ORS. Amino-acid-containing ORS formulations are not recommended for either non-cholera or cholera diarrhoea, since they are more costly and have no clinical advantage over WHO-ORS for children with acute non-cholera diarrhoea or over rice-based ORS for persons with cholera.     

L-isoleucine-supplemented Oral Rehydration Solution in the Treatment of Acute Diarrhoea in Children: A Randomized Controlled Trial

Antimicrobial peptides represent an important component of the innate immune defenses of living organisms, including humans. They are broad-spectrum surface-acting agents secreted by the epithelial cells of the body in response to infection. Recently, L-isoleucine and its analogues have been found to induce antimicrobial peptides. The objectives of the study were to examine if addition of L-isoleucine to oral rehydration salts (ORS) solution would reduce stool output and/or duration of acute diarrhoea in children and induce antimicrobial peptides in intestine. This double-blind randomized controlled trial was conducted at the Dhaka Hospital of ICDDR,B. Fifty male children, aged 6-36 months, with acute diarrhoea and some dehydration, attending the hospital, were included in the study. Twenty-five children received L-isoleucine (2 g/L)-added ORS (study), and 25 received ORS without L-isoleucine (control). Stool weight, ORS intake, and duration of diarrhoea were the primary outcomes. There was a trend in reduction in mean±standard deviation (SD) daily stool output (g) of children in the L-isoleucine group from day 2 but it was significant on day 3 (388±261 vs 653±446; the difference between mean [95% confidence interval (CI) (-)265 (−509, −20); p=0.035]. Although the cumulative stool output from day 1 to day 3 reduced by 26% in the isoleucine group, it was not significant. Also, there was a trend in reduction in the mean±SD intake of ORS solution (mL) in the L-isoleucine group but it was significant only on day 1 (410±169 vs 564±301), the difference between mean (95% CI) (-)154 (-288, −18); p=0.04. The duration (hours) of diarrhoea was similar in both the groups. A gradual increase in stool concentrations of ß-defensin 2 and 3 was noted but they were not significantly different between the groups. L-isoleucine-supplemented ORS might be beneficial in reducing stool output and ORS intake in children with acute watery diarrhoea. A further study is warranted to substantiate the therapeutic effect of L-isoleucine.Key words: Dehydration, Diarrhoea, Acute, Diarrhoea, Infantile, Double-blind method, Oral rehydration solutions, Randomized controlled trials, Bangladesh     

Oral rehydration therapy in the home by village mothers in Burma

Acceptability and effectiveness of oral rehydration therapy (ORT) when given by mothers in the home under village conditions was investigated in six (two control and four test) communities at Htauk-kyant near Rangoon, Burma. The control and test village communities had populations of 2085 and 4278 respectively, of which 218 and 623 were children under five. In the test villages, Oral Rehydration Salts (ORS) were made constantly available by providing each household with one packet of ORS, which was replenished whenever a used packet was returned to the field workers during their daily surveillance rounds. In control villages ORS packets were not provided. Daily diarrhoea surveillance was made for one year, including daily weighing of each child with diarrhoea, and across-episode weight changes were calculated. Monthly mass anthropometric measurements (weight and height) were carried out on over 90% of all children in test and control villages. Stool samples were investigated for bacterial aetiological agents. In test villages 327 children developed diarrhoea (52% of all children) with a total of 639 episodes and an incidence of 1.3 episodes per child per year. 314 diarrhoea episodes (49% of all) occurred in 67 children who had three or more episodes each. ORS was readily accepted and administered by mothers in 96% of the diarrhoea episodes. The impact of ORS on mortality and morbidity could not be demonstrated as there was no death, nor necessity for admission to hospital for diarrhoea in either test or control village populations.(ABSTRACT TRUNCATED AT 250 WORDS)     

Does an L-glutamine-containing,Glucose-free,Oral Rehydration Solution Reduce Stool Output and Time to Rehydrate in Children with Acute Diarrhoea? A Double-blind Randomized Clinical Trial

This study assessed whether an oral rehydration solution (ORS) in which glucose is replaced by L-glutamine (L-glutamine ORS) is more effective than the standard glucose-based rehydration solution recommended by the World Health Organization (WHO-ORS) in reducing the stool volume and time to rehydrate in acute diarrhoea. In a double-blind, randomized controlled trial in a Mexican hospital, 147 dehydrated children, aged 1-60 month(s), were assigned either to the WHO-ORS (74 children), or to the L-glutamine ORS (73 children) and followed until successful rehydration. There were no significant differences between the groups in stool output during the first four hours, time to successful rehydration, volume of ORS required for rehydration, urinary output, and vomiting. This was independent of rotavirus-associated infection. An L-glutamine-containing glucose-free ORS seems not to offer greater clinical benefit than the standard WHO-ORS in mildly-to-moderately-dehydrated children with acute non-cholera diarrhoea.     

Health improvement for disadvantaged people in Nepal – an evaluation

Background

Diarrhoea is the second leading cause of death in children under five accounting for 1.8 million deaths yearly. Despite global efforts to reduce diarrhoea mortality through promotion of proper case management, there is still room for ample improvement. In order to seek options for such improvements this study explored the knowledge and practices of diarrhoea case management among health care providers at health centres and drug shops in Uganda.

Methods

Records were reviewed for case management and structured interviews concerning knowledge and practices were conducted with the staff at all health centres and at all identified drug shops in the rural district of Namutumba, Uganda.

Results

There was a significant gap between knowledge and documented practices among staff. Antibiotics, antimalarials and antipyretics were prescribed or recommended as frequently as Oral Rehydration Solution (ORS). In almost a third of the health facilities, ORS was out of stock. 81% of staff in health centres and 87% of staff in drug shops stated that they prescribed antibiotics for common diarrhoea. Zinc was not prescribed or recommended in any case.

Conclusions

The findings indicate that many children presenting with diarrhoea are inadequately treated. As a result they may not get the rehydration they need and are at risk of potential side effects from unjustified usage of antibiotics. Practices must be improved at health centres and drug shops in order to reduce childhood mortality due to diarrhoeal diseases.     

Treatment patterns for childhood diarrhoea: evidence from demographic and health surveys.

Treatment patterns for childhood diarrhoea among providers in public and private settings have been examined using data from 28 surveys in the Demographic and Health Surveys programme. In the majority of surveys, at least 50% of the children with diarrhoea who sought care from a health provider (public or private) received treatment that included oral rehydration salts (ORS). Private providers are a significant source of care for children with diarrhoea, but they are less likely to use ORS and more likely to prescribe unneeded drugs than providers in public settings. In countries where data are available, bloody diarrhoea appears to be undertreated. The results indicate that national public health programmes must continue to improve their strategies to ensure correct treatment of childhood diarrhoea by all health providers.     

Efficacy of standard glucose-based and reduced-osmolarity maltodextrin-based oral rehydration solutions: effect of sugar malabsorption.

Previously we reported that standard oral rehydration salts (ORS) solution is not as effective as a reduced-osmolarity glucose-based ORS for the treatment of children with acute noncholera diarrhoea: with standard ORS the diarrhoea lasts longer, stool output is greater, serum sodium is higher, and there is more need for supplemental intravenous infusion. We studied a reduced-osmolarity maltodextrin (MD)-based ORS to determine whether it had similar benefits, and also the effect of sugar malabsorption on the efficacy of standard and MD-based ORS. A total of 90 boys aged 3-24 months with acute noncholera diarrhoea and moderate dehydration were randomly assigned to either standard ORS (glucose 20 g/l, osmolarity 311 mmol/l) or MD-ORS (MD 50 g/l, osmolarity 227 mmol/l). There were no differences in treatment results. Some 46% of subjects had a high total stool output (> 300 g/kg), which was unrelated to the type of ORS given. High stool output was significantly associated with a longer duration of diarrhoea (33 vs. 15 hours; P < 0.001), a persistently elevated serum sodium (149 vs. 144 mmol/l at 24 h; P < 0.02), the need for intravenous infusion (11/41 vs. 0/48; P < 0.002), and an increase in faecal reducing substances (10.8 vs. 3.4 g/l at 24 h; P < 0.001). We conclude that some children given standard ORS develop osmotic diarrhoea owing to the combined effect of transient sugar malabsorption and slight hypertonicity of the ORS. Earlier studies show that this adverse outcome can largely be avoided when extra water is given in reduced-osmolarity glucose-based ORS. Reduced osmolarity has no benefit, however, when glucose is replaced by maltodextrin, probably because the sugars released by hydrolysis of MD, when malabsorbed, raise the intraluminal osmolarity to equal or exceed that of standard ORS. Thus, reduced-osmolarity glucose-based ORS is superior to both standard ORS and reduced-osmolarity solutions based on maltodextrin and probably other complex carbohydrates. Studies are in progress to define the optimal formulation of reduced-osmolarity glucose-based ORS.     

Standard WHO-ORS versus reduced-osmolarity ORS in the management of cholera patients

The study compared the safety and efficacy of an oral rehydration salts (ORS) solution, containing 75 mmol/L of sodium and glucose each, with the standard World Health Organization (WHO)-ORS solution in the management of ongoing fluid losses, after initial intravenous rehydration to correct dehydration. The study was conducted among patients aged 12-60 years hospitalized with diarrhoea due to cholera. One hundred seventy-six patients who were hospitalized with acute diarrhoea and signs of severe dehydration were rehydrated intravenously and then randomly assigned to receive either standard ORS solution (311 mmol/L) or reduced-osmolarity ORS solution (245 mmol/L). Intakes and outputs were measured every six hours until the cessation of diarrhoea. During maintenance therapy, stool output, intake of ORS solution, duration of diarrhoea, and the need for unscheduled administration of intravenous fluids were similar in the two treatment groups. The type of ORS solution that the patients received did not affect the mean serum sodium concentration at 24 hours after randomization and the relative risk of development of hyponatraemia. However, patients treated with reduced-osmolarity ORS solution had a significantly lower volume of vomiting and significantly higher urine output than those treated with standard WHO-ORS solution. Reduced-osmolarity ORS solution was as efficacious as standard WHO-ORS solution in the management of cholera patients. The results indicate that reduced-osmolarity ORS solution is also as safe as standard WHO-ORS solution. However, because of the limited sample size in the study, the results will have to be confirmed in trials, involving a larger number of patients.     

Community-based cluster surveys on treatment preferences for diarrhoea, severe diarrhoea, and dysentery in children aged less than five years in two districts of Ghana

Hospital-based surveillance for severe diarrhoea has been recommended to assess the burden of disease due to rotavirus. However, information on healthcare-seeking patterns of residents in the hospital catchment area is needed first to obtain the burden of disease in the community using the hospital data. A community-based cluster survey was conducted in two districts of Ghana, each served by a single district hospital, to determine the prevalence of severe diarrhoea among and treatment preferences for children aged less than five years. Caretakers of 619 children in Tema, an urban district, and caretakers of 611 children in Akwapim South, a rural district, were interviewed. During the month preceding the survey, the prevalence of severe diarrhoea in children aged less than five years was similar in the two districts (13.6% urban and 12.9% rural), as was the proportion of mothers who sought care outside the home (69.0% urban and 70.9% rural). 48.8% of urban mothers of children with severe diarrhoea visited public/private clinics, 9.5% pharmacies, and 3.6% the district hospital. Whereas, 22.8% of rural mothers visited public/private clinics, 19.0% pharmacies, and 13.9% the district hospital. Results of the study suggest that rotavirus surveillance should be guided by community studies on healthcare-use patterns. Where hospital use is low for severe diarrhoea, rotavirus surveillance should include other health facilities.     

Treatment of infants with acute diarrhea in Hungary

In the treatment of infants with acute diarrhoea complicated by mild to moderate dehydration, there is a great importance of rapid rehydration over 3-4 hours with oral rehydration solution containing 60 mmol/l sodium and then the rapid reintroduction of normal diet or breast feeding which should be continued all the time if possible. The pharmacological treatment of diarrhoea is not justified. In the present study which was part of a European multicentre survey using questionnaires the authors analysed how the recommendation of European Society of Pediatric Gastroenterology, Hepatology and Nutrition are followed in Hungary. It was evaluated 131 returned questionnaires, 80 of primary care and 51 of hospital-based pediatricians. The overwhelming majority of pediatricians (92%) recommended the oral rehydration at the beginning of treatment. The four fifth of them use the ORS with recommended composition. Only 31% of them use rapid oral rehydration over 3-4 hours. Merely 10% of them suggest the early reintroduction of normal feeding after the oral rehydration, while more than half of the respondent pediatricians (52%) think that temporarily the use of lactose free formula is justified. It is a very favourable fact that 84% of doctors recommend the continuation of breast feeding. Some kind of drugs for the treatment of diarrhoea is suggested by 15% of repliers. On the base of results it is obvious that the guidelines for the treatment of acute diarrhoea in infancy is complied only partially in Hungary and the reintroduction of normal feeding is delayed.     

Replacement of intravenous therapy by oral rehydration solution in a large treatment centre for diarrhoea with dehydration

Intravenous fluid therapy is particularly effective in reversing severe dehydration due to diarrhoea, but it can be replaced by oral rehydration, with the advantages of lower risks and costs, in the treatment of mild, moderate and some severe cases of dehydration. In this study, the efficacy of oral rehydration solution was compared with that of intravenous fluid in the treatment of moderate and some severe cases of dehydration due to diarrhoea in a treatment centre in Bangladesh during a period of 5 months in 1980 and the same months in 1981. The results of this study show that rehydration by oral rehydration solution (ORS) is as effective as intravenous fluid therapy. ORS can be used for the treatment of diarrhoeas in all age groups including young infants. The costs were reduced by 33% despite an increase in the duration of stay of some patients.