Management Of Acute Watery Diarrhea Research Articles

M-Follow up for zinc adherence by caretakers of children with acute watery diarrhoea: A randomized controlled trial.

The standard of care for children with acute watery diarrhea (AWD) with no dehydration comprises oral rehydration solution, zinc, and feeding advice. Adherence to zinc therapy may be an issue in the management of acute watery diarrhoea. Mobile phones are used by over 90% of the population in Tanzania, thus good means to improve adherence to prescribed medication and/or attendance to follow-up visits. The objective of this study was to see whether m-follow-up improves adherence rate to zinc therapy, possible reasons for non-adherence, in children with diarrhea.: A randomized controlled trial was carried out in a suburban municipality in Dar-es-Salaam. Block randomization of participants was carried out with a block size of 4 and a 1:1 ratio of intervention: control. The intervention group comprised participants who were to be followed up using text messages and voice calls; the control group was to be followed up in outpatient. The outcome of interest was adherence to the full course of 10 days' oral zinc, reasons for nonadherence and acceptability. Chi-square was used to compare the categorical variables. δ, the targeted difference in adherence between arms, was pre-set at 20%. The total number of participants were 196, of which 98 participants were enrolled in each arm. Full adherence to the 10-day course of zinc sulphate in children with AWD and no dehydration was 84.1% in the control arm and 89.7% in the m-follow up group (P = 0.33). m-follow up significantly improved physical attendance at 14-day clinic visit compared to control group (39.8% vs. 60.2%; P = 0.006). Commonest reasons for non-adherence in both groups were related to vomiting (67%). Vomiting at enrolment due to gastroenteritis was significantly associated with vomiting zinc sulphate with RR 2.17 (95% CI 1.24-3.79, P = 0.007). The acceptability of m-follow-up was high (99%). In conclusion the idea of m-follow-up was well received by participants who considered it acceptable. In this study, the adherence to Zinc dosing was not significantly different between the intervention and control group, and we consider that for zinc in AWD, counselling alone was good enough to achieve high adherence. The trial was registered with the Pan-African Clinical Trial Registry. Trial number: PACTR201711002737120.

Effect of Zinc Supplementation on Duration of Acute Watery Diarrhoea in Children aged Six Months to Five Years

Background: Diarrheal disease is one of the leading causes of morbidity and mortality among young children under five years of age in developing countries. The longer duration of diarrhea increases the chance of morbidity and mortality. Zinc supplementation decreases the duration of diarrhea. It is a straightforward, acceptable, low-cost, and effective treatment that could easily be affordable in our country.
 Objective: This study aimed to determine the effect of zinc supplementation on the duration of acute watery diarrhea. Materials and Methods: A total of 106 subjects were included in this study over six months, from December 2014 to May 2015. Detailed information was obtained from each patient. A total of 106 patients were taken. Among them, 53 patients (group A) were given zinc with Oral Rehydration Salts (ORS), and 53 patients (Group B) were given ORS only. However, three patients in each group were lost during follow-up. Data were analyzed by using a standard statistical method (SPSS version 16.0).
 Results: The duration of diarrhea was three days in 56% of patients in the zinc-supplemented group, but it was only 20% in the control group. The frequency of stool gradually decreased over five days. It was more marked in zinc supplemented group. The p-value was 0.001. Vomiting occurred in 30% of patients in zinc supplemented group, and in the control group, it was only 20%. The p-value was 0.5. So we conclude that oral zinc administration in acute watery diarrhea (AWD) decreases the duration and causes early recovery and may be considered in the management of AWD.
 Conclusion: Oral zinc administration in acute watery diarrhea decreases the duration and frequency of diarrhea in children aged six months to five years by changing the natural course of acute diarrheal disease.
 TAJ 2022; 36: No-1: 107-112

The Comparison of the Efficacy of Probiotic (Bacillus Clausii)with Yoghurt in the Management of Acute Watery Diarrhoea

Objective: To compare the efficacy of Probiotics with the yoghurt in the management of children with acute diarrhoea in terms of frequency and consistency of stools.
 Study Design: Quasi-experimental study.
 Place and Duration of Study: Department of Paediatric Medicine, Combined Military Hospital, Peshawar Pakistan, from Jun to Dec 2020.
 Methodology: Patients were allotted into three Groups A, B, or C. Group-A received a Probiotic (Bacillus Clausii), Group-B received plain yoghurt, and Group-C did not receive yoghurt or Probiotic. The outcome was an improvement in stool consistency at 72 hours. Stool consistency was assessed via Bristol stool chart along with frequency. Data were collected 72 hours after initiation of treatment.
 Result: The total number of patients enrolled was 159(53 in each Group). Among these, 85(53.5%) were males, and 74(46.5%) were females. There was a statistically significant association in terms of consistency (p=0.001) and term of frequency (p<0.001) in the Probiotic and Yoghurt-Group.
 Conclusion: The outcome in terms of consistency is almost equal in the Probiotic and Yoghurt-Group. However, Probiotic is superior to yoghurt in terms of frequency.

Prescription of medicines for the management of childhood acute watery diarrhoea at a tertiary hospital in Ebonyi state, Nigeria

Background: The burden of childhood diarrhoea in Nigeria is huge and has been persistently high over the years with an estimated 205 under-fifives dying daily. Asimple combination of oral rehydration salts (ORS) and zinc tablets (ORS/Zinc) has been approved for its treatment by the WHO since it is benefificial for rehydration which is the goal of therapy. However, huge resources are spent on antibiotics and other medications which are not benefificial for rehydration, thereby exposing children to unnecessary medications and other drug therapy problems. This study was set to evaluate the prescription of medicines for acute watery diarrhea (AWD) in under-fifive children and to determine the appropriateness of these prescriptions. Method: This study was conducted in a tertiary hospital in Abakaliki, Ebonyi State. It was a retrospective review of prescriptions of medicines for AWD in under-fifives for a period of 28 months (January 2019 to April 2021). All available cases of AWD (338) were extracted from the prescription registers. Data were entered into SPSS version 24.0 and descriptive analysis was done. The guideline set by WHO for the management of AWD was followed for evaluating the prescriptions. Results: Out of the 338 cases of AWD, 190 (56.2%) occurred in male children and 265 (84.4%) in children under 24 months. Of the total cases, 291 (86.1%) received prescriptions containing ORS, zinc, and probiotics either alone or in difffferent combinations with only 154 (45.6%) containing ORS and zinc together. Of these prescriptions with ORS/Zinc, 47 (30.5%) also contained antibiotics, antimalarials and infusions. In total, there were 99(29.3%) and 48 (14.2%) prescriptions containing antibiotics and antimalarials respectively. The most frequently prescribed antibiotic classes were sulfonamides (41; 40.6%), cephalosporins (29; 28.7%) and flfluoroquinolones (13; 12.9%). Less prescribed antibiotic classes include macrolides, penicillins and nitroimidazoles. Other groups of medicines prescribed were analgesics, anthelmintics, oral potassium and antacids, and antihistamines. Overall, only 107 (36.8%) prescriptions were appropriate for the management of AWD. Conclusion: This study revealed that only 36.8% of AWD cases received appropriate prescriptions according to guideline. Therefore, there is urgent need for intervention in the study setting to improve appropriate treatment of AWD.

The Prescription of Medicines for Childhood Acute Diarrhoea: A Retrospective Study at Four Secondary Healthcare Facilities in Lagos State, Nigeria

Background: Diarrhoea remains the second leading cause of mortality in children, with an estimated 205 children under the age of 5 dying daily in Nigeria. Combination therapy of ORS with zinc tablets is the cornerstone for its management. Secondary healthcare facilities (SHFs) represent the second level of contact for patients requiring professional care; hence an appropriate prescription for diarrhoea is crucial for the survival of under-fives. Objectives: To evaluate the prescription of medicines in the management of acute watery diarrhoea (AWD) in under-fives at SHFs, and determine the appropriateness of the prescriptions. Method: A descriptive cross-sectional study was done at four randomly selected SHFs in Lagos State. A retrospective review of prescriptions for diarrhoea cases totaling 480, was done using records from the General Out-Patient Department from September 2018 to August 2019. A descriptive analysis was performed.Results: All cases reviewed were diagnosed as AWD occurring either alone (352; 73.3%) or in combination with malaria/fever (55; 11.5%), cough/URTI (23; 4.8%), and other conditions (50; 10.4%). Of the 352 AWD only cases, there were 121 (34.4%) prescriptions for ORS/Zinc as combined therapy without addition of antibiotics, 120 (34.1%) for antibiotics, and 134 (38.1%) for probiotics. Other prescriptions include analgesics (18.2%), injectables (9.7%) and antimalarials (8.8%). Conclusion: The study revealed suboptimal prescriptions of ORS/Zinc with the appropriateness of prescription at 34.4%. The prescription of antibiotics and other medicines which have no rehydration benefits was high.

Role of antisecretory drug in treatment of children with acute watery diarrhea: A Randomized Controlled Trial

Background and aim Previous studies have shown that Racecadotril is safer and more effective in treating children with acute diarrhea. This study aimed to evaluate the effect of Racecadotril as a booster to oral rehydration solution in the management of acute watery diarrhea among children aged 5 years or less.Patients and methods This random clinical trial included 50 children with acute watery diarrhea for less than or equal to 5 days with a frequency of more than or equal to three diarrheic stools in the past 24 h before admission to the hospital, with no mild-to-moderate dehydration. Our study is registered to clinicaltrials.gov (NCT05216822).Results The main findings of this study were that Racecadotril reduced the duration of the diarrheal episodes and the duration of hospitalization significantly. This study revealed that Racecadotril showed an improvement in the consistency of stool, which protects the patient from fluid loss and dehydration.Conclusion Racecadotril is an effective booster-rehydration drug that carries out its antidiarrheal effect by inhibiting intestinal enkephalinase. It is efficient in reducing the volume and frequency of stool output.

Effect of 3 Days of Oral Azithromycin on Young Children With Acute Diarrhea in Low-Resource Settings

World Health Organization (WHO) guidelines do not recommend routine antibiotic use for children with acute watery diarrhea. However, recent studies suggest that a significant proportion of such episodes have a bacterial cause and are associated with mortality and growth impairment, especially among children at high risk of diarrhea-associated mortality. Expanding antibiotic use among dehydrated or undernourished children may reduce diarrhea-associated mortality and improve growth. To determine whether the addition of azithromycin to standard case management of acute nonbloody watery diarrhea for children aged 2 to 23 months who are dehydrated or undernourished could reduce mortality and improve linear growth. The Antibiotics for Children with Diarrhea (ABCD) trial was a multicountry, randomized, double-blind, clinical trial among 8266 high-risk children aged 2 to 23 months presenting with acute nonbloody diarrhea. Participants were recruited between July 1, 2017, and July 10, 2019, from 36 outpatient hospital departments or community health centers in a mixture of urban and rural settings in Bangladesh, India, Kenya, Malawi, Mali, Pakistan, and Tanzania. Each participant was followed up for 180 days. Primary analysis included all randomized participants by intention to treat. Enrolled children were randomly assigned to receive either oral azithromycin, 10 mg/kg, or placebo once daily for 3 days in addition to standard WHO case management protocols for the management of acute watery diarrhea. Primary outcomes included all-cause mortality up to 180 days after enrollment and linear growth faltering 90 days after enrollment. A total of 8266 children (4463 boys [54.0%]; mean [SD] age, 11.6 [5.3] months) were randomized. A total of 20 of 4133 children in the azithromycin group (0.5%) and 28 of 4135 children in the placebo group (0.7%) died (relative risk, 0.72; 95% CI, 0.40-1.27). The mean (SD) change in length-for-age z scores 90 days after enrollment was -0.16 (0.59) in the azithromycin group and -0.19 (0.60) in the placebo group (risk difference, 0.03; 95% CI, 0.01-0.06). Overall mortality was much lower than anticipated, and the trial was stopped for futility at the prespecified interim analysis. The study did not detect a survival benefit for children from the addition of azithromycin to standard WHO case management of acute watery diarrhea in low-resource settings. There was a small reduction in linear growth faltering in the azithromycin group, although the magnitude of this effect was not likely to be clinically significant. In low-resource settings, expansion of antibiotic use is not warranted. Adherence to current WHO case management protocols for watery diarrhea remains appropriate and should be encouraged. ClinicalTrials.gov Identifier: NCT03130114.

Effect of Saccharomyces boulardii CNCM-I 3799 and Bacillus subtilis CU-1 on Acute Watery Diarrhea: A Randomized Double-Blind Placebo-Controlled Study in Indian Children

PurposeTo assess the effect of combination probiotic Saccharomyces boulardii CNCM-I 3799 and Bacillus subtilis CU-1 in outpatient management of acute watery diarrhea in children.MethodsA randomized double-blind placebo-controlled study was conducted in 180 participants aged six months to five years with acute mild to moderate diarrhea. All were enrolled from six centers across India and centrally randomized to receive S. boulardii CNCM-I 3799 and B. subtilis CU-1 or a placebo along with oral rehydration salts and zinc supplementation. Each participant was followed up for three months to assess recurrence of diarrhea.ResultsThe mean duration of diarrhea in the probiotic and placebo groups were 54.16 hours and 59.48 hours, respectively. The difference in the duration of diarrhea in those administered with probiotic or placebo within 24 hours of diarrhea onset was 25.21 hours. Furthermore, the difference in duration of diarrhea was 13.84 hours (p<0.05) for participants who were administered with probiotics within 48 hours. There were no significant differences in the stool frequencies between the two arms. After three months, 15% in the probiotic group and 18.5% in the placebo group reported episodes of diarrhea. The mean duration of diarrhea was considerably lower in the probiotic group, 31.02 hours versus 48 hours in placebo (p=0.017).ConclusionS. boulardii CNCM-I 3799 and B. subtilis CU-1 combination was effective in reducing the duration of diarrhea when administered within 48 hours of diarrhea onset. Similarly, it reduced recurrence of diarrhea and its intensity in the subsequent three months.

767. Identification and Management of Diarrhea in Children Under Five in Bamako, Mali

BackgroundDiarrhea is a leading cause of death for Children Under Five Years Old (CUFYO) worldwide, and Mali has the second highest diarrhea-related case fatality rate among African countries. The World Health Organization’s Integrated Management for Childhood Illness (IMCI) handbook provides recommendations for management of acute watery diarrhea (AWD), including: increased fluids, continued feeding, and zinc supplementation. It restricts antibiotics to dysentery. The 2018 Malian Demographic and Health Survey noted low rates of rehydration and zinc use. This study aimed to evaluate how provider knowledge, beliefs, and practices (KBPs) align with IMCI recommendations for diagnosis and management of diarrhea in Mali.MethodsThis qualitative cross-sectional study interviewed 136 providers who manage diarrhea in CUFYO in Bamako, Mali from July - August 2017. Providers included: doctors (D), pharmacists (P), market vendors of allopathic medications (MV), traditional healers (TH), and vendors of traditional medicines (TV). Participants were randomly selected and presented with scenarios depicting diarrheal syndromes. They provided a diagnosis, etiology of illness, and management recommendations. Providers were surveyed on KBPs regarding IMCI recommendations.ResultsOnly 43% of providers provided the IMCI definition of AWD. Participant-IMCI concordant diagnosis varied by provider group for AWD (D-73%, P-67%, MV-31%, TH-18%, TV-40%), Dysentery (D-38%, P-75%, MV-38%, TH-61%, TV-40%), and Some Dehydration (D-31%, P-4%, MV-4%, TH-7%, TV-40%). Only 41% of all providers identified dehydration as a sequela of AWD; 18% noted mortality. Etiologies of AWD cited included: infection, teething, diet, hygiene, and many others. Participants volunteered treatment of AWD with fluids (D-52%, P-8%, MV-0%, TH-0%, TV-0%), but not zinc (0%). MK alone offered inappropriate use of antibiotics for AWD (23%).ConclusionProvider identification and management of diarrheal syndromes in CUFYO remain largely inconsistent with IMCI recommendations across all sectors of providers interviewed, specifically for rehydration therapy and zinc supplementation.Disclosures All Authors: No reported disclosures

Perception and Practices of Home Management of Acute Watery Diarrhoea and Its Impact on Dehydration

Background: Diarrhoea is one of the commonest causes of death in children in developing countries. Proper home management can reduce morbidity and mortality. High rates of dietary restriction, poor knowledge of preparation of ORS solutions and low attention given to clinical indicators are causes for seeking hospital management. This study was done to observe the knowledge of caregivers regarding home management of acute watery diarrhoea and to assess the impact of home management on severity of dehydration.&#x0D; Methods: This study was a prospective study carried out on children with acute diarrhea who attended outpatient department (OPD) of Rangpur Medical College Hospital and duration of the study was 6 months. A total of 100 cases were included in this study who fulfilled the definition of acute diarrhea by WHO. The investigator questioned each mother with the help of a preformed questionnaire.&#x0D; Results: In 85% of cases, caregivers perception about diarrhea was an increase in the frequency and fluidity of stool. About 95% of cases were initially treated at home; treatment was given at home with ORS (95%). There was change in feeding pattern and modified food was given (24%). Perception about ORS preparation was appropriate in 64% and inappropriate in 31% of cases. Inadequate amount of ORS was given in 74% cases. There was no interruption of breast feeding; dietary restriction during diarrhoea was observed only in 2% cases. Most of the parents did not know when to return immediately to hospital. Dehydration status of diarrhoeal cases was no dehydration (81%), some dehydration (18%) and severe dehydration (1%). In majority of the cases different drugs were used.&#x0D; Conclusion: Most of the caregivers’ decided to treat diarrhoea at home. Many of them had wrong perception about preparation of ORS and some of them did not know how to make ORS solution. Inadequate amount of ORS was given in most of the cases. Thus to lessen hospital burden and to prevent dehydration increased emphasis should be given to health education of home management of diarrhea.

A double-blind placebo-controlled trial of azithromycin to reduce mortality and improve growth in high-risk young children with non-bloody diarrhoea in low resource settings: the Antibiotics for Children with Diarrhoea (ABCD) trial protocol

BackgroundAcute diarrhoea is a common cause of illness and death among children in low- to middle-income settings. World Health Organization guidelines for the clinical management of acute watery diarrhoea in children focus on oral rehydration, supplemental zinc and feeding advice. Routine use of antibiotics is not recommended except when diarrhoea is bloody or cholera is suspected. Young children who are undernourished or have a dehydrating diarrhoea are more susceptible to death at 90 days after onset of diarrhoea. Given the mortality risk associated with diarrhoea in children with malnutrition or dehydrating diarrhoea, expanding the use of antibiotics for this subset of children could be an important intervention to reduce diarrhoea-associated mortality and morbidity. We designed the Antibiotics for Childhood Diarrhoea (ABCD) trial to test this intervention.MethodsABCD is a double-blind, randomised trial recruiting 11,500 children aged 2–23 months presenting with acute non-bloody diarrhoea who are dehydrated and/or undernourished (i.e. have a high risk for mortality). Enrolled children in Bangladesh, India, Kenya, Malawi, Mali, Pakistan and Tanzania are randomised (1:1) to oral azithromycin 10 mg/kg or placebo once daily for 3 days and followed-up for 180 days. Primary efficacy endpoints are all-cause mortality during the 180 days post-enrolment and change in linear growth 90 days post-enrolment.DiscussionExpanding the treatment of acute watery diarrhoea in high-risk children to include an antibiotic may offer an opportunity to reduce deaths. These benefits may result from direct antimicrobial effects on pathogens or other incompletely understood mechanisms including improved nutrition, alterations in immune responsiveness or improved enteric function. The expansion of indications for antibiotic use raises concerns about the emergence of antimicrobial resistance both within treated children and the communities in which they live. ABCD will monitor antimicrobial resistance. The ABCD trial has important policy implications. If the trial shows significant benefits of azithromycin use, this may provide evidence to support reconsideration of antibiotic indications in the present World Health Organization diarrhoea management guidelines. Conversely, if there is no evidence of benefit, these results will support the current avoidance of antibiotics except in dysentery or cholera, thereby avoiding inappropriate use of antibiotics and reaffirming the current guidelines.Trial registrationClinicaltrials.gov, NCT03130114. Registered on April 26 2017.

The Clinical Efficacy of Multi-strain Probiotics in the Management of Acute Watery Diarrhoea of Children aged 2 Months to 5 Years-a Randomized Controlled Trial

Background: Acute gastroenteritis is considered as one of the most common causes of under-five morbidity and mortality worldwide. Standard treatment is the use of oral rehydration solution (ORS), intravenous fluid if indicated, and zinc supplement. Recently, the use of probiotics has been introduced as an adjunct to the treatment of acute gastroenteritis. The aim of this study is to determine the clinical efficacy of multi-strain probiotics as adjunct treatment of acute gastroenteritis.&#x0D; Methodology: A randomized controlled trial was done in 250 bed district Sadar Hospital, Brahmanbaria, Bangladesh from January 2016 to June 2017. After fulfilling the inclusion criteria, 507 children aged 2 months to 5 years were enrolled in this study. Those with dysentery, chronic diarrhea, diarrhea due to known genetic disorder, chronic illness, malnutrition, systemic infection, CNS disorder and congenital malformation were excluded. Children were divided into two groups randomly. One group was With Probiotic, zinc and standard WHO (ORS) as case and other group was Without Probiotic, zinc and standard WHO ORS as control.&#x0D; Results: Among 507 children, 257 were without probiotic while 250 were with probiotic. The mean difference in stool frequency between the two groups were 3.3 after 24 hours, 3.5 after 48 hours and 1.6 after 72 hours after hospitalization which was statistically significant (p=0.000). Reduction of stool frequency was highest after 48 hours of admission. Mean duration of hospital stay was 4.40±1.22 days in control and 4.03±.89 days in case group. Probiotic group children with exclusive breastfeeding had mean recovery time of 3.95±0.85 days and those who were not exclusively breastfeed had recovery time of 4.2±0.95 days (p=0.025).&#x0D; Conclusion: Probiotic is efficacious in reducing purging duration and frequency of acute watery diarrhea in children.&#x0D; Bangladesh J Child Health 2019; VOL 43 (2) :97-101

Current Practices by Mothers about the Management of Acute Watery Diarrhea Attending Sharif Medical City Hospital, Lahore

Current Practices by Mothers about the Management of Acute Watery Diarrhea Attending Sharif Medical City Hospital, Lahore

Community pharmacists' views of the use of oral rehydration salt in Nigeria.

Background Oral rehydration salt (ORS) is an affordable and effective intervention for the management of acute watery diarrhoea (AWD), especially in children under 5years. A knowledge/practice gap exists among community pharmacists (CPs) in Lagos, Nigeria, and in many low to middle income countries. This gap results in underutilization of ORS for diarrhoea management. Objective The objective was to explore CPs' views of the barriers and facilitators to the use of ORS in practice. Setting Community pharmacy practices, Lagos, Nigeria. Methods Qualitative methods were used to explore pharmacists' views. Recruitment of participants were mainly at zonal meetings. A total of ten CPs participated based on maximum variation and snowballing sampling. Semi-structured interviews conducted covered knowledge, experiences and contextual issues. Interviews were audiorecorded, transcribed and analysed using framework approach to thematic analysis. Main outcome measure Pharmacists' views of barriers and facilitators to the use of ORS. Results Barriers to the use of ORS include caregivers' expectation for an antimicrobial, which was often explicitly and specifically for metronidazole. Also, CPs seemed to doubt applicability of ORS alone, therefore, responded to caregivers' complaints about ORS, by dispensingmetronidazole. These barriers appeared to have normalisedmetronidazole for AWD treatment in this setting. Current facilitators include the caregivers' improved awareness of ORS and access to primary health centers that often resulted in increased demand for ORS in pharmacies. Conclusion CPs' views showed that caregivers' expectations for an antimicrobial may be the main barrier to the use of ORS in their practices.

Strategies to Improve Management of Acute Watery Diarrhea during a Military Deployment: A Cost Effectiveness Analysis

.To inform policy and decision makers, a cost-effectiveness model was developed to predict the cost-effectiveness of implementing two hypothetical management strategies separately and concurrently on the mitigation of deployment-associated travelers’ diarrhea (TD) burden. The first management strategy aimed to increase the likelihood that a deployed service member with TD will seek medical care earlier in the disease course compared with current patterns; the second strategy aimed to optimize provider treatment practices through the implementation of a Department of Defense Clinical Practice Guideline. Outcome measures selected to compare management strategies were duty days lost averted (DDL-averted) and a cost effectiveness ratio (CER) of cost per DDL-averted (USD/DDL-averted). Increasing health care and by seeking it more often and earlier in the disease course as a stand-alone management strategy produced more DDL (worse) than the base case (up to 8,898 DDL-gained per year) at an increased cost to the Department of Defense (CER $193). Increasing provider use of an optimal evidence-based treatment algorithm through Clinical Practice Guidelines prevented 5,299 DDL per year with overall cost savings (CER −$74). A combination of both strategies produced the greatest gain in DDL-averted (6,887) with a modest cost increase (CER $118). The application of this model demonstrates that changes in TD management during deployment can be implemented to reduce DDL with likely favorable impacts on mission capability and individual health readiness. The hypothetical combination strategy evaluated prevents the most DDL compared with current practice and is associated with a modest cost increase.

Antibiotic prescriptions in the case management of acute watery diarrhea in under fives

Background: Diarrhea disease is a leading cause of under-five mortality globally. The World Health Organization recommends low osmolality oral rehydration solution, zinc supplementation and adequate nutrition in the management. Antibiotic is indicated only in specific circumstances. This study was aimed at determining the antibiotic prescription in the management of under-fives with acute watery diarrhea.Methods: An audit of under-fives managed for acute watery diarrhea was conducted between January and February 2012. A multi-stage stratified random sampling technique was used to select 32 health facilities (21 primary and 11 secondary) from two local government areas of Cross River State. Case records of children managed for the condition six months prior to the audit were retrieved and evaluated. The appropriateness, types and frequency of antibiotic prescriptions were assessed.Results: A total of 370 case records were evaluated. Antibiotic was not indicated in any of the children but was prescribed for 291 (78.6%). Of this number, 169 (45.7%) received one antibiotic while 122 (33.0%) received two or more antibiotics. The difference in the prescription of multiple antibiotics between health workers in the primary and secondary facilities was statistically significant (p value = 0.00001). Metronidazole was the most prescribed antibiotic 228 (50.9%), followed by co-trimoxazole 88 (19.6%) and gentamicin 55 (11.8%).Conclusions: There is a high level of irrational antibiotic prescriptions in the State with oral metronidazole being the most prescribed. Periodic training of health workers on indications for antibiotic prescriptions in the management of diarrhea in under-fives is necessary.

The benefit of co-trimoxazole treatment in the management of acute watery diarrhea caused by invasive bacterial infection

Background World Health Organization (WHO) states thatantimicrobials are reliably helpful only for children with bloodydiarrhea (probable shigellosis), suspected cholera with severedehydration, and symptomatic infection caused by Giardia lamblia.The benefit of antimicrobial treatment in management of acutewatery diarrhea caused by invasive bacterial infection is still debated.Objective To prove the benefit of co-trimoxazole treatment inthe management of acute watery diarrhea caused by invasivebacterial infection in patients age 2–24 months.Methods This was a randomized, double blind clinical trialinvolving infants and children aged 2–24 months with acutewatery diarrhea caused by invasive bacterial infection withoutco-morbidity or complications. Invasive bacterial infection wasdefined by fecal leukocytes greater than ten cells (+2) per highpower field on stool. Subjects were assigned to receive either co-trimoxazole or placebo. The duration and frequency of diarrheabetween two groups were compared.Result Of 70 patients (co-trimoxazole, n=35; placebo, n=35),42 (60%) were children aged 12–24 months, of whom 61% wereundernourished. Males were affected 1.2 times as much as females.The clinical manifestations were mild-moderate dehydration(64%), mucus in the stool (100%), fever (24%), vomiting (10%),fever with vomiting (56%) and lactose malabsorption (53%).Duration of diarrhea in placebo group (mean 117.0 [SD 28.1]hours) was not significantly different (P=0.43) compared to thatin co-trimoxazole group (mean 122.5 [SD 30.1] hours). Frequencyof diarrhea per day in placebo group (mean 5.23 [SD 1.48] times)was not significantly different either (P=0.37) compared to thatin co-trimoxazole group (mean 5.64 [SD 2.20] times).Conclusion It is concluded that co-trimoxazole therapy providesno benefit to patients with acute watery diarrhea caused byinvasive bacterial infection. This disorder seems to be self-limited.

Detection of Genogroup I and II human picobirnaviruses showing small genomic RNA profile causing acute watery diarrhoea among children in Kolkata, India

Picobirnaviruses (PBVs) with bisegmented small RNA genome profile (1.75 and 1.55 kbp for segment 1 and 2, respectively) were detected from 1999 to 2003 in faecal specimens of acute watery diarrhoea cases, largely children ( n = 20) and an adult in Kolkata, India. Varying degrees of dehydration necessitated their visit to hospital for further treatment and management of acute watery diarrhoea. PBV was associated with rotavirus ( n = 3) or astrovirus ( n = 3) and with both in one case. No co-infection with norovirus, sapovirus or adenovirus was detected in the picobirnavirus positive cases. No co-infection with parasites ( Cryptosporidium spp., Giardia spp., Entamoeba spp., helminths) or bacteria ( Vibrio spp., Shigella spp., Escherichia coli) was detected among the picobirnavirus positive cases. There was a single instance of co-infection with Salmonella spp. ( n = 1). PBVs not associated with serious diarrhoea illness and showing large genome profile (2.3–2.6 and 1.5–1.9 kbp for segment 1 and 2, respectively) have earlier been reported in adult individuals and recently among children from a slum community in Kolkata, India. The short genome profile PBVs associated with acute watery diarrhoea may be another emerging diarrhoeagenic virus in Kolkata, India. Molecular characterization using reported primers PicoB25–PicoB43 for Genogroup I and PicoB23–PicoB24 for Genogroup II in RT-PCR showed the presence of Genogroup I PBVs ( n = 6) and Genogroup II PBVs ( n = 5), while some could not be amplified ( n = 3) with these primers. Sequence analysis of Genogroup I amplicons indicated remarkable sequence heterogeneity. After more than a decade, four PBV positives of Genogroup II were detected during this study. Phylogenetic analysis showed varying degree of genetic diversity amongst PBV strains from Kolkata and other countries.

Zinc Supplementation in Acute Diarrhea is Acceptable, Does Not Interfere with Oral Rehydration, and Reduces the Use of Other Medications

Assess the impact of zinc supplementation with locally developed culturally specific educational statements (messages) on oral rehydration solution (ORS) and antibiotics or antidiarrheal use in children with acute watery diarrhea as well as to assess adherence and side effects of zinc. This was a randomized effectiveness trial conducted in outpatient health facilities of six sites in five countries, namely, Fortaleza (Brazil), Addis Adaba (Ethiopia), Cairo (Egypt), Lucknow and Nagpur (India), and Manila (Philippines). Participants were 2,002 children aged 2 to 59 months. Intervention was zinc (20 mg orally, once daily for 14 days) with ORS (zinc group) compared with ORS alone (control group). Primary outcomes were ORS use on day 3 to 5; adherence to zinc; and any use of an antibacterial/antidiarrheal up to day 14. One thousand ten and 992 children enrolled in zinc and control groups, respectively. Loss to follow-up on days 3 to 5 and 15 to 17 was 1.2% and 2.8% in the zinc group and 0.8% and 1.7% in the control group. In five of six sites, ORS use in cases with continued diarrhea on days 3 to 5 was the same in the two groups or higher in zinc group. Overall adherence to zinc supplementation was 83.8% (95% confidence interval [CI] 81-86). There was no difference in vomiting by group. In consideration of the six countries overall, less antibiotic/antidiarrheal use occurred in the zinc group (absolute difference, 3.8% [95% CI 1.7-5.9]). In the management of acute watery diarrhea, zinc plus ORS along with culturally appropriate, site-specific messages in local language does not affect overall ORS use generally and decreases antibiotic/antidiarrheal use; children had good adherence without side effects.

Treatment of Infectious Diarrhea in Children

Diarrheal diseases remain an important cause of childhood morbidity and death in developing countries, although diarrheal deaths have significantly declined in recent years, mostly due to successes in the implementation of oral rehydration therapy (ORT), which is the principal treatment modality.Diarrhea may occur for varied reasons; however, most episodes of diarrhea in developing countries are infectious in origin. Three clinical forms of diarrhea (acute watery diarrhea, invasive diarrhea, and persistent diarrhea) have been identified to formulate a management plan. Acute diarrhea may be watery (where features of dehydration are prominent) or dysenteric (where stools contain blood and mucus).Rehydration therapy is the key to management of acute watery diarrhea, whereas antimicrobial agents play a vital role in the management of acute invasive diarrhea, particularly shigellosis and amebiasis. In persistent diarrhea, nutritional therapy, including dietary manipulations, is a very important aspect in its management, in addition to rehydration therapy. Rehydration may be carried out either by the oral or intravenous route, depending upon the degree of dehydration. Oral rehydration salts (ORS) solution (World Health Organization formula) is recommended for ORT. Intravenous fluid is recommended for initial management of severe dehydration due to diarrhea, followed by ORT with ORS solution for correction of ongoing fluid losses. Antimicrobial therapy is beneficial for cholera and shigellosis. Antiparasitic agents are indicated only if amebiasis and giardiasis are present.Appropriate feeding during diarrhea is recommended for nutritional recovery and to prevent bodyweight loss. Antidiarrheal agents do not provide additional benefit in the management of infectious diarrhea. Although some probiotics have been shown to be beneficial in the treatment of acute diarrhea due to rotavirus, their use in the treatment of diarrhea is yet to be recommended, even in developed countries. The children of developing countries might benefit from zinc supplementation during the diarrheal illness, but its mode of delivery and cost effectiveness are yet to be decided.