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Medical practitioners' knowledge of dysentery treatment in Bangladesh

^a International Centre for Diarrhoeal Disease Research, Bangladesh, ^b Gonoshasthaya Kendra, Savar, Bangladesh, ^c Departments of Paediatrics and Medicine, New England Medical Center, Tufts University School of Medicine, Boston, MA, USA

Correspondence to: Dr C Ronsmans, Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT (email cronsman{at}lshtm.ac.uk).

The irrational use of drugs is common in Bangladesh.^{1 2} To assess medical practitioners' knowledge of treatment for dysentery and whether their knowledge is influenced by their training, we interviewed four groups of medical practitioners in Bangladesh and compared the treatment that they recommended with what is advocated by the World Health Organisation.

Subjects, methods, and results

We conducted our study in the capital, Dhaka, and in rural Matlab. In Dhaka we interviewed 136 doctors (46 with postgraduate training and 90 without), 87 drug dispensers, and 50 medical students, and in Matlab we interviewed 150 drug dispensers. All participants were selected randomly, except for the medical students, who were recruited opportunistically.

We presented a simple case to each person: "A 2 year old child has had bloody diarrhoea for three days. What treatment would you recommend?" The correct answer is use of oral rehydration solution and a single antibacterial drug appropriate for treating shigellosis, as recommended by the WHO.^{3 4} Appropriate antibacterial drugs are ampicillin, co-trimoxazole, nalidixic acid, and pivmecillinam.

Less than half of the people in each of the four groups recommended the correct treatment (table 1). Fewer drug dispensers recommended correct treatment (8% of urban and 11% of rural dispensers) than did doctors with postgraduate training (44%), medical students (46%), and doctors without postgraduate training (47%). The commonest incorrect recommendations were the use of multiple antibiotics, use of an inappropriate antibiotic, and failing to use oral rehydration solution. Of the 423 people interviewed, 398 recommended the use of at least one antibiotic, and 155 recommended two or more antibiotics. The most commonly recommended combination of antibacterial drugs was metronidazole with ampicillin, co-trimoxazole, or nalidixic acid. Drug dispensers in Matlab were more likely to recommend use of multiple antibiotics or use of metronidazole or furazolidone (two drugs not indicated for treating dysentery in children) and were less likely to recommend oral rehydration solution than were the other groups of medical practitioners.

Table 1--Treatment for childhood dysentery recommended by different groups of medical practitioners in Bangladesh.
Values are numbers (percentage) of practitioners
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                                            Doctors                                             Drug dispensers
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                                     With              Without
                                 postgraduate        postgraduate      Medical         In capital city,   In rural area,
Treatment recommended           training (n=46)     training (n=90)  students (n=50)    Dhaka (n=87)      Matlab (n=150)
--------------------------------------------------------------------------------------------------------------------------------------
Nalidixic acid                      17 (37.0)           33 (36.7)*        6 (12.0)       32 (36.8)*       17 (11.3)*
Metronidazole                        5 (10.9)*          23 (25.6)        13 (26.0)       32 (36.8)        71 (47.3)*
Ampicillin                           8 (17.4)           25 (27.8)        19 (38.0)       12 (13.8)*       72 (48.0)*
Co-trimoxazole                      10 (21.7)           24 (26.7)         7 (14.0)       11 (12.6)        45 (30.0)
Furazolidone                         6 (13.0)            5 (5.6)*         0*             18 (20.7)        42 (28.0)*
Pivmecillinam                        3 (6.5)             2 (2.2)          1 (2.0)         0                0
Oral rehydration solution           27 (58.7)           61 (67.8)*       40 (80.0)*     41 (47.1)         63 (42.0)*
Correct treatment                   20 (43.5)*          42 (46.7)*       23 (46.0)*      7 (8.0)*         16 (10.7)*
Incorrect treatment:
  Incorrect No of antibiotics        7 (15.2)*          25 (27.8)*       11 (22.0)*     41 (47.1)         96 (64.0)*
  Incorrect single antibiotic        6 (13.0)            6 (6.7)         10 (20.0)      23 (26.4)*        18 (12.0)
  Correct single antibiotic but no
  oral rehydration solution         13 (28.3)           17 (18.9)         6 (12.0)      16 (18.4)         20 (13.3)
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* P<0.01 for 2 test or Fisher's exact test comparing one category of practitioners with the four other categories combined.

Comment

Because we examined people's knowledge rather than actual prescribing, factors such as economic incentives or patient demand were less likely to have affected recommendations for treatment. It is therefore disturbing that three quarters of the medical practitioners surveyed failed to manage the hypothetical patient according to standard guidelines. Incorrect treatment was most common among pharmacy staff, of whom only one in 10 advocated the correct treatment.

The use of drugs no longer active against Shigella was common. When we conducted our survey 58% of shigella isolates in Bangladesh were resistant to ampicillin and 44% were resistant to co-trimoxazole, though most were susceptible to nalidixic acid.⁵ For this evaluation, we considered ampicillin and co-trimoxazole to be appropriate treatments as they were among the drugs recommended by the WHO for treating dysentery.⁴ If ampicillin and co-trimoxazole were considered to be inappropriate only 8% of all the medical practitioners recommended correct treatment. We are uncertain why metronidazole and furazolidone were still so popular despite both drugs being ineffective against bacillary dysentery and abundant evidence that amoebiasis is an extremely uncommon cause of dysentery in children.³

Private pharmacies are the predominant source of acute medical care in Bangladesh and many other poor countries.² If treatment of common illnesses such as dysentery is to improve, drug dispensers' knowledge of their management and knowledge of common pathogens' susceptibility to antibiotics must be improved. Currently, drug companies are the only organisations in Bangladesh to provide such information to pharmacists, and the information supplied is often not consonant with recommendations from public health bodies.

We thank Kashem Chowdhury of Gonoshasthaya Kendra for his help with starting the study, the staff at Gonoshasthaya Kendra and Mr Jyotsnamoy Chakraborty for help with collecting data in Matlab, Mr Musarraf Hossain for help with interviews in Matlab, and Mr Humayun Kabir for data entry.

Funding: CR was supported by the Belgian Administration for Development Cooperation. The study was supported by Gonoshasthaya Kendra and by the International Centre for Diarrhoeal Disease Research, Bangladesh, which is currently supported by the governments of Australia, Bangladesh, Belgium, Canada, Denmark, France, Japan, the Netherlands, Norway, Sweden, Switzerland, the United Kingdom, and the United States; the United Nations Development Programme; the United Nations Children's Fund (Unicef); the World Health Organisation; and the Ford Foundation.

Conflict of interest: None.

1. Guyon AB, Barman A, Ahmed JU, Ahmed AU, Alam MS. A baseline survey on use of drugs at the primary health care level in Bangladesh. Bull World Health Organ 1994;72:265-71. [Medline]
2. Ronsmans C, Bennish ML, Chakraborty J, Fauveau V. Current practices for treatment of dysentery in rural Bangladesh. Rev Infect Dis 1991;13(suppl 4):S351-6.
3. Ronsmans C, Bennish ML, Wierzba T. Diagnosis and management of dysentery by community health workers. Lancet 1988;ii:552-5.
4. World Health Organisation. The outpatient management of bloody diarrhoea in young children. Update (Division of Diarrhoeal and Acute Respiratory Disease Control) 1994;16:1-4.
5. Bennish ML, Salam MA, Hossain MA, Myaux J, Khan EH, Chakraborty J, et al. Antimicrobial resistance of shigella isolates in Bangladesh, 1983-1990: increasing frequency of strains multiply resistant to ampicillin, trimethoprim-sulfamethoxazole, and nalidixic acid. Clin Infect Dis 1992;14:1055-60. [Medline]

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