Treating dysentery with metronidazole in Pakistan

BMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7074.146a (Published 11 January 1997) Cite this as: BMJ 1997;314:146
  1. Tariq Iqbal Bhutta, Professor of paediatricsa,
  2. Agnes Vitry, Drug information pharmacistb
  1. a King Edward Medical College and Mayo Hospital, Lahore, Pakistan
  2. b Medical Lobby for Appropriate Marketing, PO Box 172, Daw Park, SA 5041, Australia

    Editor–Carine Ronsmans and colleagues' study of health professionals' knowledge of the treatment of dysentery in Bangladesh showed that less than half chose the correct treatment as recommended by the World Health Organisation in Bangladesh.1 Metronidazole was chosen by 10.9-25.6% of the doctors and by 36.8-47.3% of the drug dispensers. Similar and worrying inappropriate prescribing practices for antiamoebic drugs have been reported recently in Pakistan.2 In an editorial accompanying Ronsmans and colleagues' report Richard Cash points out that inappropriate prescribing and dispensing might be explained by health professionals' dependence on drug companies for their information and medical education.3

    The Medical Lobby for Appropriate Marketing (MaLAM) has recently questioned Rhône-Poulenc Rorer about its promotion for metronidazole (Flagyl) in Pakistan, which exhorts doctors to “Suspect amoebiasis/giardiasis in all cases of diarrhoea …. Immediate treatment is vital.”4 In its response Rhône-Poulenc Rorer endorsed that exhortation and stated that “If you agree that amoebiasis and giardiasis should be treated urgently due to their potential impact on morbidity and mortality, then empirical treatment [with metronidazole] becomes routine in a community unable to afford the charges for stool examination and other associated laboratory or office costs.”

    With respect, Rhône-Poulenc Rorer's assumption of amoebic hyperendemicity in childhood diarrhoea is not supported by the epidemiological evidence. Last year about 4500 children with acute diarrhoea were admitted to the King Edward Medical College and Mayo Hospital in Lahore. Only 80 (less than 2%) were found to be positive for giardiasis or amoebiasis.

    Rhône-Poulenc Rorer's current promotion for the routine empirical use of metronidazole is in opposition to the WHO's recommendations, which state:

    “Antiparasitic drugs should be used only for:

    • amoebiasis, after antibiotic treatment of bloody diarrhoea for suspected shigella infection has failed or when trophozoites of Entamoeba histolytica containing red blood cells are seen in the faeces;

    • giardiasis, when diarrhoea has lasted at least 14 days and cysts or trophozoites of Giardia intestinalis are seen in faeces or in the contents of the small intestine.”5

    Education programmes to change prescribing patterns for treating diarrhoea are needed. Any improvements, however, are unlikely to be sustained in the long term if health professionals and consumers remain exposed to prolonged drug promotion of this nature. Multinational drug companies promoting their products in developing countries are susceptible to the influence of international protest.6 We invite the BMJ's readers to support health professionals in Pakistan by expressing their concerns to Rhône-Poulenc Rorer about its recent promotion for metronidazole.


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