Adherence to Treatment Guidelines for Acute Diarrhoea in Children up to 12
Years in Ujjain, India*
Ashish Pathak(1,2) , Deepali Pathak (1,3), Gaetano Marrone(1), Vishal Diwan(1,4), and Cecilia Stålsby Lundborg(1)
Policy implications and conclusions:
 Low adherence to treatment guidelines, low use of zinc and the high use of antibiotics
To improve case management of acute diarrhoea, continuing professional development targeting practitioners of all systems of medicine is
necessary.
Fig: ORT in a child
Objective: To analyze prescriptions for adherence to
Results: Information was collected from 843 diarrhoea prescriptions.
treatment guidelines
 Only 6 prescriptions adhered with the recommended treatment
Design: Cross-sectional study done between June to
(ORS along with zinc) with no additional probiotics, antibiotics,
August 2010
racecadotril, or antiemetics (except Domperidone for vomiting)
Setting: Pharmacies and major hospitals of Ujjain,
 ORS alone was prescribed to 58% and ORS with zinc to 22%
Madhya Pradesh, India. Pharmacists in pharmacies and
 Antibiotics were prescribed in 71% of prescriptions. Broad-
resident medical officers in hospitals transferred the
spectrum antibiotics were prescribed in illogical fixed-dose
information of the diarrhoeal episode and the treatment
combinations, such as ofloxacin with ornidazole (22% of antibiotics
given to a data collection instrument
prescribed).
Fig: GIS map of Ujjain city showing the
participating pharmacies and hospitals
Study population: Prescriptions for children up to 12
 Practitioners from alternate systems of medicine and IHPs were
years of age with diarrhoea from
significantly less likely (OR 0.13, 95% CI 0.04-0.46, P = 0.003) to
Introduction
medicine, ayurveda, homeopathy, and informal health
prescribe ORS and zinc than pediatricians
In India, diarrhoea accounts for 20% of all
care providers (IHPs)
 Practitioners from free hospitals were more likely to prescribe
Outcome measures:
ORS and zinc (OR 4.94, 95% CI 2.45-9.96, P < 0.001) and less
paediatric deaths
WHO recommendations, the Indian Academy of
Paediatrics, and the Government of India treatment
guidelines are in place, but adherence to these
guidelines is not analyzed
of modern
1) Prescription of ORS alone and ORS with zinc
likely to prescribe antibiotics (OR 0.01, 95% CI 0.01-0-04, P <
0.001) compared to practitioners from other hospitals
2) Prescriptions containing antibiotics
3) Factors affecting prescription of ORS and zinc and
 Accompanying symptoms (fever, pain, blood in the stool, and
vomiting) significantly increased antibiotic prescribing.
antibiotics
1. IHCAR, Division of Global Health, Karolinska Institutet, Sweden, India;
2. Department of Paediatrics, R.D. Gardi Medical College, Ujjain, India;
3. Grasim Trust‘s G.D. Birla Memorial Hospital, Ujjain, India;
4. Department of Public Health and Environment, R.D. Gardi Medical College, Ujjain, India
*Published in:
BMC Infect Dis. 2011 Jan 28;11:32. PubMed PMID: 21276243
E-mail: ashish.pathak@.ki.se
Funding: Swedish Research Council
Scholarship: Erasmus Mundus Lot 15 India to 1st, 2nd and 4th authors
Travel Grant: Axel Hirsch´s travel fund, Karolinska Institutet to Ashish Pathak