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Indian Pediatr 2013;50: 340-341 |
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Clinical Response to Antibiotics Among
Children with Bloody Diarrhea
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Priya Sreenivasan, *Zinia T Nujum and KK Purushothaman
Department of Pediatrics, Government Medical College,
Thrissur; and *Department of Community Medicine, Government Medical
College, Thiruvananthapuram; Kerala.
Email: [email protected]
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WHO recommends ciprofloxacin as the drug of choice for bloody diarrhea.
We retrospectively analyzed antibiotic response in 100 children with
bloody diarrhea admitted between 2006-2010. Cotrimoxazole (n=55)
had higher chance of attaining improved appetite and normal activity in
48h, hospitalization of <3d, blood disappearance in
≤5d and
not requiring a second antibiotic compared to others (n=45).
Older antimicrobials should be tried in all possible situations.
Key words: Antibiotic response, Bloody diarrhea,
Children, Dysentry, India.
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WHO recommends ciprofloxacin as the
drug of choice for treatment of bloody diarrhea [1]. In this
context, we recorded clinical response to antibiotics in 127
children from case records, admitted with a clinical
diagnosis of bloody diarrhea to Government Medical College,
Thrissur between 2006-2010. Inclusion criteria were children
1 mo-12 y with visible red blood in loose stools at
admission / during ward stay. Those with melena, blood
streaks over formed stools, chronic hepatic / renal /
bleeding disorders, surgical abdomen, those who left our
hospital before satisfactory completion of treatment, and
blood detected only on microscopy were excluded. We finally
analyzed 100 patients. Data on demography, presentation,
complications, risk factors, co-morbidities and antibiotics
used were collected. Clinical response to therapy was based
on 6 WHO parameters - disappearance of fever, fewer stools,
less blood, less pain, improved appetite and attainment of
normal activity [1]. Each parameter if achieved within 48 h
was scored 1. Outcome measures were total score, duration of
hospitalization, time taken for blood disappearance, and
need for a second antibiotic from our ward.
89% had risk factors- infancy (20),
non-breastfed (19), unconsciousness (6), hyperthermia (37)
and malnutrition (48). 59% had complications- dehydration
(43), metabolic derangement (11), seizures (19) and rectal
prolapse (3). Presence of complications had 2.8 times higher
chance of need for second antibiotic from our wards (P=
0.019, 95% CI=1.165- 6.730). 34% had co-morbidities. Two
children who died had co-morbidities. Absence of
co-morbidities had 3.5 times higher chance of attaining
total scores 5 or 6 (P=0.007, 95% CI=1.366- 8.969)
and 2.78 times higher chance of a lesser hospital stay of <
5d (P=0.028, 95% CI=1.096-7.079). Guidelines should
stress the need to look for co-morbidities.
We gave co-trimoxazole in 55 subjects as
first line; 44 responded within 48 h (table I). Co-trimoxazole
as our first line had higher chance of attaining normal
activity (P=0.027, OR 2.82, 95%CI=1.102-7.216) and
improved appetite (P=0.044, OR 2.768, 95%
CI=1.003-7.740) within 48 h, blood disappearance in 5d (P=0.004,
OR5.180, 95% CI=1.553-17.278), hospital stay of <3d (P=0.008,
OR3, 95% CI=1.319-6.823) and not requiring a second
antibiotic from our ward ( P=0.000, OR 9.24, 95%
CI=3.62-23.706) when compared to those who were initially
given antibiotics other than co-trimoxazole. 59% who
responded to co-trimoxazole had more than one risk factor.
Reasons for not starting co-trimoxazole in 45 subjects
included altered sensorium/ seizures (18), severe
dehydration (8), co-morbidities (4), unresponsive to two
antibiotics (4), good response to prior antibiotic (3),
persistent vomiting (2), severe malnutrition (2), recent
inter-state travel (2), infancy (1) and parental anxiety
(1). One study from Bangalore (2002-07) showed decreased co-trimoxazole
and chloramphenicol resistance, and another from Vietnam
(2009) showed significant ampicillin and chloramphenicol
sensitivity in bloody diarrheas [3,4].
Co-trimoxazole still works well in our
setting as first line antibiotic even in children with
multiple risk factors. Older antimicrobials should be tried
in outpatients without risk factors, complications/serious
co-morbidities. If inadequate clinical response occurs in
48h, newer antibiotics may be started. The latter may be
kept in reserve as resistance to these including
ciprofloxacin, and cephalosporins has occurred in India
[4,5]. Those with risk factors, complications / serious
co-morbidities should be admitted, started on older drugs if
possible. Early switch to newer antibiotics should be done
if needed.
References
1. World Health Organization (WHO).
Guidelines for Control of Shigellosis, including epidemics
due to Shigella dysenteriae Type 1. Geneva,
Switzerland: WHO; 2005.
2. Srinivasa H, Baijayanti M, Raksha Y.
Magnitude of drug resistant shigellosis: A report from
Bangalore. Indian J Med Microbiol. 2009;27:358-60.
3. Vinh H, Nhu NT, Nga TV, Duy PT,
Campbell JI, Hoang NV, et al. A changing picture of
shigellosis in Southern Vietnam: shifting species dominance,
antimicrobial susceptibility and clinical presentation. BMC
Infect Dis. 2009; 9:204.
4. Taneja N. Changing epidemiology of
shigellosis and emergence of ciprofloxacin-resistant
shigellae in India. J Clin Microbiol. 2007;45:678-9.
5. Mandal J, Mondal N, Mahadevan S, Parija SC. Emergence
of resistance to third-generation cephalosporin in Shigella-
A case report. J Trop Pediatr. 2010;56:278-9.
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