Acceptability and feasibility Salbutamol for treatment of acute wheezeasthma and

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7. Evidence for recommendations for treatment of dysentery

7.1 Antibiotics for treatment of dysentery

a Children with diarrhoea and blood in stool i.e. dysentery should be treated with ciproloxacin as a irst line treatment. Cetriaxone should be given as a second line treatment in severely ill children where local antimicrobial sensitivity is not known. — Ciproloxacin: 15 mgkgdose twice daily for 3 days — Cetriaxone: 50–80 mgkg daily for 3 days Strong recommendation, low quality evidence b Where local antimicrobial sensitivity is known, local guidelines should be followed. Strong recommendation, low quality evidence he panel noted that the evidence of impact of antibiotics comes from epidemics in the 1970s where diferent antibiotics were used with widely varying case fatality rates, and only one randomized control trail. It was also noted that although the evidence from RCTs is speciically for management of Shigella dysentery, the guidelines refer to bloody diarrhoea as in most cases there will be no prior testing before treatment. he increasingly widespread antibiotic resistance to ampicillin, co-trimoxazole, chloramphenicol, nalidixic acid, tetracycline, gentamicin, and 1st and 2nd generation cephalosporin make them less efective for treatment. here is also reported resistance to ciproloxacin, and hence the need for continued drug resistance surveillance.

7.1.1 Evidence and summary of findings

here was low quality evidence from two systematic reviews, a recently updated Cochrane review see GRADE table A7.14 and a WHO Children Health Epidemiology Reference Group CHERG review that most of the antibiotics used were efective depending on antimicrobial sensitivity patterns [Christopher, 2010; Traa, 2010]. he reviews conirm the current WHO recommendations and current practice as it is not possible to recommend a speciic antibiotic or antibiotic group that would be universally efective due to wide variation in antimicrobial sensitivity. he Cochrane review included all RCTs comparing the eicacy of one antibiotic to placebo, or comparing the eicacy of various antibiotics, in children as well as in adults. Many of the RCTs included in this systematic review were conducted 49 prior to the 1990s and involved antibiotics that are no longer used because of highly resistant Shigella i.e., cotrimoxazole, ampicillin, nalidixic acid. he review focused on outcome variables of limited interest: duration of diarrhoea and continuation of dysentery. It also includes studies conducted in developing as well as developed countries, without taking into account the type of Shigella strains responsible for the dysentery, therefore limiting the generalizability of the indings. he CHERG review only included studies published ater 1990, evaluating the eicacy of antibiotics presently recommended by WHO i.e. ciproloxacin, cetriaxone, pivmecillinam, and azithromycin and to which resistance is so far not a problem in children aged 16 years, and conducted in middle- and low-income countries. he review was, therefore, more generalizable to the paediatric population and low-resource settings. he review also focused on three outcome variables that have a direct impact on survival: n Clinical failure: Absence of marked improvement in, or worsening of, illness with the presence of bloody mucoid stools, more than a trace of blood in stool, abdomi- nal pain, tenesmus andor fever; n Cacteriological failure: Failure to clear an enteropathogen isolated from an indi- vidual on admission to the study, by the end of the treatment period; and n Bacteriological relapse: Reappearance of an enteropathogen in stool ater the en- teropathogen was cleared by treatment. he Cochrane systematic review identiied two RCTs comparing antibiotics and placebo or no drug, and 14 RCTs comparing the efectiveness of diferent antibiotics regimens for treatment of Shigella dysentery [Christopher, 2010]. he trials included a total of 1748 participants and were randomized based on clinical symptoms of dysentery, prior to bacteriological conirmation. he GRADE tables show low- to moderate quality evidence that antibiotic therapy signiicantly reduces the number of children with dysentery on follow-up compared to no antibiotic [Kabir 1986; Rodriguez 1989]. he review had two primary eicacy outcomes. he irst primary outcome, diarrhoea on follow-up, was reported by all but three trials [Kabir 1986; Gotuzzo 1989; Islam 1994]; the duration of follow-up was ive days in 10 out of 13 trials. he second primary outcome, relapse, was reported by four trials [Haltalin 1973; Salam, 2010; Shanks 1999; Leibovitz 2000; the duration of follow-up for this outcome ranged from 10 to 20 days. Limited data from one three-armed trial of people with moderately severe illness suggest that antibiotics reduce the episodes of diarrhoea at follow-up furazolidone versus no drug RR 0.21, 95 CI 0.09 to 0.48, 73 participants; cotrimoxazole versus no drug RR 0.30, 95 CI 0.15 to 0.59, 76 participants[ Rodriguez 1989]. he review did not ind robust evidence to suggest that antibiotics of a particular class were better than those belonging to a diferent class. However, there were limited data from a subgroup of studies to suggest that luoroquinolone ciproloxacin was more efective than beta-lactam ampicillin in reducing diarrhoea among adults and