Bismuth Curbs Antibiotic Use for Diarrhea in Pakistan

By Marilynn Larkin

August 24, 2019

NEW YORK (Reuters Health) - Encouraging bismuth subsalicylate (BSS) use as a first-line treatment for acute diarrhea and promoting its use for self-management can reduce antibiotic use in Pakistan and other countries around the world, researchers suggest.

"In many parts of the world, diarrhea is a major driver of unnecessary antibiotic use," Dr. Anna Bowen of the U.S. Centers for Disease Control and Prevention in Atlanta said in an email to Reuters Health. "We wanted to test whether a simple intervention could help optimize antibiotic use for diarrhea. We were excited to find meaningfully less antibiotic use among patients in Pakistan who were given bismuth subsalicylate, compared to those given placebo."

"While additional studies would help sort out how this intervention works in other settings and how best to implement it," she added, "the intervention's simplicity and the size of its impact in this study make it a promising tool in the fight against antibiotic resistance."

Dr. Bowen and colleagues randomized patients with acute, nonbloody diarrhea from 22 outpatient clinics in Karachi, Pakistan, to either BSS or placebo for 48 hours or less. The main outcome was use of systemic antibiotics within five days of enrollment.

As reported online August 16 in JAMA Network Open, 439 patients (median age, 32; 43% men) were included in the analysis. Overall, 54 participants (12%) used systemic antibiotics - 16% in the placebo group and 9% in the BSS group - after consulting with a physician.

Use of any antibiotic was significantly lower in the BSS group (odds ratio, 0.54), as was use of fluoroquinolones (OR, 0.38).

Rates of care-seeking and hospitalization were similar between groups, as was timing of diarrhea resolution.

However, fewer participants in the BSS group received intravenous rehydration (OR, 0.48), and they missed less work (median 0 vs. 1 day) during follow-up.

Summing up, the authors state, "This study found less antibiotic use among participants given BSS for acute diarrhea in a setting where antibiotics are commonly used to treat diarrhea. Encouraging healthcare professionals in such settings to recommend BSS as frontline treatment for adults with diarrhea, and promoting BSS for diarrhea self-management, may reduce antibiotic use and rates of antibiotic resistance globally."

Dr. Bernard Camins, Professor of Medicine and Infectious Diseases at the Icahn School of Medicine at Mount Sinai in New York City, commented by email, "The findings of this study are applicable to the US and other countries. The majority of patients with acute gastroenteritis do not need antibiotic therapy since the illness is mostly self-limiting."

"A lot of efforts have been dedicated to improving antibiotic use in the U.S. by the Centers for Disease Control and Prevention and other public health agencies," he told Reuters Health. "This study provides clinicians a safe and viable option to present to patients who insist on being treated for their diarrhea in addition to the usual interventions."

"The caveat is that this treatment has only been studied in patients who are symptomatic for 48 hours or less," he noted. "Clinicians should consider this approach, especially in patients who do not have severe symptoms."

"Clinicians should familiarize themselves with the indications for antibiotic therapy in patients with diarrheal illnesses," he added. "Most patients do not require antibiotic therapy."

"If clinicians follow(ed) these guidelines and avoid(ed) overprescription of antibiotics, this clinical trial would have been unnecessary," he concluded.

The study was funded by an agreement between the CDC and Procter and Gamble, the manufacturer of the study drug. Two coauthors are employees of the company and Dr. Bowen receives funds from the company. The company also provides a product to purify drinking water to the organization where two coauthors work.


JAMA Netw Open 2019.