Effect of Bismuth Subsalicylate vs Placebo on Use of Antibiotics Among Adult Outpatients With Diarrhea in Pakistan

Abstract

IMPORTANCE Many of the 4.5 billion annual episodes of diarrhea are treated unnecessarily with antibiotics; prevalence of antibiotic resistance among diarrheal pathogens is increasing. Knowledgebased antibiotic stewardship interventions typically yield little change in antibiotic use. OBJECTIVE To compare antibiotic use among adult outpatients with diarrhea given bismuth subsalicylate (BSS) or placebo. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial took place from April to October 2014. Participants were patients aged 15 to 65 years with acute, nonbloody diarrhea from 22 outpatient clinics in Karachi, Pakistan. Participants were interviewed about symptoms and health care utilization during the 5 days after enrollment. Group assignment was concealed from participants, field staff, and the statistician. Primary analysis occurred from August to September 2015. INTERVENTIONS Participants were randomly assigned (1:1) to receive BSS or placebo for 48 hours or less. MAIN OUTCOMES AND MEASURES Use of systemic antibiotics within 5 days of enrollment. Secondary outcomes included measures of duration and severity of illness. RESULTS Among eligible patients, 39 declined to participate, 440 enrolled, and 1 enrolled participant was lost to follow-up, for a total of 439 patients included in the analysis. Median (interquartile range) participant age was 32 (23-45) years and 187 (43%) were male. Two hundred twenty patients were randomized to BSS and 220 were randomized to placebo. Overall, 54 participants (12%) used systemic antibiotics (16% in the placebo group and 9% in the BSS group); all antibiotic use followed consultation with a physician. Use of any antibiotic was significantly lower in the BSS group (20 of 220 vs 34 of 219 patients; odds ratio [OR], 0.54; 95% CI, 0.30-0.98), as was use of fluoroquinolones (8 of 220 vs 20 of 219 patients; OR, 0.38; 95% CI, 0.16-0.88). Rates of care seeking and hospitalization were similar between groups and no difference was detected in timing of diarrhea resolution. However, those in the BSS group less commonly received intravenous rehydration (14 of 220 vs 27 of 219 patients; OR, 0.48; 95% CI, 0.25-0.95) and missed less work (median [interquartile range], 0 [0-1] vs 1 [0-1] day; P = .04) during follow-up. CONCLUSIONS AND RELEVANCE 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 health care professionals in such settings to recommend BSS as frontline treatment for adults with (continued) Key Points Question Among adults with diarrhea, does use of bismuth subsalicylate reduce antibiotic consumption? Findings In this placebo-controlled randomized trial that included 439 adults in Pakistan, antibiotic use occurred among 16% of participants who received placebo and 9% of those who received bismuth subsalicylate, a significant difference. Meaning The findings suggest that recommending bismuth subsalicylate as a frontline treatment for adults with diarrhea, inclu...

The Role of Purported Mucoprotectants in Dealing with Irritable Bowel Syndrome, Functional Diarrhea, and Other Chronic Diarrheal Disorders in Adults

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