Official Journal of the Society of Hospital Pharmacists of Australia

RESEARCH ARTICLE

Dispensing pattern for acute non-infectious diarrhoea in children at

community pharmacies in Thailand
Siriluk Jaisue, PhD1, Sommaly Phomtavong, MPharm2, Sasithorn Eua-anant, MPharm3, Glenn N. Borlace, PhD1
1 Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen, Thailand
2 Faculty of Pharmacy, University of Health Sciences, Ministry of Health, Vientiane, Lao People’s Democratic Republic
3 Khon Kaen Provincial Health Office, Khon Kaen, Thailand

Abstract
Background: In cases of non-infectious diarrhoea in children, the WHO and the Thai Antibiotic Smart Use (ASU) project recommend
that no antibiotics should be given and drinking water should be replaced with oral rehydration salt (ORS) solution until the diar-
rhoea is finished.
Aim: To survey the dispensing pattern for non-infectious diarrhoea treatment in children in Thailand.
Methods: Simulated clients visited 91 Class I community pharmacies in five districts in Khon Kaen province and asked for advice
to treat non-infectious diarrhoea in a 14-month-old child. The patient history questions asked by the dispensers, the medications dis-
pensed and non-pharmacological advice given were recorded by the simulated clients immediately after leaving the pharmacy.
Results: In this study, ORS solution was correctly dispensed to the simulated clients in only 7.7% of pharmacies with 68.1% incor-
rectly dispensing antibiotics. More than half of the dispensers (57.1%) did not give any advice regarding non-pharmacological treat-
ment.
Conclusion: The results of this study indicate the need to implement a program to emphasise the importance of providing ORS and
discourage the dispensing of antibiotics in this circumstance.

Keywords: pharmacy practice, practice, pharmacy, dispensing, antibiotics.

INTRODUCTION the Thai Antibiotic Smart Use (ASU) program.5 Nutri-

Diarrhoea is the fourth biggest killer of children under
5 years globally, causing more than 500 000 deaths each
year.1 Diarrhoea is also a major cause of morbidity
through malnutrition, which can delay the physical
development of affected children.2 In Thailand, diar-
rhoea is the leading cause of morbidity and mortality
in children under 5 years.1 The main etiological agents
of diarrhoea in children under 5 years are viruses,
which means that antibiotic treatment is usually ineffec-
tive.3 The aims of watery diarrhoea treatment are pre-
vention or treatment of dehydration, prevention of
nutritional damage, reduction in the duration and
severity of symptoms and prevention of future epi-
sodes.4 Dehydration can be primarily treated by giving
oral rehydration salt (ORS) solution, and this is the
first-line therapy recommended by the WHO and in
Address for correspondence: Siriluk Jaisue, Faculty of Pharmaceu-
tical Sciences, Khon Kaen University, Khon Kaen 40002, Thailand
E-mail: sirjai@kku.ac.th
tional damage can be prevented by supplying addi-
tional food and supplemental zinc (10–20 mg/day) is
effective in reducing the duration and severity of symp-
toms. Due to their accessibility, pharmacists working in
community pharmacies are the primary healthcare ser-
vice providers for patients seeking treatment and
advice for diarrhoea. If inappropriate treatment or
advice is given at the community pharmacy, it can
delay appropriate treatment and endanger the child’s
health. Despite this, multiple studies have shown that
inappropriate treatment and advice for diarrhoea in
children is a common occurrence worldwide.6–11
Khon Kaen is a province in Thailand with a popu-
lation of two million people12 serviced by two public
tertiary hospitals. Among the 26 districts in Khon
Kaen, the Muang district is the largest and most pop-
ulated area. Many pharmacies are located in this dis-
trict and 95% of them are Class I pharmacies,
operated by licensed pharmacists.13 In Thailand, con-
trolled class drugs such as oral corticosteroids can be
dispensed with a doctor’s prescription by pharmacists

© 2017 The Society of Hospital Pharmacists of Australia Journal of Pharmacy Practice and Research (2017) 47, 383–388
doi: 10.1002/jppr.1345
384
in Class I pharmacies, while cautionary class drugs
can be dispensed without a prescription.14,15 Many
oral antibiotics are classified as cautionary class
drugs, including ciprofloxacin and cotrimoxazole, all
of which are recommended for infectious diarrhoea.16
Recently, the Bureau of Drug Control in the Thailand
Ministry of Public Health proposed to limit the dis-
pensing of antibiotics by reclassifying them as con-
trolled class drugs under the Thailand Antimicrobial
Resistance Containment and Prevention Program
(AMRCP)17, but the official reclassification has not yet
been established. The objective of this study was to
survey the dispensing pattern for acute non-infectious
diarrhoea in children at Class I pharmacies in the
Muang district of Khon Kaen, using a simulated cli-
ent method.
METHOD
Ethics Approval
This study was approved by the Khon Kaen University
Ethics Committee (HE 562306).
Simulated Clients and Scenario
This study was conducted in the Muang district of
Khon Kaen Province, Thailand during January to
March 2014. Two pharmacy students and one non-
health science student (age 21–22 years) acted as simu-
lated clients. The non-health science student was
recruited because of concern that some dispensers
might be affiliated with the Faculty of Pharmaceutical
Sciences at Khon Kaen University and therefore recog-
nise the pharmacy students. Pharmacies that were iden-
tified to be owned by pharmacists who might recognise
the pharmacy students were assigned to the non-health
science student. All simulated clients were trained to
simulate the scenario of a parent visiting a pharmacy
to get medication and advice for a child with non-infec-
tious diarrhoea. The scenario was of a 14 months old,
11 kg boy with watery diarrhoea occurring four to five
times per day for 1 day, with no blood or mucous in
the stools, no fever, no vomiting, no dry eyes or mouth
or crying without tears (indicating no serious dehydra-
tion). The scenario included that the child still took
food and milk, had not eaten anything unusual prior
to the diarrhoea, had not changed the brand of milk or
taken any medications, and had completed their vacci-
nation course. The simulated clients were trained to not
provide any information unless they were asked by the
dispenser.
Journal of Pharmacy Practice and Research (2017) 47, 383–388
S. Jaisue et al.
Data Collection
Immediately after leaving the pharmacy, the simulated
clients recorded the details of their consultation. This
included the patient history questions asked by the dis-
penser, the medications dispensed and the advice given.
Data were collected and are presented as percentages.
RESULTS
The simulated clients visited 91 out of a total of 222 reg-
istered (Class I) pharmacies in Khon Kaen province
(40.9%). The majority of these were in the most popu-
lous district, Nai Muang, which accounted for 69
(75.8%) of the total pharmacy visits. The remaining 22
pharmacies were distributed around four districts, ten
in Banpet (11.0%), nine in Sila (9.9%), two in Muangkao
(2.2%) and one in Bantum (1.1%).
For the patient history, dispensers enquired about the
patient’s age and weight (demographic data), symptoms
(onset, frequency, appearance of stools), complications
(fever, vomiting, pain, weakness) and cause (food taken
before onset of symptoms). The most frequently
requested demographic information was the patient’s
age (asked by 92.3% of dispensers) with 25.3% of dis-
pensers asking about the patient’s weight. Approxi-
mately half of the dispensers asked about the
appearance of stools (51.6%) and if the patient had a
fever (53.8%). Less than half of the dispensers asked
about the time of diarrhoea onset (36.3%) and frequency
(40.7%) and if there was any vomiting (38.5%) or
abdominal pain (37.4%). Very few dispensers enquired
about the patient’s hydration status (3.3%). Other ques-
tions asked by dispensers pertained to the cause of the
diarrhoea (type of food taken before onset, 18.7%), com-
plications such as weakness (13.2%) and presence of
blood in the stool (8.8%) and drug allergy (15.4%). All
of the dispenser questions and their frequencies are pre-
sented in Table 1.
The most frequently dispensed medication type was
antibiotics with 62 dispensers (68.1%) dispensing a total
of 64 antibiotics (Table 2). The most frequently dis-
pensed antibiotics were nitrofurans, specifically furazoli-
done (34.1%) and nifuroxazide (18.7%), followed by
co-trimoxazole (11.0%). Cephalexin and metronidazole
were dispensed on two occasions (2.2%) and azithromy-
cin and norfloxacin were both dispensed once. ORS was
dispensed by almost half (49.5%) of dispensers and
adsorbents were dispensed to 16 simulated clients
(17.6%). Two dispensers (2.2%) dispensed prokinetic
drugs (domperidone or dicyclomine) while the probiotic
© 2017 The Society of Hospital Pharmacists of Australia
Dispensing for diarrhoea in children 385

Table 1 Patient information requested by dispensers at community pharmacies during consultation with simulated clients for non-infec-
tious, acute, watery diarrhoea in a child

Category Detail Actual dispenser enquiry Scenario Frequency

Demographic Age – 14 months 84 (92.3%)

Weight – 11 kg 23 (25.3%)
Symptoms Acute Time since diarrhoea started 1 day 33 (36.3%)
Frequency 4–5 times/day 37 (40.7%)
Stools Appearance of stools Watery 47 (51.6%)
Infectious Fever No fever 49 (53.8%)
Vomiting No vomiting 35 (38.5%)
Complications Abdominal pain None given 34 (37.4%)
Weakness 12 (13.2%)
Blood in stool 8 (8.8%)
Less active 1 (1.1%)
Dehydration Sunken eyes No dry eyes/mouth 2 (2.2%)
Tears when crying Tears 1 (1.1%)
Nutrition status Still taking food/milk OK 3 (3.3%)
Cause Type of food eaten before onset None given 17 (18.7%)
Unusual objects eaten before onset 2 (2.2%)
Recent change of milk product 8 (8.8%)
Milk allergy 1 (1.1%)
Common cold 1 (1.1%)
Medications 3 (3.3%)
Treatment Contraindications Drug allergy None given 14 (15.4%)
Underlying disease 6 (6.6%)
Taking medication 3 (3.3%)
Other Type of regular meal None given 7 (7.7%)
Brand of milk 2 (2.2%)

treatment groups. The most common treatments were

Table 2 Frequency of medications dispensed to simulated clients
antibiotics alone (40.7%) or antibiotics in combination
by medication type and item dispensed
with ORS (24.2%). ORS alone (7.7%) and ORS in combi-
Number of nation with adsorbents (12.1%) were the next most com-
Medication pharmacies Item dispensed Frequency mon treatments. The simulated clients were referred to
ORS 45 (49.5%) ORS 45 (49.5%) the doctor on five occasions (5.5%) and provided with
Antibiotic 62 (68.1%) Furazolidone 31 (34.1%) adsorbents alone on three occasions (3.3%). The remain-
Nifuroxazide 17 (18.7%) ing treatments were ORS in combination with an antibi-
Co-trimoxazole 10 (11.0%) otic and an adsorbent (2.2%), ORS combined with a
Metronidazole 2 (2.2%) prokinetic (2.2%), ORS in combination with an antibiotic
Cephalexin 2 (2.2%)
and a probiotic (1.1%) and an anti-diarrhoeal alone
Azithromycin 1 (1.1%)
Norfloxacin 1 (1.1%)
(1.1%) (Figure 1).
Adsorbent 16 (17.6%) Dioctahedral smectite 15 (16.5%) The most common single piece of advice given to the
Activated charcoal 1 (1.1%) simulated clients was by the people who dispensed
Miscellaneous 4 (4.4%) Domperidone 1 (1.1%) ORS. All 45 of the ORS dispensers correctly advised the
Dicyclomine 1 (1.1%) simulated clients to replace the patient’s drinking water
Loperamide 1 (1.1%) with ORS until the diarrhoea was finished. Despite this,
Probiotic 1 (1.1%)
the majority of dispensers actually gave no advice about
ORS = oral rehydration salt. non-pharmacological treatments to the simulated clients
(57.1%). Of the 42.9% dispensers that did give the simu-
lated clients non-pharmacological advice, the most com-
Saccharomyces boullardii and the opioid antidiarrhoeal mon advice was to avoid milk (16.5%), take only a soft
agent loperamide were both dispensed on one occasion. food diet (14.3%) and to consult a doctor if symptoms
The medications and advice provided by pharmacists persist (14.3%). A small number of dispensers advised
to the simulated clients could be classified into ten the simulated clients to try preventing the spread of

© 2017 The Society of Hospital Pharmacists of Australia Journal of Pharmacy Practice and Research (2017) 47, 383–388
386 S. Jaisue et al.

1% no fever, no vomiting and no blood or mucus in the

1%
2% 2% stool. This figure compares to the 52.2% rate of inappro-
3% priate antibiotic dispensing reported in the simulated
Anbiocs alone
6% client study in southern Thailand6 and the 72.6% rate
ORS + anbiocs
ORS + adsorbents reported in a cross-sectional study of children less than
8% 41%
ORS alone 5 years presenting with diarrhoea at a public hospital in
Refer to doctor central Thailand.7 Antibiotic overuse is a major contribu-
Adsorbents alone
12%
tor to the development of antibiotic resistance, which is
ORS + anbiocs + adsorbents
ORS + prokinec drugs now of great concern at global and national levels.
ORS + anbiocs + probiocs Indeed, it is this issue that led to the establishment of
An-diarrhoeal agent alone the AMRCP in 201217 to reduce the unnecessary and
24% unsuitable provision of antibiotics for non-bacterial dis-
eases. The high rate of antibiotics overuse observed in
Figure 1 Medications and advice provided to simulated clients by this study 2 years after the establishment of the AMRCP
treatment group is likely to be because the first phase of the program
infection by avoiding contact (3.3%) and replacing was mainly concerned with the establishment and
showers with washing with a warm water-soaked cloth development of governance structures.17 Thus, the prin-
(3.3%). Two dispensers advised the simulated clients to cipal advantage of the current study was to identify the
avoid giving the simulated patient fresh or sour food, types of dispensing errors being encountered in the
one dispenser said to avoid ice and one dispenser community to assist in the design of appropriate inter-
advised the simulated clients to use an antipyretic if a ventions.
fever presents (Table 3). In addition to these problems with general overuse of
antibiotics, the types of antibiotics dispensed to the sim-
ulated clients were often inappropriate for the disease
DISCUSSION and, in some cases dangerous for the simulated patient.
For example, the dispensing of metronidazole to the
Of the 91 pharmacies visited for this study, only seven simulated clients was inappropriate as it is only
(7.7%) complied with WHO recommendations4 and approved for the treatment of diarrhoea due to Clostrid-
ASU guidelines5 to dispense ORS alone to a child with ium difficile, amoebiasis and giardiasis.16 On the other
watery diarrhoea. This is a similar rate to that reported hand, the fluoroquinolone antibiotic norfloxacin is not
in a previous simulated client study conducted in south- recommended for use in children under 18 years due to
ern Thailand, where the rate of correctly dispensing concerns based on animal studies that it may cause
only ORS was 5.2%.6 The overall rate of dispensing ORS problems with bones, joints and tissues.18 In addition,
(with or without other medications) was 49.5% which is the nitrofurans, i.e. furazolidone and nifuroxazide, were
lower than the 65% rate reported by the WHO.1 withdrawn from the Thailand veterinary drug list in
More than two-thirds (68.1%) of the pharmacies vis- 2002 due to concerns that they are carcinogenic.19 While
ited in this study dispensed antibiotics to the simulated nitrofurans have not been removed from the human
clients. This is inappropriate as the scenario indicated drug list, there has been an ongoing debate among Thai
that the simulated patient has non-infectious diarrhoea: health professionals for many years about their safety.
Indeed, due to a lack of evidence to support their effi-
cacy in diarrhoea treatment, the Thailand Ministry of
Table 3 Advice provided to simulated clients regarding non-
Public Health has recently reclassified furazolidone as a
pharmacological treatment
controlled class drug and there are plans to withdraw
Advice Frequency (%) nifuroxazide in the near future.19 As more than half of
the dispensers in this study dispensed these two drugs
No advice 52 (57.1%)
Avoid or dilute milk before drinking 15 (16.5%) to the simulated clients, this matter needs legislative
Take only soft diet 13 (14.3%) attention.
Consult doctor if the symptoms persist 13 (14.3%) The adsorbents (activated charcoal and dioctahedral
Avoid body contact to prevent infection 3 (3.3%) smectite) and probiotic (S. boullardii) dispensed to the
Replace showering with sponge bath 3 (3.3%) simulated clients were unnecessary and unsuitable for
Avoid fresh or sour food 2 (2.2%)
the scenario of non-infectious diarrhoea, but they are
Use antipyretic if fever presents 1 (1.1%)
not dangerous. Using probiotics to treat watery diar-
Avoid ice 1 (1.1%)
rhoea in children is not included in the WHO

Journal of Pharmacy Practice and Research (2017) 47, 383–388 © 2017 The Society of Hospital Pharmacists of Australia
Dispensing for diarrhoea in children
recommendations because of the considerable variability
among the microorganism strains contained in commer-
cially available treatments and the lack of conclusive
evidence indicating efficacy in children.20 Dispensing a
probiotic in this simulated scenario was therefore con-
sidered inappropriate.
Supplemental zinc was not dispensed at any pharma-
cies despite evidence that zinc can decrease the inci-
dence of recurrent episodes of diarrhoea in children.21
As this recommendation was only recently included in
the WHO guidelines, this issue should be addressed
in any intervention to improve the quality of dispensing
in children with diarrhoea.
Typically, dispensers did not ask about frequency of
diarrhoea (59.3%), presence of sunken eyes (97.8%) and
production of tears when crying (98.9%), all of which can
indicate dehydration in the patient. This implies that the
dispensers did not realise the importance of fluid replace-
ment in childhood diarrhoea. Similarly, inadequate
patient history taking is likely to have led to the inappro-
priate supply of antibiotics as the dispensers only asked
questions related to infectious diarrhoea (presence of
fever, vomiting or blood in stools) about half the time.
According to Thai regulations, community pharma-
cies must have a licensed pharmacist on duty at all
times, but anecdotally the enforcement of this law is not
strong. This is supported by data from a survey con-
ducted by the Thailand Ministry of Public Health and
The Pharmacy Council of Thailand in 2013 that revealed
there was no pharmacist on duty at 76.4% of Class I
pharmacies visited in some regions of Thailand.22 For-
mally trained and licensed pharmacists are expected to
know the current guidelines for watery diarrhoea treat-
ment, but this cannot be expected of people who work
at pharmacies on their behalf. As the simulated client
method employed for this study did not seek consent
from the participants, it must preserve their anonymity
and cannot determine if the dispensers were actually
licensed pharmacists. Therefore, it cannot be concluded
if the high level of inappropriate dispensing we
observed was due to poor decisions by unqualified dis-
pensers or a lack of knowledge about disease manage-
ment in licensed staff. The framework to improve this
situation therefore needs to include aspects that are
applicable to either scenario.
Previous recommendations to improve retail phar-
macy behaviour in developing countries have included:
providing relevant and up-to-date information, influenc-
ing the dispensers’ decision making via effective com-
munication of the guidelines, rewarding dispensers who
follow the guidelines, and banning the stocking and sell-
ing of certain drugs.23 While interventions that reward
dispensers for correctly following the guidelines are
© 2017 The Society of Hospital Pharmacists of Australia
387
effective, it is a difficult strategy to implement over a
wide area due to the in-built costs. A study of interven-
tions in diarrhoea management in Thai hospitals found
that interactive educational meetings and offering free-
of-charge stool cultures dramatically decreased antibiotic
use for watery diarrhoea.7 Another study found that
only enforcement of the appropriate laws by officials
could change the dispensing behaviour for watery diar-
rhoea in community pharmacies in Thailand.24
Recommendations obtained from this study consist of
three parts, and are targeted to dispensers in the com-
munity pharmacies, regardless of their pharmacy license
status. First, dispensers should be informed of the prob-
lem as described in the current study and provided the
ASU guidelines. Although the ASU and WHO guideli-
nes are freely available online, this does not seem to
have prevented inappropriate prescribing in this circum-
stance. Sending the study results and ASU guidelines
directly to pharmacies ensures access to the relevant
knowledge. The second step of the framework is to
organise meetings with dispensers in this area to edu-
cate them on appropriate watery diarrhoea treatment.
The last step is law enforcement. Implementation of
these recommendations as educational, managerial and
regulatory interventions has been shown to be effective
whether implemented individually or in combination.25
However, it is important to recognise that this is a con-
tinuous process and the ongoing monitoring of pharma-
cies and the appropriate enforcement of laws are
required to ensure good pharmacy practice.
Overall, the dispensing pattern observed in this study
was of insufficient fluid replacement and antibiotic over-
use. New interventions focused on educating the dis-
pensers about these two issues are required as the
proportion of appropriate treatments remains danger-
ously low.6 Improving the proportion of appropriate
treatments in the community would have significant
benefits as diarrhoea is still the fourth major cause of
death in children under 5 years in this region.1
ACKNOWLEDGEMENT
The authors would like to acknowledge the Faculty of
Pharmaceutical Sciences, Khon Kaen University, Thai-
land for financial support and Miss Ammarat Saensorn,
Miss Panitnan Saensorn and Mr Teerawat Boonlerd for
playing the role of simulated clients.
Conflict of interests statement
The authors declare that they have no conflicts of
interests.
Journal of Pharmacy Practice and Research (2017) 47, 383–388
388
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Received: 09 November 2016
Revised version received: 24 January 2017
Accepted: 16 March 2017
© 2017 The Society of Hospital Pharmacists of Australia