Harmful practices in the management of childhood diarrhea in low- and middle-income countries: a systematic review

Antibiotic resistance trends for common bacterial aetiologies of childhood diarrhoea in low- and middle-income countries: A systematic review

Background

Diarrhoea is the second most common cause of death among children under the age of five worldwide. The World Health Organization (WHO) recommends treating diarrhoea with oral rehydration therapy, intravenous fluids for severe dehydration, and zinc supplements. Antibiotics are only recommended to treat acute, invasive diarrhoea. Rising antibiotic resistance has led to a decrease in the effectiveness of treatments for diarrhoea.

Methods

A systematic literature review in PubMed, Web of Science, and EMBASE was conducted to identify articles relevant to antibiotic-resistant childhood diarrhoea. Articles in English published between 1990 to 2020 that described antibiotic resistance patterns of common pathogens causing childhood diarrhoea in low- and middle-income countries were included. The studies were limited to papers that categorized children as 0-5 years or 0-10 years old. The proportion of isolates with resistance to major classes of antibiotics stratified by major WHO global regions and time was determined.

Results

Quantitative data were extracted from 44 articles that met screening criteria; most focused on children under five years. Escherichia coli isolates had relatively high resistance rates to ampicillin and tetracycline in the African (AFR), American (AMR), and Eastern Mediterranean Regions (EMR). There was moderate to high resistance to ampicillin and third generation cephalosporins among Salmonella spp in the AFR, EMR, and the Western Pacific Region (WPR). Resistance rates for ampicillin, co-trimoxazole, and chloramphenicol for Shigella in the AFR started at an alarmingly high rate ( ~ 90%) in 2006 and fluctuated over time. There were limited antibiotic resistance data for Aeromonas, Yersinia, and V. cholerae. The 161 isolates of Campylobacter analysed showed initially low rates of fluoroquinolone resistance with high rates of resistance in recent years, especially in the Southeast Asian Region.

Conclusions

Resistance to inexpensive antibiotics for treatment of invasive diarrhoea in children under ten years is widespread (although data on 6- to 10-year-old children are limited), and resistance rates to fluoroquinolones and later-generation cephalosporins are increasing. A strong regional surveillance system is needed to carefully monitor trends in antibiotic resistance, future studies should include school-aged children, and interventions are needed to reduce inappropriate use of antibiotics for the treatment of community-acquired, non-invasive diarrhoea.

Registration

This systematic review was registered in Prospero (registration number CRD42020204004) in August 2020.

Antibacterial Ag/Graphene-Integrated

Air pollution and infectious diseases (such as the COVID-19 pandemic) have attracted considerable attention from governments and scientists worldwide to find the best solutions to address these issues. In this study, a new simultaneous antibacterial and particulate matter (PM) filtering Ag/graphene-integrated non-woven polypropylene textile was fabricated by simply immersing the textile into a Ag/graphene-containing solution. The Ag/graphene nanocomposite was prepared by reducing Ag ions on the surface of graphene nanoplatelets (GNPs) using the leaf extract. The prepared Ag/graphene textile was characterized using scanning electron microscopy (SEM), X-ray diffraction (XRD), Energy Dispersive X-ray (EDX), and contact angle measurements. The results showed excellent integration of the Ag/GNP nanocomposite into the non-woven polypropylene textile matrix. The prepared textile exhibited superhydrophobicity with a contact angle of 152°. The maximum PM removal percentage of the Ag/GNP-integrated textile was determined to be 98.5% at an Ag/GNP content of 1.5% w/w and a silicon adhesive of 1% w/w. The Ag/GNP textile exhibited high antibacterial activity toward Escherichia coli with no sign of bacteria on the surface. Remarkably, the as-prepared Ag/GNP textile was highly durable and stable and could be reused many times after washing.

Graphical Abstract

Factors Influencing Antibiotic Consumption in Adult Population of Kazakhstan

Poor or suboptimal knowledge of appropriate antibiotic use is a cause for global concern and little is known about Central Asian countries. Therefore, this survey is aimed at evaluating awareness about antibiotic use and resistance among the adult population of Kazakhstan. A cross-sectional study of a random sample was conducted between October 2021 and February 2022 among 727 individuals without medical education and followed the methodology described in the WHO report “Antibiotic Resistance: Multi-country public awareness survey”. Half of the respondents (50.4%) received antibiotic therapy within the last 12 months, 40.1% had no prescription for this and 40.4% received no advice from a medical professional. Nearly two-thirds of respondents (65.3%) never heard about antibiotic resistance and 57.2% believed that it is worth requesting the same antibiotic if it helped to treat a similar condition previously. In general, knowledge about antibiotic use proved to be low in 82.1% of respondents and 91.9% agreed with the statement that a common cold requires antibiotics. There is a need for awareness-raising campaigns to improve the knowledge about antibiotic use and resistance in the population of Kazakhstan.

Appropriate feeding practice and associated factors among under-five children with diarrheal disease in sub-Saharan Africa: a multi-country analysis

BACKGROUND

Diarrheal disease is one of the leading causes of child mortality and morbidity in low-income countries. Although the provision of more fluid and solid foods during diarrhea are important to treat the diseases, in Africa, food and fluid restrictions are common during diarrheal illness. Therefore, the aim of this study was to determine appropriate feeding practice and associated factors among under-five children with diarrheal disease in sub-Saharan Africa (SSA).

METHODS

We have used the appended most recent demographic and health survey (DHS) datasets of 35 sub-Saharan countries conducted from 2010 to 2020. A total weighted sample of 42,882 living children with diarrhea were included in the analyses. Multivariable multilevel binary logistic regression was used to identify factors associated with appropriate child feeding practice in SSA. A p value of ≤ 0.05 was used as a cut of point to declare statistically significant variables.

RESULTS

The overall prevalence of appropriate child feeding practice in this study was 10.45% (95% CI 10.17-10.74). The odds of having appropriate child feeding practice was higher among women with primary (AOR = 1.27: 1.17-1.37), secondary (AOR = 1.38: 1.25-1.52), and higher education level (AOR = 1.52: 1.21-1.90), media exposure (AOR = 1.11: 1.11-1.29), richer (AOR = 1.23:1.01-1.26) and richest (AOR = 1.19:1.05-1.35) wealth index, and currently working (AOR = 1.12: 1.04-1.19).

CONCLUSION

The prevalence of appropriate child feeding practice in this study was found to be very low. It advisable to reduce diarrhea-related child mortality through enhancing diarrhea management practice especially by working on the after mentioned factors.

Antibiotic Prescription Patterns in Children Under 5 Years of Age With Acute Diarrhea in Quito-Ecuador

BACKGROUND

Diarrheal disease remains a significant cause of child mortality, particularly in regions with limited access to healthcare and sanitation. Inappropriate practices, including unjustified medication prescriptions, pose challenges in the management of acute diarrhea (AD), especially in low- and middle-income countries.

OBJECTIVE

This study analyzed antibiotic prescription patterns and assessed compliance with Integrated Management of Childhood Illness (IMCI) guidelines in children under 5 with AD in the Ministry of Public Health (MOPH) Ambulatory Care Centers of Quito city, Ecuador.

METHODS

A cross-sectional design was used, collecting electronic health records (EHR) of patients diagnosed with AD from 21 health facilities in District 17D03. A probabilistic and stratified sampling approach was applied. Patient characteristics, prescriber characteristics, treatments, and compliance of IMCI guideline recommendations were evaluated. A stepwise logistic regression analysis examined the association between antibiotic prescription and patient and physician characteristics.

RESULTS

A total of 359 children under 5 years of age were included, with 58.77% being girls. 85.24% of the cases of AD were attributed to gastroenteritis and colitis of infectious and unspecified origin. Amebiasis and other protozoal intestinal diseases accounted for 13.37% and 1.11% of the cases, respectively. The completion rates of recording various IMCI parameters varied; parameters such as duration of diarrhea, presence of blood in stool, and evidence of sunken eyes had high completion rates (100%, 100%, and 87.47%, respectively), while parameters like state of consciousness, presence of thirst, and type of diarrhea had low completion rates (0.28%, 0.28%, and 0.84%, respectively). None of the cases had all parameters fully recorded. Antimicrobials were prescribed in 38.72% of the cases. Children aged 3 to 5 years had higher odds of receiving antimicrobial prescription for AD (aOR: 4.42, 95% CI 2.13-9.18, P < .0001) compared to those under 1 year, after adjusting for the number of loose stools per day, gender, and age of the health professional.

CONCLUSION

Variations in IMCI guideline compliance were observed, with no cases fully adhering to the guidelines. Antimicrobial prescription rates were notably high, especially among older children. Further research and specialized interventions are necessary to gain comprehensive insight into the factors underlying non-compliance with the IMCI guidelines.

Medical cost of acute diarrhea in children in ambulatory care

OBJECTIVE

The aim of this study was to estimate the direct medical cost per episode and the annual cost for acute diarrhea (AD) in children under five years of age in Ambulatory Care Centers of the Ministry of Public Health (MOPH) of Ecuador.

METHODS

A cost of illness study with a provider perspective was carried out through a micro-costing of health resources and valuated in international dollars. Medical consultations and laboratory tests were valued using the tariff framework of services for the National Health System and for the prescribed medications, a reported cost registry of pharmacy purchases made in the year of study was used.

RESULTS

A total of 332 electronic health records of children under five years of age were included in the analysis. Laboratory tests were performed on 37.95% (126/332), medications were prescribed to 93.67% (311/332) of the children, and antimicrobials were prescribed to 37.35% (124/332) of the children, representing an antibiotic prescription rate of 26.51% (88/332) and an antiparasitic prescription rate of 10.84% (36/332). The mean cost of the MOPH per child per episode of AD was US$45.24 (2019 dollars) (95% CI:43.71 to 46.76).

CONCLUSION

The total estimated cost of AD in children under five years of age for the MOPH in 2019 was about US$6,645,167.88 million (2019 dollars) (95% CI: 6,420,430.77 to 6,868,436.12). A high proportion of the direct medical cost of AD in children under five years of age in outpatient settings is due to unnecessary laboratory tests.

Assessment of Maternal Knowledge and Practices Regarding Acute Diarrheal Illnesses in Children in Saudi Arabia: A Tertiary Care Center Survey

Background Diarrheal illness remains one of the most common causes of death among children specifically those who live in developing countries. Appropriate mothers' knowledge and practice regarding acute diarrhea illness in children can considerably reduce diarrhea-related morbidity and mortality. So, the aim of this study was to evaluate mothers' knowledge and practice regarding acute diarrheal illness in children. Method This cross-sectional study was conducted in a tertiary hospital in Riyadh, Saudi Arabia using a newly developed questionnaire that was distributed to King Abdullah Specialist Children. The calculated sample size was 375. Results A total of 375 mothers were included in this study and the majority of them (99%) were Saudis. More than half of the participants (61%) were university graduates. The majority (96.5%) chose previous experience as the main source of information about diarrhea while (40%) chose physician. Most of the mothers (69.6%) believed that teething is the leading cause of diarrheal illness in children. Regarding the treatment, fluid was recognized to be the major treatment for diarrhea as chosen by the mothers. Around (42.7%) of the respondents thought intravenous fluid is more effective than oral rehydration solution (ORS) in treating dehydration associated with diarrheal episodes. ORS was the main type of fluid (74.1%) which was selected by the mothers to be given during the diarrheal episode. Conclusion Mothers showed good knowledge and practice overall in regard to acute diarrheal illness in children. However, this study revealed some misconceptions among the caregivers which necessitates more educational sessions to be conducted in the community and during the hospital visit.

Knowledge of ORS packet or pre-packaged liquids and its determinants for the management of diarrhea among women of reproductive age: multilevel analysis of 32 sub-Saharan African countries demographic and health survey

BACKGROUND

Infant and child mortality due to diarrhea is a very serious and widespread problem all over the world, particularly in sub-Saharan African countries. Using an oral rehydration solution (ORS) is an easy, inexpensive, and reliable way of treating dehydration and reducing diarrhea-related mortalities. However, there is limited evidence on the magnitude of knowledge of ORS packets or pre-packaged liquids and determinant factors among women in sub-Saharan African countries. Hence, This study sought to assess knowledge of ORS packets or pre-packaged liquids and determinant factors for the management of diarrhea among women of reproductive age in 32 sub-Saharan African countries.

METHOD

Data for the study were drawn from a recent 32 demographic and health surveys (DHS) conducted in sub-Saharan African countries. A total sample of 234,848 mothers who gave birth in the last 5 years preceding the survey was included. STATA version 16 was used to clean and analyze the data. Multilevel multivariable logistic regression was employed to identify factors associated with knowledge of ORS packets or pre-packaged liquids in sub-Saharan African countries. In the multivariable analysis, an adjusted odd ratio with a 95% confidence level was reported to indicate statistical association with a P value < 0.05.

RESULTS

The overall magnitude of knowledge of ORS packets or pre-packaged liquids in sub-Saharan African countries were 80.59% (95% CI: 80.42%, 80.74%). Individual-level factors such as women who were aged 25 -39, (AOR = 1.30; 95%CI; 1.27, 1.34) and aged > 35 (AOR = 1.44; 95%CI; 1.40,1.49),women having primary education (AOR = 1.51; 95%CI; 1.47, 1.56), secondary and above education (AOR = 1.80; 95%CI; 1.74, 1.86), women who were working (AOR = 1.38; 95%CI; 1.35, 1.42), household size of 6-10, & > 10, (AOR = 1.08; 95%CI; 1.05, 1.10) and (AOR = 1.10; 95%CI; 1.06, 1.14), women from middle and rich household (AOR = 1.09 95%CI; 1.06, 1.12) and (AOR = 1.51 95%CI; 1.47, 1.56), media exposure (AOR = 1.20 95%CI; 1.17, 1.23), ANC visit (AOR = 2.11 95%CI; 2.04, 2.17), living in regions of East Africa, West Africa and Southern Africa have 2.45 (AOR = 2.45 95%CI; 2.36, 2.53), 2.21 (AOR = 2.21 95%CI; 2.14, 2.27), 1.95 (AOR = 1.95 95%CI; 1.83, 2.08) were significantly associated with womens knowledge about ORS packet or pre-packaged liquids.

CONCLUSION

One in five women does not know ORS packets or pre-packaged liquids. Maternal age, women's education, working status, household wealth index, household size Media exposure, ANC visit, and region were significant predictors of knowledge of ORS packets or pre-packaged liquids. Therefore, it is better to give special emphasis to young age, women who had no formal education and who have no media exposure, poor households, those women who have not currently working as well as those who have a household size of greater than six. Furthermore, it is critical to increase ANC visits to improve knowledge of ORS packets or pre-packaged liquids.

Diarrhoeal prevalence and handwashing practices of children attending early childhood development centres in KwaZulu-Natal, South Africa

Background

Diarrhoea, a leading cause of childhood morbidity and mortality, spread through contaminated food or water or from person to person, is a major cause of hospitalisation in South African children.

Aim

To determine if hygiene practices of parents or guardians and early childhood development centre (ECD) educators contributed to diarrhoea in children attending the centres.

Setting

The study was conducted at ECD centres in Mpumalanga Township of KwaZulu-Natal province, South Africa.

Methods

A descriptive cross-sectional study was conducted at 10 ECD centres. Parents or guardians (n = 385) and educators (n = 121) answered self-administered questionnaires. Frequencies, bivariate associations and multivariate regression modelling were conducted.

Results

The prevalence of diarrhoea in children ≤ 5 years was 67.3%. Most parents or guardians washed their hands after defecating and handling a child's faeces as well as before preparing food. Handwashing after urination was low. Washing of children's hands after these events was lower. Although all educators reported always washing the child's hands after defecating and before handling or eating food, they were less likely to wash the children's hands after urination (p = 0.003). Childhood diarrhoea was associated with the type of toilet, households with pit latrines having a higher prevalence of diarrhoea (p < 0.001). It was also associated with washing of children's hands after urination (p = 0.014), before handling or eating food (p = 0.001) and with increased number of children in the household (p = 0.001).

Conclusion

In this population, the high prevalence of diarrhoea is related to the number of children in a household and handwashing practices.

Contribution

This study highlights the importance of handwashing practices in the prevention of diarrhoea in children.

Childhood diarrhoea: a cross-sectional survey on maternal knowledge, hygienic practices and use of oral zinc for home management in a Nigerian community

Introduction

diarrhoea is the second leading cause of morbidity and mortality in young children. The aim was to assess maternal knowledge, hygienic practices and home management (HM) of diarrhoea with oral rehyrdation therapy (ORT) and oral zinc in children aged 6-23 months in western Nigeria. Predictors of good knowledge and practice were also assessed.

Methods

this was a community based analytic cross-sectional study. Multistage sampling was used to select mothers of children 6-23 months of age. Data were collected using pre-tested, interviewer administered questionnaires and analyzed using SPSS version 20. Bivariate analysis and multiple logistic regression for predictor variables were done. Level of significance was set at 0.05.

Results

three hundred and seventy one (371) respondents were interviewed (mean age 30.4 ± 5.02 years). 305 (82.2%) had good knowledge of diarrhoeal diseases, 208(56.1%) had good knowledge of home management of childhood diarrhoea, 274 (73.9%) had good maternal hygienic practices and 161 (61.2%) of the 263 mothers who had managed diarrhoea in their children, had good practice. Only 34 (12.9%) of them used zinc tablets and 11 (32.4%) did not complete the full course. Maternal age 30-39 years predicted good knowledge (AOR 3.19 CI 2-6.05). Predictors of good home management practices were: maternal age 30-39 years (AOR 2.78 CI 1.44-5.37), >40 years (AOR 5.55 CI 1.54-20.01) and younger age of the index child, 6-11 months (AOR 4.83 CI 2.29-10.18).

Conclusion

mothers had poor knowledge of the role of zinc supplementation in childhood diarrhoea and use of zinc tablets for diarrhoea was very low. Community based health education should be carried out.

Rotaviruses and Noroviruses as Etiological Agents of Acute Intestinal Diseases of Ukrainian Children

(1) Background: Rotavirus and norovirus infections are the primary viral causes of childhood diarrhea. In Ukraine, the diarrhea-linked infant mortality rate is low, but the number of children infected is quite high. This study examined the rates of rotavirus and norovirus infections throughout Ukraine. (2) Methods: Fecal samples for children admitted to hospitals in six Ukrainian cities (Kyiv, Lviv, Sumy, Odesa, Kharkiv, and Uman) were tested for the presence of rotavirus and norovirus. (3) Results: The overall rate of hospitalized children suffering from diarrhea with confirmed presence of rotavirus or norovirus in fecal samples was significant (20.67% and 27.94%, respectively). Samples obtained from children from Lviv had significantly higher rates of the viruses, and Kyiv and Uman had significantly lower rotavirus or norovirus detection levels than expected. (4) Conclusion: Childhood diarrhea impacts Ukraine significantly. The economic and societal effects of the failure to address this public health issue are indicated by the hospitalization rate of children with preventable illnesses. The geographical disparities in Ukraine for child hospitalizations caused by rotavirus and norovirus infections could result from environmental (sanitary factors or water purity issues) or social factors. Further research is needed to completely characterize infant viral infections in Ukraine.

Do private providers give patients what they demand, even if it is inappropriate? A randomised study using unannounced standardised patients in Kenya

INTRODUCTION

Low and varied quality of care has been demonstrated for childhood illnesses in low-income and middle-income countries. Some quality improvement strategies focus on increasing patient engagement; however, evidence suggests that patients demanding medicines can favour the selection of resistant microbial strains in the individual and the community if drugs are inappropriately used. This study examines the effects on quality of care when patients demand different types of inappropriate medicines.

METHODS

We conducted an experiment where unannounced standardised patients (SPs), locally recruited individuals trained to simulate a standardised case, present at private clinics. Between 8 March and 28 May 2019, 10 SPs portraying caretakers of a watery diarrhoea childhood case scenario (in absentia) conducted N=200 visits at 200 private, primary care clinics in Kenya. Half of the clinics were randomly assigned to receive an SP demanding amoxicillin (an antibiotic); the other half, an SP demanding albendazole (an antiparasitic drug often used for deworming), with other presenting characteristics the same. We used logistic and linear regression models to assess the effects of demanding these inappropriate medicines on correct and unnecessary case management outcomes.

RESULTS

Compared with 3% among those who did not demand albendazole, the dispensing rate increased significantly to 34% for those who did (adjusted OR 0.06, 95% CI 0.02 to 0.22, p<0.0001). Providers did not give different levels of amoxicillin between those demanding it and those not demanding it (adjusted OR 1.73, 95% CI 0.51 to 5.82). Neither significantly changed any correct management outcomes, such as treatment or referral elsewhere.

CONCLUSION

Private providers appear to account for both business-driven benefits and individual health impacts when making prescribing decisions. Additional research is needed on provider knowledge and perceptions of profit and individual and community health trade-offs when making prescription decisions after patients demand different types of inappropriate medicines.

TRIAL REGISTRATION NUMBERS

American Economic Association Registry (#AEARCTR-0000217) and Pan African Clinical Trial Registry (#PACTR201502000770329).

The burden of diarrhea, etiologies, and risk factors in India from 1990 to 2019: evidence from the global burden of disease study

Background

This study aims to measure the burden of diarrhea in India and analyze the trend of mortality associated with it for the past 30 years. We also intend to find the prevailing etiology and risk factors associated with diarrheal mortality in India.

Methods

The study has used the latest round of Global Burden of Disease (GBD) study-2019. GBD data is available across age groups and gender-wise over the period from 1990 to 2019. The study has identified 13 etiologies for the cause of diarrhea deaths and 20 risk factors to analyze the burden of disease.

Results

Our study shows, childhood diarrhea has declined over the years significantly, yet contributes to a larger share of DALYs associated with the disease. Among all the death cases of Diarrhea, in 2019, the most prevalent disease-causing pathogen is found to be Campylobacter. But Adenovirus is the major contributor to childhood diarrheal deaths. Though the burden of diarrhea is declining over the period, still there is a need to progress the interventions to prevent and control diarrhea rapidly to avoid the huge number of deaths and disabilities experienced in India.

Conclusions

Consumption of safe and clean water, proper sanitation facility in every household, required nutrition intake by mother and child, safe breastfeeding and stool disposal practices and careful case management, rotavirus vaccination are some of the effective interventions to be implemented all over the country. Further, evidence-based policies should be made and implemented to sustain diarrhea prevention programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12515-3.

Socio-cultural factors for breastfeeding cessation and their relationship with child diarrhoea in the rural high-altitude Peruvian Andes - a qualitative study

Background

In some areas of the world, breast milk is seen as a potential source of child diarrhoea. While this belief has been explored in African and Southeast Asian countries, it remains vastly understudied in Latin American contexts. We investigate socio-cultural factors contributing to breastfeeding cessation in rural high-altitude populations of the Peruvian Andes. The role of socio- cultural factors in the local explanatory model of child diarrhoea, and whether these perceptions were integrated in the local healthcare system were assessed.

Methods

Within the framework of a randomised controlled trial, we conducted semi-structured interviews with 40 mothers and 15 health personnel from local healthcare centres involved in the trial.

Results

Cultural beliefs on breastfeeding cessation included the perception that breast milk turned into “blood” after six months and that breastfeeding caused child diarrhoea. We identified eight local types of child diarrhoea, and women linked six of them with breastfeeding practices. “Infection” was the only diarrhoea mothers linked to hygiene and the germ disease concept and perceived as treatable through drug therapy. Women believed that other types of diarrhoea could not be treated within the formal healthcare sector. Interviews with health personnel revealed no protocol for, or consensus about, the integration of the local explanatory model of child diarrhoea in local healthcare and service provision.

Conclusions

The local explanatory model in rural Andean Peru connected breastfeeding with child diarrhoeas. Cultural beliefs regarding diarrhoea management may increase home treatments, even in cases of severe diarrhoeal episodes. Future national breastfeeding support programmes should promote peer-counselling approaches to reduce negative attitudes towards breastfeeding and health practitioners. Local explanatory models should be incorporated into provincial and regional strategies for child diarrhoea management to promote equity in health and improve provider-patient relationships.

Antidiarrheal Effect of DLBS1Y62, a Bioactive Fraction of Uncaria gambir Roxb. Dried Sap Extract, in Wistar Rats

Background

Diarrhea is a common health problem worldwide, especially in developing countries. It is the second leading cause of mortality for children. Uncaria gambir Roxb. extract has been used to treat diarrhea and dysentery, and as an astringent medicine, in Asian countries. Here, we investigated the antidiarrheal effect of DLBS1Y62, which is the bioactive fraction of dried sap extract from U. gambir, using castor oil-induced diarrhea and castor oil-induced enteropooling in rats.

Methods

DLBS1Y62 was obtained by crushing and milling the dried sap extract of U. gambir leaves. Male Wistar rats, 2–3 months old, weighing 200–250 g (n=30), were used for this study. Negative controls received 0.05 mL purified water. Positive controls were treated with 2 mg/kg BW loperamide orally as a suspension. Groups I, II, and III received 6.25, 12.5, and 25 mg/kg BW DLBS1Y62, respectively. Group IV received a combination of 6.25 mg/kg BW DLBS1Y62 and 20 mg/kg BW attapulgite. Diarrheal onset and frequency were observed; then, the weight and volume of intestinal contents were measured.

Results

DLBS1Y62 at all dose levels and in combination with attapulgite could inhibit the formation of further fecal forms of diarrhea, without delaying the onset of diarrhea. The rats that received DLBS1Y62 25 mg/kg BW had the lowest frequency of diarrhea and average intestinal contents compared with the treatment and negative control groups. DLBS1Y62 at a dose of 25 mg/kg BW also gave similar results to 2 mg/kg BW loperamide as a positive control in reducing diarrheal frequency and intestinal content.

Conclusion

The results of this study suggest that DLBS1Y62, particularly at a dose of 25 mg/kg BW, containing tannin as a compound, may become an alternative treatment for diarrhea.

Diarrhoea Management using Over-the-counter Nutraceuticals in Daily practice (DIAMOND): a feasibility RCT on alternative therapy to reduce antibiotic use

BACKGROUND

Although rarely indicated, antibiotics are commonly used for acute diarrhoea in China. We conducted a randomised, double blind exploratory clinical trial of loperamide, berberine and turmeric for treatment of acute diarrhoea.

METHODS

Adults with acute uncomplicated diarrhoea aged 18 to 70 were randomised to 4 groups: (A) loperamide; (B) loperamide and berberine; (C) loperamide and turmeric; (D) loperamide, berberine and turmeric. All participants were given rescue ciprofloxacin for use after 48 h if symptoms worsened or were unimproved. Primary endpoints were feasibility and ciprofloxacin use during the 2-week follow-up period. Semi-structured interviews were conducted following recruitment and were analysed thematically. Recruiting doctors, delivery pharmacists and research assistants were blinded to treatment allocation.

RESULTS

Only 21.5% (278/1295) of patients screened were deemed eligible, and 49% (136/278) of these consented and were entered into the final analysis. Most participants had mild symptoms, because most patients with moderate or severe symptoms wanted to be given antibiotics. Follow-up was good (94% at 2 weeks). Only three participants used rescue antibiotics compared to 67% of acute diarrhoea patients in the hospital during the recruitment period. The median symptom duration was 14 h in group B (interquartile range (IQR) 10-22), 16 h in group D (IQR 10-22), 18 h in group A (IQR 10-33) and 20 h in group C (IQR 16-54). Re-consultation rates were low. There were no serious treatment-related adverse events. Most interviewed participants said that although they had believed antibiotics to be effective for diarrhoea, they were surprised by their quick recovery without antibiotics in this trial.

CONCLUSION

Although recruitment was challenging because of widespread expectations for antibiotics, patients with mild diarrhoea accepted trying an alternative. The three nutraceuticals therapy require further evaluation in a fully powered, randomised controlled trial among a broader sample.

TRIAL REGISTRATION

ChiCTR-IPR-17014107.

Assessment of the Management of Diarrhoea Among Children Under Five in Addis Ababa, Ethiopia

Purpose

Irrational antibiotic use is a worldwide problem. One of the main reasons for excessive use of antibiotics is the failure to follow the clinical guidelines. Inappropriate use of antibiotics for infectious diarrhea is associated with the risk of increasing the development of antimicrobial resistance and the cost of health care. We therefore pursued to assess the appropriateness of the management of diarrhea in children in Addis Ababa.

Materials and Methods

A retrospective cross-sectional study was conducted in the health centers of Addis Ababa, Ethiopia, between September 2014 and February 2015. Demographic characteristics, signs of dehydration, stool characteristics, drug types and other relevant information have been collected. Data analysis was performed using version 20 of the SPSS. Logistic regression was used to examine the association between dependent and independent variables. Indicators for the appropriateness of diarrhoea management have been established on the basis of the Standard Treatment Guideline and the guidelines of the World Health Organization.

Results

A total of 803 medical records of children have been checked. Of this, 54.4% had received inappropriate management. At least one antimicrobial was prescribed to 73.2% of the children who visited the health centres. Oral rehydration solution (ORS) and zinc were prescribed only in 66.7% and 47.5%, respectively. Appropriate management among children diagnosed with dysentery was found to be 6.38 times higher adjusted odds ratios (AOR=6.38 (3.11, 13.63)) than children with watery diarrhea. Although antibiotics are prescribed inappropriately for most children, it is appropriate when the diarrhea is bloody. Appropriate management of diarrhoea among infants aged 2-11 months was 54% less compared to children aged 12-59 months (AOR=0.46 (0.24, 0.90)).

Conclusion

The magnitude of inadequate antibiotic prescription while managing diarrhoea in our setting was high. On the contrary, a low prescribing rate of ORS and zinc was observed. Our result highlights the need for urgent action to prevent the development of antibiotic-resistant microorganisms. Health-care professionals should have clear information on the risks of inadequate diarrhoea treatment in children under five.

An observational study found large methodological heterogeneity in systematic reviews addressing prevalence and cumulative incidence

OBJECTIVES

The objective of this study was to assess reporting and methodological aspects of systematic reviews (SRs) on prevalence and cumulative incidence data.

STUDY DESIGN AND SETTING

We searched PubMed up to 18 April, 2018, and drew a random sample of eligible SRs.

RESULTS

The included 215 SRs were reported in 187 different journals. 58.1% were published between 2015 and 2018. Few SRs were registered with PROSPERO (5.6%). One-quarter considered articles without languages restrictions (25.1%). Regional restrictions of included studies were applied in 22.8%. A meta-analysis was carried out in 40.5% of the SRs. One hundred and six studies (49.3%) assessed risk of bias or study quality. A total of 41 different existing tools as well as 15 tools developed by the authors themselves were used. The most commonly applied tools were the Newcastle-Ottawa Scale (15.1%), STROBE (13.5%), and the Cochrane Collaboration's tool for assessing risk of bias (7.9%).

CONCLUSION

We found large heterogeneity in characteristics, reporting, and methodological aspects of SRs on prevalence and cumulative incidence data, especially when compared with other types of SRs. Newly developed or revised guidance on how to conduct and report SRs as well as instruments for critical appraisal should consider the diversity of review types.

The Consequences of AMR Education and Awareness Raising: Outputs, Outcomes, and Behavioural Impacts of an Antibiotic-Related Educational Activity in Lao PDR

Education and awareness raising are the primary tools of global health policy to change public behaviour and tackle antimicrobial resistance. Considering the limitations of an awareness agenda, and the lack of social research to inform alternative approaches, our objective was to generate new empirical evidence on the consequences of antibiotic-related awareness raising in a low-income country context. We implemented an educational activity in two Lao villages to share general antibiotic-related messages and also to learn about people’s conceptions and health behaviours. Two rounds of census survey data enabled us to assess the activity’s outputs, its knowledge outcomes, and its immediate behavioural impacts in a difference-in-difference design. Our panel data covered 1130 adults over two rounds, including 58 activity participants and 208 villagers exposed indirectly via conversations in the village. We found that activity-related communication circulated among more privileged groups, which limited its indirect effects. Among participants, the educational activity influenced the awareness and understanding of “drug resistance”, whereas the effects on attitudes were minor. The evidence on the behavioural impacts was sparse and mixed, but the range of possible consequences included a disproportionate uptake of antibiotics from formal healthcare providers. Our study casts doubt on the continued dominance of awareness raising as a behavioural tool to address antibiotic resistance.

Potential Diarrheal Pathogens Common Also in Healthy Children in Angola

BACKGROUND

Globally, diarrhea kills almost 1500 children daily. In diagnostics, molecular methods are replacing traditional assays. We aimed to investigate enteropathogens in children with and without diarrhea in Luanda, the capital of Angola.

METHODS

One hundred and ninety-four stool samples from 98 children with acute diarrhea and 96 children without diarrhea were investigated for 17 enteropathogens with multiplex real-time polymerase chain reaction.

RESULTS

The median age of children was 10.5 months. Enteropathogens, bacteria, viruses and parasites were detected in 91%, 78%, 50% and 25%, respectively. A positive finding was significantly (P = 0.003) more common in diarrhea when testing for all pathogens combined, for bacteria alone and for viruses alone. More than one pathogen was found more frequently in diarrhea than in non-diarrhea stool samples, in 87% and in 59% (P < 0.0001), respectively. The median number (interquartile range) of pathogens detected was 3 (2) versus 1.5 (2; P < 0.0001), respectively. When age was taken into account, diarrhea was found to be associated with enterotoxigenic and enteroaggregative Escherichia coli, Shigella, Campylobacter, rotavirus, sapovirus and Cryptosporidium.

CONCLUSIONS

Multiplex polymerase chain reaction detected enteropathogens in almost all stool samples of children in Luanda, albeit this occurred more often in diarrhea. Children with diarrhea showed more mixed infections than children without diarrhea.

Burden and Risk Factors of Antimicrobial Use in Children Less Than 5 Years of Age with Diarrheal Illness in Rural Bangladesh

Antimicrobial overuse contributes to antimicrobial resistance. Empiric use of antimicrobials for diarrheal illness is warranted only in a minority of cases, because of its self-limiting nature and multifactorial etiology. This study aims to describe the factors contributing to antimicrobial overuse for diarrheal disease among children less than 5 years of age in rural Bangladesh. A total of 3,570 children less than 5 years of age presenting with diarrhea in a tertiary level hospital were enrolled in the study. The rate of antimicrobial use at home was 1,395 (39%), compared with 2,084 (89%) during a hospital visit. In a multivariate analysis, factors associated with antimicrobial use at home included residence located more than 5 miles from a hospital; use of zinc and oral rehydration salts at home; vomiting; greater than 10 stools per 24 hours; diarrheal duration greater than 3 days; and rotavirus diarrhea (P < 0.05 for all). Characteristics of children more likely to be given antimicrobials in a health-care setting included greater than 10 stools per 24 hours; duration of diarrhea greater than 3 days; use of antimicrobials before hospital presentation; fever (≥ 37.8°C); rectal straining; and Shigella infection (P < 0.05 for all). The most commonly used drugs in rotavirus diarrhea were azithromycin and erythromycin, both before hospital presentation and during hospital admission. Our study underscores the importance of diligent vigilance on the rationale use of antimicrobials both at home and in health-care facilities with a special concern for children less than 5 years of age living in rural Bangladesh.

Antibiotics and activity spaces: protocol of an exploratory study of behaviour, marginalisation and knowledge diffusion

BACKGROUND

Antimicrobial resistance (AMR) is a global health priority. Leading UK and global strategy papers to fight AMR recognise its social and behavioural dimensions, but current policy responses to improve the popular use of antimicrobials (eg, antibiotics) are limited to education and awareness-raising campaigns. In response to conceptual, methodological and empirical weaknesses of this approach, we study people's antibiotic-related health behaviour through three research questions.RQ1: What are the manifestations and determinants of problematic antibiotic use in patients' healthcare-seeking pathways?RQ2: Will people's exposure to antibiotic awareness activities entail changed behaviours that diffuse or dissipate within a network of competing healthcare practices?RQ3: Which proxy indicators facilitate the detection of problematic antibiotic behaviours across and within communities?

METHODS

We apply an interdisciplinary analytical framework that draws on the public health, medical anthropology, sociology and development economics literature. Our research involves social surveys of treatment-seeking behaviour among rural dwellers in northern Thailand (Chiang Rai) and southern Lao PDR (Salavan). We sample approximately 4800 adults to produce district-level representative and social network data. Additional 60 cognitive interviews facilitate survey instrument development and data interpretation. Our survey data analysis techniques include event sequence analysis (RQ1), multilevel regression (RQ1-3), social network analysis (RQ2) and latent class analysis (RQ3).

DISCUSSION

Social research in AMR is nascent, but our unprecedentedly detailed data on microlevel treatment-seeking behaviour can contribute an understanding of behaviour beyond awareness and free choice, highlighting, for example, decision-making constraints, problems of marginalisation and lacking access to healthcare and competing ideas about desirable behaviour.

TRIAL REGISTRATION NUMBER

NCT03241316; Pre-results.

Diarrheal knowledge and preventative behaviors among the caregivers of children under 5 years of age on the Tonle Sap Lake, Cambodia

PURPOSE

Although Cambodia has made significant progress toward lowering the under-five mortality rate since 2000, diarrhea still accounts for 6% of the total number of these deaths. A vast majority of these deaths is preventable. In this study, we sought to examine diarrheal knowledge and preventative behaviors of caregivers of children under the age of 5 years, to determine caregiver factors associated with knowledge and behavior scores.

PATIENTS AND METHODS

This was a cross-sectional household-level study conducted in two floating villages on the Tonle Sap Lake, Cambodia between January and February 2014. Caregivers of children under 5 years of age in the villages of Steung Trov and Moat Khla were asked 31 true or false questions to assess their knowledge of diarrhea. They also filled out a questionnaire to assess diarrhea preventative behaviors (DPBs). Comparison of mean scores to categorical caregiver variables was performed using one-way ANOVA analysis. Spearman's rank correlation was applied to identify the relationship between the knowledge and preventative behavior scores and independent quantitative variables.

RESULTS

A total of 101 caregivers of 161 children under 5 years of age were interviewed. The majority of them (85.1%) was classified as having good knowledge and scored >80% on the assessment. Those with Khmer ethnicity (mean=28.10) scored significantly higher than those with Vietnamese ethnicity (mean 26.00; p=0.004). Older age was correlated with higher knowledge scores (ρ=0.2260; p=0.023) and DPB scores (ρ=0.2320; p=0.019). Significant differences were found between the DPB score and ethnicity, educational background, and wealth (p<0.01).

CONCLUSION

Although the majority of caregivers had high diarrheal knowledge scores, preventative behaviors for diarrhea as assessed by this study were poor among almost all study participants. Vietnamese, wealthier, older, and more educated participants had better prevention scores. Future interventions in this remote region may benefit from these data as a guide to determine which specific preventative behaviors should be targeted.

Interactions between intestinal pathogens, enteropathy and malnutrition in developing countries

Purpose of review

This review focuses on recent data highlighting the interactions between intestinal pathogens, enteropathy and malnutrition in developing countries, which drive morbidity and mortality and hinder the long-term developmental potential of children.

Recent findings

Diarrhoea remains the second commonest cause of death in children below 5 years, and malnutrition underlies 45% of all child deaths. Even in the absence of diarrhoea, subclinical pathogen carriage and enteropathy are almost universal in developing countries. Here, we review recent studies addressing the causes and consequences of diarrhoea; emerging data on environmental influences that govern postnatal development of the gut and microbiota; current concepts of environmental enteric dysfunction; and recent intervention trials in the field. We highlight the interactions between these processes, whereby intestinal pathogens drive a cycle of gut damage, malabsorption, chronic inflammation and failed mucosal regeneration, leading to malnutrition and susceptibility to further enteric infections.

Summary

Efforts to improve child survival and long-term developmental potential need to address the overlapping and interacting effects of diarrhoea, enteropathy and malnutrition. Recent insights from human and animal studies suggest potential targets for intervention.

Galleria mellonella is low cost and suitable surrogate host for studying virulence of human pathogenic Vibrio cholerae

Vibrio cholerae causes a severe diarrheal disease affecting millions of people worldwide, particularly in low income countries. V. cholerae successfully persist in aquatic environment and its pathogenic strains results in sever enteric disease in humans. This dual life style contributes towards its better survival and persistence inside host gut and in the environment. Alternative animal replacement models are of great value in studying host-pathogen interaction and for quick screening of various pathogenic strains. One such model is Galleria mellonella, a wax moth which has a complex innate immune system and here we investigate its suitability as a model for clinical human isolates of O1 El TOR, Ogawa serotype belonging to two genetically distinct subclades found in Pakistan (PSC-1 and PSC-2). We demonstrate that the PSC-2 strain D59 frequently isolated from inland areas, was more virulent than PSC-1 strain K7 mainly isolated from coastal areas (p=0.0001). In addition, we compared the relative biofilm capability of the representative strains as indicators of their survival and persistence in the environment and K7 showed enhanced biofilm forming capabilities (p=0.004). Finally we present the annotated genomes of the strains D59 and K7, and compared them with the reference strain N16961.

Diarrhea management in children under five in sub-Saharan Africa: does the source of care matter? A Countdown analysis

Background

Diarrhea remains a high burden disease, responsible for nine percent of deaths in children under five globally. We analyzed diarrhea management practices in young children and their association with the source of care.

Methods

We used Demographic and Health Survey data from 12 countries in sub-Saharan Africa with high burdens of childhood diarrhea. We classified the quality of diarrhea management practices as good, fair, or poor based on mothers’ reports for children with diarrhea, using WHO/UNICEF recommendations for appropriate treatment. We described the prevalence of diarrhea management by type and assessed the association between good management and source of care, adjusting for potential confounders.

Results

Prevalence of good diarrhea management is low in 11 of the 12 analyzed surveys, varying from 17 % in Cote d’Ivoire to 38 % in Niger. The exception is Sierra Leone, where prevalence of good practice is 67 %. Prevalence of good management was low even among children taken to health facilities [median 52 %, range: 34–64 %]. Diarrhea careseeking from health facilities or community providers was associated with higher odds of good management than care from traditional/informal sources or no care. Careseeking from facilities did not result systematically in a higher likelihood of good diarrhea management than care from community providers. The odds of good diarrhea management were similar for community versus facility providers in six countries, higher in community than facility providers in two countries, and higher in facility than in community providers in four countries.

Conclusion

Many children’s lives can be saved with correct management of childhood diarrhea. Too many children are not receiving adequate care for diarrhea in high-burden sub-Saharan African countries, even among those seen in health facilities. Redoubling efforts to increase careseeking and improve quality of care for childhood diarrhea in both health facilities and at community level is an urgent priority.

Management of children's acute diarrhea by community pharmacies in five towns of Ethiopia: simulated client case study

BACKGROUND

Acute diarrhea is the major cause of child morbidity and mortality in low-income nations. It is the second most common cause of death among children <5 years of age globally. The indispensable role of community pharmacists is clearly observed in the prevention and treatment of diarrhea. However, there is a paucity of data on how community pharmacies manage acute childhood diarrhea cases in Ethiopia. This study aimed to evaluate the experience of community pharmacies in the management of acute diarrhea in northern Ethiopia.

METHODS

A simulated case-based cross-sectional study was conducted in community pharmacies from five towns of northern Ethiopia between April 2015 and September 2015. Convenience sampling technique was used to select sample towns. A structured questionnaire was organized to collect the information. Descriptive statistics, chi-squared test, one-way analysis of variance, and binary logistic regression were performed to describe, infer, and test for association between the variables. SPSS for Windows Version 21 was used to enter and analyze the data. A 95% confidence interval and P-value of 0.05 were set to test the level of significance.

RESULTS

Approximately 113 community pharmacies were visited to collect the required data from five towns. Majority (78, 69%) of them were located away from hospitals and health care areas. Nine components of history taking were presented for dispensers. Regarding the patient history, "age" was frequently taken, (90.3%), whereas "chief complaint" was the least to be taken (23%), for patients presenting with diarrhea. Approximately 96 (85.0%) cases were provided with one or more medications. The remaining 17 (15%) cases did not receive any medication. A total of six pharmacologic groups of medications were given to alleviate acute diarrheal symptoms. Majority (66, 29.6%) of the medications were oral rehydration salts with zinc. The mean number of medications was 1.99 per visit. Components of advice, such as dose, frequency, duration, drug action, and adverse drug reactions, were found to vary among the five towns at a statistically significant level.

CONCLUSION

Community pharmacies provided inadequate treatment for acute childhood diarrhea. Inappropriate history taking and incorrect drug and food instructions have been frequently encountered during acute diarrhea management. Practitioners working in northern Ethiopia should receive proper training on the management of acute childhood diarrhea.