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

Derivation and External Validation of a Clinical Prediction Model for Viral Diarrhea Etiology in Bangladesh

Background

Antibiotics are commonly overused for diarrheal illness in many low- and middle-income countries, partly due to a lack of diagnostics to identify viral cases, in which antibiotics are not beneficial. This study aimed to develop clinical prediction models to predict risk of viral-only diarrhea across all ages, using routinely collected demographic and clinical variables.

Methods

We used a derivation dataset from 10 hospitals across Bangladesh and a separate validation dataset from the icddr,b Dhaka Hospital. The primary outcome was viral-only etiology determined by stool quantitative polymerase chain reaction. Multivariable logistic regression models were fit and externally validated; discrimination was quantified using area under the receiver operating characteristic curve (AUC) and calibration assessed using calibration plots.

Results

Viral-only diarrhea was common in all age groups (<1 year, 41.4%; 18-55 years, 17.7%). A forward stepwise model had AUC of 0.82 (95% confidence interval [CI], .80-.84) while a simplified model with age, abdominal pain, and bloody stool had AUC of 0.81 (95% CI, .78-.82). In external validation, the models performed adequately although less robustly (AUC, 0.72 [95% CI, .70-.74]).

Conclusions

Prediction models consisting of 3 routinely collected variables can accurately predict viral-only diarrhea in patients of all ages in Bangladesh and may help support efforts to reduce inappropriate antibiotic use.

Non-prescribed antibiotic use for children at community levels in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Non-prescribed antibiotic use is an emerging risky practice around the globe. An inappropriate use involving nonprescription access is one cause of the rapid increase in antibiotic resistance. Children commonly encounter many self-limiting illnesses for which they frequently use antibiotics without prescription. However, no specific and conclusive evidence exists to inform actions against this unsafe practice. We thus aimed to estimate the pooled proportion of non-prescribed antibiotic use for children at community levels in low- and middle-income countries.

METHODS

A systematic search of records was conducted from PubMed/Medline, Embase, Scopus, CINAHL, and Google scholar. Eligible English-language publications were original articles which reported on community-based non-prescribed antibiotic use for children and conducted in low- and middle-income countries. Study features and the number of antibiotics used without prescriptions were extracted and pooled for effect sizes employing a random-effects model. The pooled proportion of non-prescribed antibiotic use was estimated as a percentage.

RESULTS

In this analysis, we included a total of 39 articles consisting of 40,450 participants. Of these, 16,315 participants used non-prescribed antibiotics. The pooled percentage for this use of non-prescribed antibiotics was 45% (95% CI: 40-50%). The estimate was considerably higher in studies involving simulated patient methods (56%; 95% CI: 49-62%) than those studies with community surveys (40%; 95% CI: 34-46%) (P = 0.001). It was also varied by the recall period of antibiotics use-56% (95% CI: 50-62%) for instantly observed practice, 36% (95% CI: 22-50%) for within two week recall, 35% (95% CI: 26-45%) for 1-6 months recall, and 46% (95% CI: 37-54%) for more than six months recall (P = 0.001). Primary access points for the non-prescribed antibiotic uses were retail drug outlets.

CONCLUSIONS

We found that nearly half of the antibiotics used for children in community settings were without prescriptions. For these unsafe practices, caregivers accessed antibiotics mainly from drug outlets. Hence, context-specific educational and regulatory interventions at these outlets and the community levels are the first steps to improving antibiotic usage for children in low- and middle-income countries.

TRIAL REGISTRATION NUMBER

CRD42021288971 (PROSPERO).  https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021288971 .

External validation of a mobile clinical decision support system for diarrhea etiology prediction in children: a multicenter study in Bangladesh and Mali

Background: Diarrheal illness is a leading cause of antibiotic use for children in low- and middle-income countries. Determination of diarrhea etiology at the point-of-care without reliance on laboratory testing has the potential to reduce inappropriate antibiotic use.

Methods: This prospective observational study aimed to develop and externally validate the accuracy of a mobile software application ('App') for the prediction of viral-only etiology of acute diarrhea in children 0-59 months in Bangladesh and Mali. The App used a previously derived and internally validated model consisting of patient-specific ('present patient') clinical variables (age, blood in stool, vomiting, breastfeeding status, and mid-upper arm circumference) as well as location-specific viral diarrhea seasonality curves. The performance of additional models using the 'present patient' data combined with other external data sources including location-specific climate, data, recent patient data, and historical population-based prevalence were also evaluated in secondary analysis. Diarrhea etiology was determined with TaqMan Array Card using episode-specific attributable fraction (AFe) >0.5.

Results: Of 302 children with acute diarrhea enrolled, 199 had etiologies above the AFe threshold. Viral-only pathogens were detected in 22% of patients in Mali and 63% in Bangladesh. Rotavirus was the most common pathogen detected (16% Mali; 60% Bangladesh). The present patient + viral seasonality model had an AUC of 0.754 (0.665-0.843) for the sites combined, with calibration-in-the-large α=-0.393 (-0.455 - -0.331) and calibration slope β=1.287 (1.207 - 1.367). By site, the present patient + recent patient model performed best in Mali with an AUC of 0.783 (0.705 - 0.86); the present patient + viral seasonality model performed best in Bangladesh with AUC 0.710 (0.595 - 0.825).

Conclusion: The App accurately identified children with high likelihood of viral-only diarrhea etiology. Further studies to evaluate the App's potential use in diagnostic and antimicrobial stewardship are underway.

Funding: Funding for this study was provided through grants from the Bill and Melinda Gates Foundation (OPP1198876) and the National Institute of Allergy and Infectious Diseases (R01AI135114). Several investigators were also partially supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (R01DK116163). This investigation was also supported by the University of Utah Population Health Research (PHR) Foundation, with funding in part from the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002538. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funders had no role in the study design, data collection, data analysis, interpretation of data, or in the writing or decision to submit the manuscript for publication.

Everything is not on track in management of diarrhoea in under-five children: Evidence from rural area of India

CONTEXT

Diarrhea is one of the leading causes of death and morbidity in under-five children. Effective management can significantly influence survival of children with diarrhea.

OBJECTIVES

This study was carried out to assess extent of diarrhea, its source of treatment, and type of therapy.

SETTINGS AND DESIGN

This snapshot study was conducted in rural setting of India.

METHODS AND MATERIAL

This study was conducted on 217 under-five children selected through multistage sampling procedure.

STATISTICAL ANALYSIS USED

Statistical association of diarrhea with age and gender of children was established by computing Chi-square.

RESULTS

Period prevalence (Recall period 2 weeks of visit) of diarrhea in rural under-five children was 35.9% (95%C.I. 29.3-42.2%). Highest prevalence in age group 0-12 months (47.8%) and lowest in 49-59 months (18.2%). Number of episode per child is 1.08. Diarrhea was watery in 69.4%. Quacks were treatment provider for 36.4% cases. In 17.6% episodes, no treatment was taken. Only 9.4% episodes were treated in government facilities. For the treatment of diarrhea, antibiotic was used in 71.8% cases, ORS use was 33.3% cases, and zinc was used 21.8% of diarrhea episodes.

CONCLUSIONS

Diarrhea is a significant problem in under-five children from a rural area of India. In spite of existence of National Program for Control of Diarrheal Diseases (NPCDD) since four decades, management of diarrhea is not on track. Focusing on primary care provision to under-five children can help in bringing the management of diarrhea on track.