Inappropriate use of antibiotics for childhood diarrhea case management — Kenya, 2009–2016

Abstract

Background Antibiotics are essential to treat for many childhood bacterial infections; however inappropriate antibiotic use contributes to antimicrobial resistance. For childhood diarrhea, empiric antibiotic use is recommended for dysentery (bloody diarrhea) for which first-line therapy is ciprofloxacin. We assessed inappropriate antibiotic prescription for childhood diarrhea in two primary healthcare facilities in Kenya. Methods We analyzed data from the Kenya Population Based Infectious Disease Surveillance system in Asembo (rural, malaria-endemic) and Kibera (urban slum, non-malaria-endemic). We examined records of children aged 2–59 months with diarrhea (≥3 loose stools in 24 h) presenting for care from August 21, 2009 to May 3, 2016, excluding visits with non-diarrheal indications for antibiotics. We examined the frequency of antibiotic over-prescription (antibiotic prescription for non-dysentery), under-prescription (no antibiotic prescription for dysentery), and inappropriate antibiotic selection (non-recommended antibiotic). We examined factors associated with over-prescription and under-prescription using multivariate logistic regression with generalized estimating equations. Results Of 2808 clinic visits with diarrhea in Asembo, 2685 (95.6%) were non-dysentery visits and antibiotic over-prescription occurred in 52.5%. Of 4697 clinic visits with diarrhea in Kibera, 4518 (96.2%) were non-dysentery and antibiotic over-prescription occurred in 20.0%. Antibiotic under-prescription was noted in 26.8 and 73.7% of dysentery cases in Asembo and Kibera, respectively. Ciprofloxacin was used for 11% of dysentery visits in Asembo and 0% in Kibera. Factors associated with over- and under-prescription varied by site. In Asembo a discharge diagnosis of gastroenteritis was associated with over-prescription (adjusted odds ratio [aOR]:8.23, 95% confidence interval [95%CI]: 3.68–18.4), while malaria diagnosis was negatively associated with antibiotic over-prescription (aOR 0.37, 95%CI: 0.25–0.54) but positively associated with antibiotic under-prescription (aOR: 1.82, 95%CI: 1.05–3.13). In Kibera, over-prescription was more common among visits with concurrent signs of respiratory infection (difficulty breathing; aOR: 3.97, 95%CI: 1.28–12.30, cough: aOR: 1.42, 95%CI: 1.06–1.90) and less common among children aged < 1 year (aOR: 0.82, 95%CI: 0.71–0.94). Conclusions Inappropriate antibiotic prescription was common in childhood diarrhea management and efforts are needed to promote rational antibiotic use. Interventions to improve antibiotic use for diarrhea should consider the influence of malaria diagnosis on clinical decision-making and address both over-prescription, under-prescription, and inappropriate antibiotic selection. Electronic supplementary material The online version of this article (10.1186/s12889-019-6771-8) contains supplementary material, which is available to authorized users. ...

Phenotypic and Genotypic Antibiotic Resistant diarrheagenic Escherichia coli pathotypes isolated from Children with Diarrhea in Nairobi City, Kenya

“…Dysentery, non-dysentery infections and other clinical complications of infections are serious among Kenyans presenting in health facilities without capacity to diagnose and detect bacterial pathogens, compelling clinicians to consider the provision of empirical antibiotic therapy ( 4 , 7 ). In addition, Kenya has no legislation for controlling antibiotic use in animals; further pressure is applied on antibiotic use as growth promoters and not for the treatment of infections of farm animals ( 34 ).…”

“…Diarrhegenic E. coli involved in diarrheal diseases is one of the most important of the various etiological agents of diarrhea ( 3 ). In Kenya, over 15% infectious diarrhea cases present in health facilities ( 4 , 5 ) but only half of health facilities are able to detect and diagnose a pathogen, which may be due to lack of or inadequate diagnostic capacity ( 6 ). Thus, indiscriminate antibiotic treatment is crucial for weak individuals with severe dysentery and nondysentery infection without secondary criteria for bacterial infection ( 4 , 7 ) increasing selection pressure of antibiotic resistant strains and decreasing the effectiveness of antibiotics ( 8 ).…”

“…In Kenya, over 15% infectious diarrhea cases present in health facilities ( 4 , 5 ) but only half of health facilities are able to detect and diagnose a pathogen, which may be due to lack of or inadequate diagnostic capacity ( 6 ). Thus, indiscriminate antibiotic treatment is crucial for weak individuals with severe dysentery and nondysentery infection without secondary criteria for bacterial infection ( 4 , 7 ) increasing selection pressure of antibiotic resistant strains and decreasing the effectiveness of antibiotics ( 8 ). With an exception of few studies ( 9 – 12 ) previous studies reported phenotypic resistance without assessing genetic changes associated with resistance in diarrhegenic and uropathogenic Escherichia coli to commonly prescribed antibiotics in Kenya ( 13 – 20 ).…”

Antibiotic use among children under five years with diarrhea in rural communities of Gulu, northern Uganda: a cross-sectional study

“…In this study we observed that children who had non-bloody diarrhea without ARIs had a lower prevalence (39%) of antibiotics use compared to those who had non-bloody diarrhea with symptoms of ARIs (54%). Similarily, another study from Kenya, also reported a high prevalence of antibacterial use among children who had diarrhea with ARIs compared to those who only had diarrhea [ 28 ]. In Uganda, antibiotics are prescription only medicines [ 29 ], however, there is inadequate enforcement of regulation of access to antibiotics, making them easily available and possible to self-medicate [ 30 ].…”

Prevalence of upper respiratory tract infections and associated factors among children in Turkey

“…The presence of primary care pediatricians and collaborations with behavioral specialists are important considerations to improve the quality of childcare (Okumura, Knauer, Calvin, & Takayama, ). Chronic comorbidities, such as diarrhea, are factors associated with URIs and increase the utilization of healthcare services among children, particularly among those hospitalized for URIs (Mbonye, ; Rhee et al, ). To prevent the increase in cost and improve the utilization of healthcare services, a strong primary care system is required to improve the coordination of pediatric healthcare services.…”