Antibiotic use prior to attending a large diarrheal disease hospital among preschool children suffering from bloody or non-bloody diarrhea: A cross-sectional study conducted in Bangladesh

by Syed Jayedul Bashar, Md. Ridwan Islam, Sharika Nuzhat, Rukaeya Amin, Md. Mushfiqur Rahman, Patricia B. Pavlinac, Samuel L. M. Arnold, Amy Newlands, Tahmeed Ahmed, Mohammod Jobayer Chisti

Among diarrheal children, injudicious use of antibiotics is a major public health concern particularly in low- and middle-income countries. There are evidence-based guidelines by the World Health Organization (WHO) to prescribe antibiotics for bloody diarrhea in children. There is a scarcity of published data regarding the judicious use of antibiotics for bloody diarrhea in children. So, we aimed to evaluate the presenting features of bloody diarrhea at hospital with prior antibiotic use at home and the prevalence of injudicious antibiotic use for bloody diarrhea in children.

We screened 7,289 children aged 24–59 months with diarrhea (≥3 loose stools in the last 24 h) at Dhaka Hospital, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), from December 5, 2021 to February 16, 2023. Antibiotic intake at home due to current diarrheal illness was evaluated and confirmed by direct observation of a prescription, the bottle of antibiotics, or asking the caregiver about the name of antibiotics.

Out of 7,289 children presented with diarrhea, 3,823 (52.45%) children consumed antibiotics before visiting hospital. 254 (3.48%) children presented with bloody diarrhea, among which 162 ingested antibiotics. Among 162 children, 88 (54.32%) received inappropriate antibiotics due to bloody diarrhea, according to the WHO guidelines. The most prevalent single antibiotic consumed in bloody diarrhea was metronidazole (n = 45, 27.78%), followed by ciprofloxacin (n = 39, 24.07%) and azithromycin (n = 32, 19.75%). After adjusting for relevant covariates like age, sex, presence of straining/tenesmus, fever during admission, history of cough, stunting, wasting, and underweight; children suffering from bloody diarrhea had 1.55 times higher odds of using metronidazole alone or in combination with other antibiotics (aOR:1.55, 95% CI: 1.10–2.19, p-value = 0.012) and 1.93 times higher odds of using multiple antibiotics (aOR:1.93, 95% CI: 1.23–3.02, p-value = 0.004) compared to children with non-bloody diarrhea.

The study underscores the excessive use of antimicrobials among children with diarrheal illnesses. It is also evident that metronidazole use and multiple antibiotic use are increasing among children due to bloody diarrhea, which is alarming and calls for antibiotic stewardship by regulating bodies in the country.