https://orcid.org/0000-0001-8836-4922
Figures
Abstract
Background
This paper aims to estimate the prevalence of antibiotic use for diarrhea among under-five children (u5c) in low- and middle-income countries (LMICs) using data from 112 Demographic Health Surveys (DHS) conducted between 2006 and 2018. The focus is on understanding the extent of antibiotic usage for managing diarrhea, a condition characterized by frequent loose or watery bowel movements that can lead to severe dehydration.
Methods and findings
A cross-sectional study design was employed in the DHS. The prevalence of antibiotic use for diarrhea among under-five children was estimated by analyzing DHS data from 2006 to 2018 and using the R statistical programming language. Out of a total of 12,69,944 children under five included in this study, 1,80,067 children had diarrhea and 19,502 children had bloody diarrhea. The overall prevalence of diarrhea estimated at ~14% (prevalence = 0.142; 95% CI = 0.141, 0.142). Among the children with diarrhea, 47,755 child received antibiotic treatment, resulting a prevalence of ~27% (prevalence = 0.27, 95% CI = 0.26, 0.27) globally. Central Asia had the highest prevalence of antibiotic use at ~55% (prevalence = (967/1748) = 0.55, 95% CI = 0.52, 0.59), followed by the Europe region with a prevalence of ~44% (prevalence = (5483/12502) = 0.44, 95% CI = 0.43, 0.45). In the South East and Central Asia region, DHS conducted between 2006 and 2018, showed the highest prevalence of antibiotic use in DHS 2007 (~44%), DHS 2012 (~49%), DHS 2016 (~40%) and DHS 2017 (~65%). The linear trend analysis showed an upward trend for using antibiotic of diarrhea in the South East and Central Asia region.
Conclusions
The Central Asia region had the highest proportion of antibiotic use, with an estimated prevalence of ~55% (95% CI = 0.52, 0.59). The Europe region followed closely with a prevalence of ~44% (95% CI = 0.43, 0.45). The South East Asia region had the lowest prevalence of antibiotic use estimated at ~23% (95% CI = 0.22, 0.24), with a gradual increasing trend.
Citation: Ahmed MS, Khanam S, Kamruzzaman M, Morshed MS (2023) Prevalence of antibiotic use for diarrhea among 1.3 million under-five years children: A multicounty retrospective analysis from 2006–2018. PLoS ONE 18(8): e0289045. https://doi.org/10.1371/journal.pone.0289045
Editor: Iddya Karunasagar, Nitte University, INDIA
Received: May 24, 2022; Accepted: July 11, 2023; Published: August 15, 2023
Copyright: © 2023 Ahmed et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The study data are available for download in Stata/SPSS format upon request. First create account on DHS website then submit a proposal for specific issues can be explore then the DHS (Demographic and Health Surveys) program approved this proposal after that the dataset will be available for download using Data tab by the following link (https://dhsprogram.com/data/).
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Diarrhea is defined as the occurrence of loose, liquid, or watery bowel movements three times or more per day [1]. Untreated persistent diarrhea can lead to severe dehydration. While vaccines can help prevent diarrhea-causing infections, antibiotic treatment is frequently administered alongside vaccines [2]. In low- and middle-income countries, diarrhea is a significant cause of antibiotic use in children. 13% of the population purchased antibiotics without a prescription, with 2% based on personal preference and 11% recommended by pharmacists [3]. The most prescribed drugs are Cotrimoxazole (51%), colistin sulfate (15.3%), norfloxacin (11%), and nalidixic acid (0.5%). Average number of antimicrobials used per inpatient case was higher than outpatients (1.15 vs 0.84, p < 0.001). Norfloxacin is commonly prescribed for childhood diarrhea [4]. In the last 20 years, the prevalence of antibiotic resistance has increased significantly [5]. It is a serious global health hazard [6]. The low- and middle-income countries face a greater threat of antibiotics depletion, higher prevalence of antibiotics use and antimicrobial resistance compared to high income countries [7]. The number of people accessing antimicrobial resistance is not only through formal health care but also through the increasing use of antibiotic treatments by both formal and informal health care providers [8, 9]. According to the worldwide Point Prevalence Survey, approximately one-third of patients admitted to hospital are prescribed antibiotic treatment [10]. In the Demographic Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS), around 21% of antibiotics were administered orally (pills or syrups) and 3% through injections. The prevalence of antibiotic treatments for childhood diarrhea varied from 3% to 78% across 38 studies [11]. Modern healthcare is predominantly reliant on antibiotic treatment [12], but the improper and excessive use of antibiotics has led to emergence of resistant bacteria strains [13, 14]. In response to the overall issue of antimicrobial resistance (AMR) the World Health Organization (WHO) initiated various AMR-related activities, including the event of the Global Action Plan on Antimicrobial Resistance (GAP-AMR) during the 68th World Health Assembly in May 2015 [15]. Published literatures demonstrates a high proportion of inappropriate use of antimicrobials, highlighting the need to optimize the utilization of antimicrobial agents, which is one among the five key strategic objectives outlined within the GAP-AMR [15]. The main objective of this paper to estimate the prevalence of antibiotic use for diarrhea of under-five children (u5c) on the DHS multi-country survey from 2006–2018.
Methods
Data sources
In this study, data from 112 Demographic Health Survey (DHS) datasets was utilized. According to the DHS protocol, detailed questioned were asked to mothers during household surveys about the management of diarrhea episodes. In the DHS, the data collected specifically focused on u5c who had experienced 2-weeks of diarrhea episodes prior to the survey date. The datasets used in this study consist of a total of 12,69,944 records for u5c obtained from 112 DHS programmed surveys conducted between 2006 and 2018 (https://dhsprogram.com/Data/). The DHS employs a cross-sectional sampling strategy and methodology, which are extensively described on the DHS website and published reports.
Statistical analysis
Outcome variable or dependent variable.
The outcome variable in this study is antibiotic use for diarrheal disease among the under-five children in DHS survey regions from 2006 to 2018.
Antibiotic treatment response category.
Given antibiotic pills or syrups:
0: No
1: Yes; oth pill, syrup
8: Don’t know
9: Missing
Independent variable or exposure variables.
Mother education, wealth index, age in months, All the statistical analysis were performed using the open-source software R statistical programming language (https://www.r-project.org/). Descriptive analysis was conducted to determine the prevalence of diarrhea and antibiotic use. For each estimate, a 95% confidence interval was calculated to provide a measure of the precision of the estimate. A Linear trend model was used to analyze the antibiotic use trend from 2006 to 2018.
Results
Overall characteristics
Out of the total 1,269,944 children under the age of five included in this study, 180,067 had diarrhea and 19,502 had bloody diarrhea. Among all types of diarrheas, 47,755 children received antibiotic treatment. The overall prevalence of diarrhea was estimated to be ~14% (prevalence = 0.142; 95% CI = 0.141, 0.142). The prevalence of bloody diarrhea was ~2% (prevalence = 0.015; 95% CI = 0.015, 0.016). The prevalence of antibiotic treatment for diarrhea among children under the age of five was ~27% (prevalence = 0.27; 95% CI = 0.26, 0.27) in the DHS regions worldwide.
Socio-economic and demographic characteristics
The wealth index is a significant indicator of socio-economic status. The median prevalence (robust measures of central tendency with 50% outliers tolerate) of antibiotic use for diarrhea was almost equal among the poorer (~22%) and poorest (~22%) group of children. In contrast, the prevalence of antibiotic use for diarrhea was ~14% among the richest individuals. Therefore, the box plot (Fig 1(A)) indicates a decreasing trend in prevalence of antibiotic use from poorest to the richest group (Table 1).
Box plot for (A) prevalence of antibiotic use by wealth index, (B) prevalence of diarrhea by mother education, (C) prevalence of diarrhea at different age groups of several DHS survey regions.
Mother’s education plays a crucial role in under five diarrhea prevalence. The prevalence of diarrhea was higher, at ~31% (median), among children whose mothers had primary education and ~28% (median) among children whose mothers had secondary education. The prevalence of diarrhea was comparatively lower ~20% (median) among children whose mother had no education. However, the prevalence of diarrhea remarkably lowers ~2% among the higher education mother (Fig 1(B) and Table 2).
The prevalence of diarrhea was higher among the age group of 6–12 months and 12–18 months, with medians of ~19% and ~18% respectively. In contrast, the prevalence of diarrhea was very low, at ~5% (median), among the age groups of 42–48 months and 48–54 months (Table 3). The box plot (Fig 1(C)) illustrates a decreasing trend in the prevalence of diarrhea from the age group of 6–12 months to 48–54 months.
Global hotspot of antibiotic use for under-five children diarrhea
Among all DHS regions, 25 countries have been identified with the highest prevalence of antibiotic use for the treatment of childhood diarrhea, ranging from 37% to 65% (Fig 2). In the South East Asia DHS region, the top three hotspot countries with the highest prevalence of antibiotic use among children under the age of five were Pakistan (2017–2018) with 47%, Indonesia (2007) with 44%, and Myanmar (2015–2016) with 40%. In Central Asia, Tajikistan (2017) had the highest prevalence of antibiotic use at 65%. In the Europe region, Jordan (2012 and 2007) had a prevalence of antibiotic use for diarrhea treatment exceeding 50%. In the Latin America region, Guatemala (2014–2015), Bolivia (2008), and Peru (2009) had prevalence rates of antibiotic use for diarrhea treatment exceeding 40%. In the Africa region, Congo (2011–2012) and Sierra Leone (2013 and 2008) had approximately 59% of people using antibiotics for the treatment of under-five children with diarrhea (Fig 2).
Prevalence of antibiotic use for under five children diarrhea
In the central Asia region, a total of 15,089 children under the age of five were included in the survey. Among them, 1,748 Children had diarrhea and 967 Children had received antibiotic treatment for diarrhea. The prevalence of antibiotic use for diarrhea in Central Asia region was ~55% (prevalence = (967/1748) = 0.55, 95% CI = 0.52, 0.59). In the Europe DHS region, the prevalence of antibiotic for diarrhea was ~44% (prevalence = (5483/12502) = 0.44, 95% CI = 0.43, 0.45). The lowest prevalence of antibiotic use for children under the age of five with diarrhea was ~23% (prevalence = (11918/51328) = 0.23, 95% CI = 0.22, 0.24) in the South East Asia DHS region. In the Latin America, and West North and Central Africa DHS region, the prevalence of antibiotic use for diarrhea were ~30% (prevalence = (7887/26396) = 0.30, 95% CI = 0.29, 0.31) and ~24% (prevalence = (21500/88093) = 0.24, 95% CI = 0.23, 0.24) respectively (Table 4).
South East Asia.
In the South East Asia region, Pakistan (2017–2018) and Indonesia (2007) had the highest prevalence of antibiotic use for diarrhea. The estimated prevalence was ~47% (prevalence = 0.47, 95% CI = 0.44, 0.50) in Pakistan and ~44% (prevalence = 0.44, 95% CI = 0.41, 0.46) in Indonesia. The lowest prevalence of antibiotic use for diarrhea was ~5% (prevalence = 0.05, 95% CI = -0.18, 0.27) in Maldives (2016–2017) and ~5% (prevalence = 0.05, 95% CI = 0.0, 0.11) in Timor-Leste (2009–2010) (Table 4 & Fig 3).
Central Asia.
In Central Asia region, the prevalence of antibiotic use for diarrhea was ~40%. Tajikistan (2017) had the highest prevalence ~65% (prevalence = 0.65, 95% CI = 0.61, 0.69) of antibiotic use for Child diarrhea (Table 4 & Fig 3).
Europe.
The highest prevalence of antibiotic use for diarrhea was observed ~54% (prevalence = 0.54, 95% CI = 0.50, 0.57) in Jordan (2012) and ~49% (prevalence = 0.49, 95% CI = 0.40, 0.58) in Azerbaijan (2006). The lowest prevalence of antibiotic use for diarrhea was ~15% (prevalence = 0.15, 95% CI = -0.01, 0.30) in Albania (2017–2018) (Table 4 & Fig 3).
Latin America.
In the Latin America DHS region, Guatemala (2014–2015) had the highest prevalence of antibiotic use for diarrhea, estimated at ~42% (prevalence = 0.42, 95% CI = 0.39, 0.45). Other countries with high prevalence rates include Bolivia (2008) with an estimated prevalence of ~40% (prevalence = 0.40, 95% CI = 0.37, 0.43), Peru (2009) with ~39% (prevalence = 0.39, 95% CI = 0.35, 0.44), Peru (2011) with ~38% (prevalence = 0.38, 95% CI = 0.34, 0.43) and Peru (2012) with ~40% (prevalence = 0.40, 95% CI = 0.36, 0.44). Haiti (2012) had the lowest prevalence of antibiotic use for diarrhea estimated at ~10% (prevalence = 0.10, 95% CI = 0.05, 0.15) (Table 4 & Fig 3).
West North and Central Africa.
In the West North and Central Africa region, Congo (2011–2012) had the highest prevalence of antibiotic use for diarrhea with an estimated prevalence of ~59% (prevalence = 0.59, 95% CI = 0.56, 0.63), followed by Liberia (2013) with a similar prevalence of ~59% (prevalence = 0.59, 95% CI = 0.56, 0.62). Burundi (2016–2017) with a prevalence of ~6% (prevalence = 0.06, 95% CI = 0.02, 0.09) and Zimbabwe (2005–2006) with prevalence of ~6% (prevalence = 0.06, 95% CI = -0.02, 0.14) had the lowest prevalence of antibiotic use for diarrhea. Sierra Leone (2008), Sierra Leone (2013) and Tanzania (2010) had higher prevalence of antibiotic use for diarrhea with prevalence of ~48% (prevalence = 0.48, 95% CI = 0.44, 0.52), ~44% (prevalence = 0.44, 95% CI = 0.38, 0.50) and ~47% (prevalence = 0.47, 95% CI = 0.43, 0.52) respectively (Table 4 & Fig 3).
The trend of antibiotic use for diarrhea
South East & Central Asia.
The prevalence of antibiotic use for under five diarrhea in the South East & Central Asia region showed an increasing trend from 2006 to 2018. The highest rates observed in DHS 2017 (~65%), DHS 2016 (~40%), DHS 2012 (~49%) and DHS 2007 (~44%). The linear trend analysis showed an upward trend in the use of antibiotics for diarrhea (Fig 4(A)).
Linear trend analysis of antibiotic use for diarrhea among (A) Southeast and Central Asia, (B) Europe, (C) Latin America, and (D) West North and Central Africa.
Europe.
The prevalence of antibiotic use for under five diarrhea in the Europe region showed a decreasing trend between 2007 and 2018. The highest prevalence estimated in DHS 2012 (~54%) followed by DHS 2007 (~50%), DHS 2014 (~47%) and DHS 2018 (~32%). The linear trend analysis confirmed downward trend in antibiotic use for diarrhea in the Europe DH survey region (Fig 4(B)).
Latin America.
The Latin America region showed a decreasing trend in the prevalence of antibiotic use between 2008 and 2018. The highest prevalence rates were estimated in DHS 2008 (~40%) followed by DHS 2009 (~40%), DHS 2006 (~37%) and DHS 2015 (~32%). The linear trend analysis showed a declining trend in the use of antibiotics for diarrhea in the region (Fig 4(C)).
West North and Central Africa.
The prevalence of antibiotic use for under-five children with diarrhea in the West North and Central Africa region varied across the DHS conducted from 2006 to 2018. The highest estimated prevalence was ~59% in DHS 2012, while the lowest estimated at ~8% in DHS 2018. DHS 2008 (~44%), DHS 2010 (~47%) and DHS 2013 (~48%) had relatively higher prevalence rates. The linear trend analysis revealed a declining trend of antibiotic use for diarrhea in this DHS region (Fig 4(D)).
Discussions
Antibiotic use for diarrhea is prevalent among under-five children in low and middle-income countries. The overall prevalence of antibiotic treatment for diarrhea among under-five children worldwide estimated at ~27% (prevalence = 0.27, 95% CI = 0.26, 0.27). Among specific regions, Central Asia had the highest prevalence of antibiotic use estimated at ~55% (prevalence = (967/1748) = 0.55, 95% CI = 0.52, 0.59), followed by the Europe region with a prevalence of ~44% (prevalence = (5483/12502) = 0.44, 95% CI = 0.43, 0.45). The lowest prevalence of antibiotic use estimated at ~23% (prevalence = (11918/51328) = 0.23, 95% CI = 0.22, 0.24) in the South East Asia region. Conversely, the linear trend analysis indicates an upward trend in the use of antibiotics for diarrhea in the South East and Central Asia region. The West North and Central Africa DHS region showed a decreasing trend in antibiotic use for under-five with diarrhea.
In summary, Central Asia and Europe have the highest proportions of antibiotic use for diarrhea among under-five children, with Central Asia showing the highest prevalence. Conversely, the trend analysis reveals an increasing trend in South East and Central Asia and decreasing trends in Europe, Latin America, and West North and Central Africa regions.
Acknowledgments
The author is cordially grateful to the DHS (https://dhsprogram.com/) for making the data access available for analysis and publications.
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