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IMPORTANCE: Inappropriate use of antibiotics for diarrheal illness can result in adverse effects and increase in antimicrobial resistance. OBJECTIVE: To determine whether the diarrheal etiology prediction (DEP) algorithm, which uses patient-specific and location-specific features to estimate the probability that diarrhea etiology is exclusively viral, impacts antibiotic prescriptions in patients with acute diarrhea. DESIGN, SETTING, AND PARTICIPANTS: A randomized crossover study was conducted to evaluate the DEP incorporated into a smartphone-based electronic clinical decision-support (eCDS) tool. The DEP calculated the probability of viral etiology of diarrhea, based on dynamic patient-specific and location-specific features. Physicians were randomized in the first 4-week study period to the intervention arm (eCDS with the DEP) or control arm (eCDS without the DEP), followed by a 1-week washout period before a subsequent 4-week crossover period. The study was conducted at 3 sites in Bangladesh from November 17, 2021, to January 21, 2021, and at 4 sites in Mali from January 6, 2021, to March 5, 2021. Eligible physicians were those who treated children with diarrhea. Eligible patients were children between ages 2 and 59 months with acute diarrhea and household access to a cell phone for follow-up. INTERVENTIONS: Use of the eCDS with the DEP (intervention arm) vs use of the eCDS without the DEP (control arm). MAIN OUTCOMES AND MEASURES: The primary outcome was the proportion of children prescribed an antibiotic. RESULTS: A total of 30 physician participants and 941 patient participants (57.1% male; median [IQR] age, 12 [8-18] months) were enrolled. There was no evidence of a difference in the proportion of children prescribed antibiotics by physicians using the DEP (risk difference [RD], −4.2%; 95% CI, −10.7% to 1.0%). In a post hoc analysis that accounted for the predicted probability of a viral-only etiology, there was a statistically significant difference in risk of antibiotic prescription between the DEP and control arms (RD, −0.056; 95% CI, −0.128 to −0.01). No known adverse effects of the DEP were detected at 10-day postdischarge. CONCLUSIONS AND RELEVANCE: Use of a tool that provides an estimate of etiological likelihood did not result in a significant change in overall antibiotic prescriptions. Post hoc analysis suggests that a higher predicted probability of viral etiology was linked to reductions in antibiotic use. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT04602676

The present study aimed to examine the risk factors for death due to pneumonia in young children and healthcare behaviors of the guardians for children in rural Bangladesh. A prospective autopsy study was conducted among guardians of children aged 4 weeks to 59 months in Mirzapur, Bangladesh, from 2008 to 2012. Pneumonia was the primary cause of death, accounting for 26.4% (n= 81) of all 307 deaths. Of the pneumonia deaths, 58% (n= 47) deaths occurred in younger infants (aged 4 weeks to < 6 months) and 24.7% (n= 20) in older infants (aged 6–11 months). The median duration of illness before pneumonia death was 8 days (interquartile range [IQR] 3–20 days). Prior to death, 91.4% (n= 74) children with pneumonia sought treatment, and of those who sought treatment, 52.7% (n= 39) sought treatment ≥ 2 days after the onset of disease. Younger infants of 4 weeks to < 6 months old were at 5.5-time (95% confidence interval [CI] 2.5, 12.0) and older infants aged 6–11 months were at 3-time (1.2, 7.5) greater risk of dying from pneumonia than older children aged 12–59 months. Children with a prolonged duration of illness (2–10 days) prior to death were at more risk for death by pneumonia than those who died from other causes (5.8 [2.1, 16.1]). Children who died from pneumonia sought treatment 3.4-time more than children who died from other causes. Delayed treatment seeking (≥ 2 days) behavior was 4.9-time more common in children who died from pneumonia than those who died from other causes. Children who died from pneumonia more often had access to care from multiple sources (5.7-time) than children who died from other causes. Delay in seeking appropriate care and access to multiple sources for treatment are the underlying risk factors for pneumonia death in young children in Bangladesh. These results indicate the perplexity in guardians’ decisions to secure appropriate treatment for children with pneumonia. Therefore, it further underscores the importance of focusing on mass media coverage that can outline the benefits of seeking care early in the progression of pneumonia and the potential negative consequences of seeking care late.

Diarrhoeal diseases cause illness and death among children younger than 5 years in low-income countries. We designed the Global Enteric Multicenter Study (GEMS) to identify the aetiology and population-based burden of paediatric diarrhoeal disease in sub-Saharan Africa and south Asia.

To examine the relation between use of antibiotics in a cohort of preschool children and nasal carriage of resistant strains of pneumococcus.