Antibiotics are being misused to treat diarrhoeal disease in children in Central Asia

Diarrhoeal disease is a common condition in childhood and a main contributor to the overall global under-five mortality rate 1. Although there are numerous treatment guidelines, such as the manual issued by the World Health Organization 2, the management of this disease is often suboptimal. The use of antibiotics has repeatedly proven to be a main concern and the guidelines generally recommend that their use should be restricted, as they are not necessary for the adequate treatment of diarrhoea. However, adherence to guidelines is often lacking, which is reflected in repeated reports of the misuse of antibiotics for treating diarrhoea 3, 4. The consequences are unnecessary harm to the patient 5 and an acceleration in the development of antibiotic resistance 6. In Uzbekistan, Central Asia, efforts have been made to improve the healthcare of children, with a focus on lowering the under-five mortality rate. As diarrhoea is responsible for 10% of this rate, the disease plays a considerable role in this objective 7. Only a few studies have been conducted that examine the use of antibiotics. There are some surveys whose findings have pointed towards over-prescribing by physicians 8, as well as misuse and a high proportion of self-medication in the population 9. We conducted a study examining how antibiotics were used for the treatment of diarrhoea in children admitted to a children's hospital, the Pediatric Infectious Disease Hospital Number Four, in Tashkent, Uzbekistan. During the study period, the hospital adhered to the treatment recommendations issued by the World Health Organization and the United Nations Children's Fund. The survey was carried out between September and November 2015, and it comprised two elements. The first part was a questionnaire regarding symptoms and antimicrobial treatment prior to hospitalisation, which was completed by the parent or legal guardian, while the second part was accessing the patients' medical records to extract data on symptoms, signs and management of the disease. All patients of five years of age or younger admitted to the hospital because of diarrhoeal disease were eligible for the study. The study participants and their parents were recruited via the attending physicians and 100 children were randomly chosen to take part, with 97 questionnaires being fully completed. The patients were evenly distributed between the sexes (51% male), but unevenly distributed with regard to age, as 77 (79%) of the 97 patients were younger than three years old. Of the 97 patients, 68 (70%) received antibiotics at some point during the hospitalisation period, while 29 (30%) did not. In total, 27 (28%) of the children had been given antibiotics during the seven days before admission because of the current episode of diarrhoeal disease and this figure excluded any antibiotic treatment administered by a physician. According to the questionnaires, 34 (35%) of the children had experienced watery diarrhoea during the seven days before hospitalisation and 19 (20%) of the children had had blood in their stools at some point during the same period. The medical records showed that 46 (47%) of the patients had fever, with a rectal temperature above 38°C, before antibiotics were administered at the hospital. Moreover, eight (8%) patients had to be cared for in the hospital's intensive care unit. Of the 88 (91%) patients who had their stools cultured for bacteria, two were positive, with one case of Shigella flexneri and one case of Salmonella enteritidis. The most striking finding was the abundant use of antibiotics, as 70% of the children were given antibiotics at some point during their hospital stay, even though the symptoms, signs and bacterial cultures offered no explanation for this treatment. Watery diarrhoea, which affected 35% of the patients, is not generally an indication for antibiotic treatment. Although profuse watery diarrhoea can be a sign of cholera, most cases of watery diarrhoea are viral or cases of bacterial diarrhoea that do not require antibiotics. Blood in the stools can be a sign of dysentery, and if so, antibiotic treatment is recommended. However, even if all the cases with blood in their stools in this study were due to dysentery, it would still not explain the extent to which the antibiotics were used. Fever was found in 46 of the patients receiving antibiotics, but it can also be found in cases of diarrhoeal disease, where antibiotic treatment is not recommended. Intensive care was necessary for 8% of the patients, and while this type of care is not in itself an indication for antibiotics, it could reflect the severity of the disease. It could indirectly provide a relative indication for the use of antibiotics, but as only eight patients needed intensive care in the study, this could not explain the frequent use of antibiotics. Furthermore, only two of the bacterial cultures from the stool samples collected were positive. Certainly, all pathogens against which antibiotics are useful cannot be identified with cultures. Despite this, it must be considered that the selection of patients who should receive antibiotics in this study could have lacked specificity. Studies have repeatedly shown that diarrhoeal disease is most commonly due to a viral pathogen, rather than bacteria, and this has also been shown to be true for this region 10. Although it might be difficult to differentiate between viral and bacterial diarrhoea, knowledge of the pathogenic spectrum should prompt physicians towards a more restrictive use of antibiotic agents. In Uzbekistan, antibiotics can be bought at any pharmacy, without a prescription, and therefore, the parents' use of them was included in the questionnaire. This showed that 28% of the children had been given antibiotics during the seven days before their hospital admission, without a prescription from a physician. Studies have shown that about 8% of all cases of hospitalised diarrhoea are caused by bacteria 10. Thus, it seems unlikely that all children receiving treatment with antibiotics outside the hospital actually needed it. Moreover, in this survey, no significant relationship could be found between patients receiving antibiotics prior to admission and receiving antibiotics in the hospital. In conclusion, this study showed that antibiotics were being misused for treating diarrhoeal disease in children in Uzbekistan. Two main improvement targets can be identified from this study: encouraging physicians to strictly adhere to the treatment guidelines and providing the general population with information on when antibiotics that are bought over the counter should be used.

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