Prediction of diarrhea etiology among kids with electronic algorithm failed to reduce antibiotic use: JAMA

Bangladesh: The use of a tool providing an estimate of the etiological likelihood that diarrhea is because of a viral cause failed to reduce overall antibiotic prescriptions, a recent study in JAMA Pediatrics has claimed. Post hoc analysis indicated that a higher predicted probability of viral etiology was tied to a decrease in the use of antibiotics.

There is increased exposure to antibiotics among children in low- and middle-income countries in early life, and antimicrobial diarrhea treatment seldom follows recommendations by international guidelines. Despite the recommendations by the WHO (World Health Organization) Integrated Management of Childhood Illness that antibiotics should be given only for bloody diarrhea or suspicion of cholera, this problem persists. Most cases of pediatric diarrhea, particularly in those younger than 24 months, are likely attributable to causes that are unresponsive to antibiotics.

In clinical settings, improving antibiotic stewardship is prone to inappropriate use of antibiotics and has been a persistent and difficult challenge, particularly for managing a diarrheal disease. Their improper use for diarrheal illness can lead to adverse effects and increased antimicrobial resistance.

Against the above background, Eric J. Nelson, University of Florida, Gainesville, and colleagues aimed to investigate whether the diarrheal etiology prediction (DEP) algorithm uses patient-specific and location-specific features for estimating the likelihood of diarrhea etiology is exclusively viral, affects antibiotic prescriptions in acute diarrhea patients.

The researchers conducted a randomized crossover study to evaluate the DEP incorporated into a smartphone-based electronic clinical decision-support (eCDS) tool. The DEP computed the probability of diarrhea's viral etiology based on location-specific and patient-specific features. In the first 4-week study period, physicians were randomized to the intervention group (intervention arm with DEP algorithm) and the control group (eCDS without the DEP). A 1-week washout followed this before a subsequent 4-week crossover period.

From November 17, 2021, to January 21, 2021, the study was conducted at three sites in Bangladesh and four sites in Mali from January 6, 2021, to March 5, 2021. Physicians who treated children with diarrhea were deemed eligible. Children between 2 and 59 months with acute diarrhea and access to a phone for follow-up were eligible for the study. The proportion of children prescribed an antibiotic was the primary outcome.

Key findings of the study:

• The enrollment was done of 30 physicians and 941 patient participants (57.1% male; median age, 12 months).
• The researchers, using the DEP, found no evidence of a difference in the proportion of children prescribed antibiotics by physicians (risk difference [RD], −4.2%).
• In a post hoc analysis that accounted for the predicted probability of a viral-only etiology, there was a statistically significant difference in the risk of antibiotic prescription between the DEP and control arms (RD, −0.056).
• At 10-day post-discharge, no known adverse effects of the DEP were detected.

"The use of the diarrheal etiology prediction (DEP) algorithm, which provides an estimate of etiological probability, did not significantly change overall antibiotic prescriptions," wrote the authors.

"If replicated, etiological prediction use in decision support tools represents a critical advancement for improving antibiotic stewardship in a clinical context prone to high rates of inadequate antibiotic use."

"The stud findings represent a meaningful proof-of-concept for probability-based decision support to enable evidence-based antibiotic stewardship, particularly in resource-limited settings," they concluded.

Reference:

Nelson EJ, Khan AI, Keita AM, et al. Improving Antibiotic Stewardship for Diarrheal Disease With Probability-Based Electronic Clinical Decision Support: A Randomized Crossover Trial. JAMA Pediatr. Published online August 29, 2022. doi:10.1001/jamapediatrics.2022.2535