The Acceptability and Impact of Diarrheal Etiology Prediction (DEP) Algorithm Among Physicians Treating Children With Diarrhea

Diarrhoeal diseases are a leading cause of morbidity and mortality in children worldwide, with an estimated one billion cases and 500,000 deaths annually. While the majority of deaths due to diarrhoea occur in lower-income countries, infectious diarrhoea remains a significant problem in high-income countries. Aside from the immediate morbidity, potential long-term sequelae of diarrhoea in children in low-resource settings include malnutrition, growth faltering, and deficits in cognitive development.

While the cornerstone of diarrhoeal disease management in children is rehydration, a number of other management decisions, including the use of antibiotics and laboratory testing, may impact the course of disease. Overuse of antibiotics may cause side-effects and lead to increased antimicrobial resistance in the community. Underuse of antimicrobials for some bacterial and protozoal pathogens may lead to prolonged duration of illness and facilitate transmission. This can result in increased days of school or parental work missed, and among malnourished children in resource-poor settings, potential for growth faltering or death. Overuse of laboratory testing may have financial impact on both the patient and the healthcare system, and underuse may delay appropriate therapy or prevent recognition of outbreaks. Thus, accurate and cost-effective determination of diarrhoea etiology is important for proper case management in children and for public health.

Clinical prediction rules (CPRs) help clinicians interpret clinical information and can improve decision making. A recent systematic review showed that out of 137 studies of conditions for which clinical prediction rules have been developed for children only 2 were for diarrhoea, both of which are for the assessment of dehydration. Similarly, the majority of available guidelines for pediatric diarrhoea are focused on the route, timing, and choice of fluids for rehydration. A few studies in the past 30 years studied the use of clinical predictors to estimate the probability of a bacterial cause of diarrhoea. However, these studies were limited by low rates of pathogen identification, small sample sizes, use of a single study site, and suboptimal prediction performance.

Given the lack of guidelines and effective clinical predictors, decisions for use of antibiotics and laboratory testing are mostly empiric in nature, based on a number of "rules of thumb" for which evidence is scant. Unfortunately, physician judgment does very poorly to predict both need for antibiotics and correct type of testing. A recent study of children presenting to Kenyan hospitals with diarrhoea showed that reliance on dysentery as a proxy for Shigella infection led to the failure to diagnose Shigellosis in nearly 90% of cases. Better tools for decision making and evidence-based guidelines regarding use of antibiotics and laboratory testing in children with diarrhoea are clearly needed.

The majority of decisions for use of antibiotics in diarrhoeal illnesses are made empirically. In lower- and middle-income countries (LMICs), due to cost constraints, etiological diagnosis is rarely made, and a large number (up to 70%) of patients with acute diarrhoea are prescribed antibiotics. However, in contrast to high resource settings, bacterial pathogens may be very common in low resource settings. In the multicenter Global Enteric Multicenter Study (GEMS) study, the investigators found that detection of Shigella ranged from 16-78% of children with dysentery and 2-43% of children with watery diarrhoea. In both high and low resource settings, inappropriate use of antimicrobials leads to unnecessary toxicity for the individual, increased costs and an increase in antibiotic resistance in the community. Thus, methods for guiding appropriate use of antibiotics for pediatric diarrhoea in both high- and low-resource settings are urgently needed.