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Abstract

Background:

Diarrheal disease remains a significant cause of child mortality, particularly in regions with limited access to healthcare and sanitation. Inappropriate practices, including unjustified medication prescriptions, pose challenges in the management of acute diarrhea (AD), especially in low- and middle-income countries.

Objective:

This study analyzed antibiotic prescription patterns and assessed compliance with Integrated Management of Childhood Illness (IMCI) guidelines in children under 5 with AD in the Ministry of Public Health (MOPH) Ambulatory Care Centers of Quito city, Ecuador.

Methods:

A cross-sectional design was used, collecting electronic health records (EHR) of patients diagnosed with AD from 21 health facilities in District 17D03. A probabilistic and stratified sampling approach was applied. Patient characteristics, prescriber characteristics, treatments, and compliance of IMCI guideline recommendations were evaluated. A stepwise logistic regression analysis examined the association between antibiotic prescription and patient and physician characteristics.

Results:

A total of 359 children under 5 years of age were included, with 58.77% being girls. 85.24% of the cases of AD were attributed to gastroenteritis and colitis of infectious and unspecified origin. Amebiasis and other protozoal intestinal diseases accounted for 13.37% and 1.11% of the cases, respectively. The completion rates of recording various IMCI parameters varied; parameters such as duration of diarrhea, presence of blood in stool, and evidence of sunken eyes had high completion rates (100%, 100%, and 87.47%, respectively), while parameters like state of consciousness, presence of thirst, and type of diarrhea had low completion rates (0.28%, 0.28%, and 0.84%, respectively). None of the cases had all parameters fully recorded. Antimicrobials were prescribed in 38.72% of the cases. Children aged 3 to 5 years had higher odds of receiving antimicrobial prescription for AD (aOR: 4.42, 95% CI 2.13-9.18, P < .0001) compared to those under 1 year, after adjusting for the number of loose stools per day, gender, and age of the health professional.

Conclusion:

Variations in IMCI guideline compliance were observed, with no cases fully adhering to the guidelines. Antimicrobial prescription rates were notably high, especially among older children. Further research and specialized interventions are necessary to gain comprehensive insight into the factors underlying non-compliance with the IMCI guidelines.

Keywords

child diarrhea anti-infective agents integrated management of childhood illness Ecuador

Background

Diarrheal disease is one of the leading causes of child mortality.¹ It mainly affects children in the first 5 years of life, especially in the second half of the first year.² Every day, over 1400 children around the world die on average from diarrhea, which is thought to affect 2.5 billion children under 5 years of age annually.³ There is evidence that acute diarrhea (AD) is more prevalent in areas with limited access to medical care, clean water, and sanitation facilities, which is often observed in low- and middle-income countries.^4,5 In Ecuador, during the year 2016, AD and gastroenteritis of presumed infectious origin emerged as the second most prevalent cause of ambulatory morbidity among children under 5 years old, representing approximately 15% of the total outpatient consultations.⁶ Similarly, in 2019, it maintained its position as the second highest cause of hospitalizations within the pediatric population.⁷

Gastrointestinal infections brought on by viruses, bacteria, and occasionally parasites are the most frequent cause of AD. 60%–70% of all diarrheal disorders are caused by rotavirus, but AD is frequently caused by E. coli, Campylobacter, Yersinia, and Salmonella spp.⁸ Viral agents (especially rotavirus and norovirus) are more likely to be identified in 0 to 11-month infants, while bacterial agents are more prevalent in the age group of 24 to 59 months.^9,10 The medical interview plays a crucial role in diagnosing AD by gathering detailed information on the duration of diarrhea and associated symptoms, including fever, vomiting, and abdominal discomfort.¹¹ Moreover, it is essential to identify underlying conditions that may increase the risk of severe disease, such as malnutrition, prematurity, immunodeficiency, and heart disease.¹² These parameters are vital for evaluating dehydration, recognizing complications, and detecting potential extraintestinal diseases linked to AD.

According to the Integrated Management of Childhood Illness (IMCI), a strategy developed by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF),¹³ the treatment of AD cases should be focused on avoiding dehydration, since most AD episodes are self-limited.¹⁴ Antibiotics, antiparasitic medicines, and antidiarrheal medications are not required and may even be hazardous for newborns and young children who have diarrhea.^15,16 Moreover, the IMCI recommends not ordering tests, since the findings of laboratory and microbiological tests do not modify how the episode is treated.¹⁷ As a result, testing should be limited and saved for patients with severe illness or with comorbidities.¹⁸

When a specific cause of the diarrhea has been identified or is strongly suspected, antibiotics or antiparasitic medicines may occasionally be given, especially following recent travel.¹⁶ Most studies worldwide have not reported on the appropriateness of antibiotic or antiparasitic use in children under 5 with AD.^19
-22 A systematic review on harmful practices in the management of childhood diarrhea in low- and middle-income countries revealed a wide range of antibiotic use prevalence, varying from 10% to 77%, suggesting that high rates of antibiotic use may be inappropriate.²³ The review also emphasized the variability in accuracy when analyzing antibiotic use, particularly when relying on questionnaires administered to physicians or caregivers, which often yield highly inaccurate findings. Consequently, alternative methods of analysis are strongly recommended to ensure more reliable and valid results.²³

Materials and Methods

Objective

The study aimed to analyze the antibiotic prescription patterns in children under the age of 5 with AD in Quito, Ecuador, and to evaluate the compliance with the IMCI guidelines in the Ambulatory Care Centers of the Ministry of Public Health (MOPH) care system in 2019.

Study Design

The research utilized a cross-sectional study design, which shares similarities with other studies conducted in a comparable manner.^22,24,25

Setting

The healthcare system in Ecuador comprises both public and private sectors. Within the public sector, the MOPH serves as a pivotal institution responsible for the governance and administration of the country’s healthcare system, catering to the entire population of Ecuador. The MOPH operates on financial support primarily derived from state contributions, playing a significant role in the provision of healthcare services, and encompassing approximately 62% of the public health system. The rest of the population is covered by a public subsystem, such as the Ecuadorian Institute of Social Security (IESS), the Institute of Security of the Armed Forces (ISSFA), and the Institute of Social Security of the National Police (ISSPOL). Conversely, the private healthcare system caters to a segment of the population with the financial capacity to afford private healthcare services.^26,27 District 17D03, located in the city of Quito, is part of the public health network of Ecuador. This district has a total population of 430 000, with approximately 36% of the residents being children aged 0 to 18 years. The district is further divided into 21 ambulatory care centers, strategically located across both rural and urban areas of the city.²⁸ These centers play a vital role in providing healthcare services to 85% of the district’s population.

Data Source

Electronic health records (EHR) of patients from 21 health facilities of the MOPH of District 17D03 of Ecuador during 2019 with AD as the main diagnosis served as the data source for the information collected for this study. Since 2010, this district has been using the EHR. During the outpatient visit, physicians use a computer to enter data directly into the EHR. Two reviewers manually extracted information from the EHR. The variables extracted from the EHR encompassed information from both patients and physicians. Patient-related data included sociodemographic variables such as age and gender, as well as clinical information like medical history and specific details about the AD episode, such as the frequency of loose stools per day, duration of the episode, presence of symptoms like fever, abdominal discomfort, thirst, sunken eyes, and consciousness status. Additionally, laboratory orders and results, as well as prescribed treatments, were extracted from the EHR. Prescribed treatments and scheduled tests were cross-referenced with laboratory and pharmacy data.

Additionally, information from the EHR aligned with the IMCI recommendations was extracted, including the classification of diarrhea, zinc prescription for diarrhea treatment, dehydration status, and recommended hydration plan according to IMCI guidelines.²⁹ Sociodemographic characteristics of physicians (prescribers) were obtained from human resources. The study included patients seen by general practitioners, family physicians, and pediatricians. To address missing data, rigorous measures were taken to minimize its occurrence through meticulous documentation and recording of variables in the EHR. Additionally, diligent efforts were made to retrieve missing data by conducting supplementary investigations. These steps were undertaken to enhance the completeness and integrity of the dataset, ensuring a more robust and reliable analysis.

Sample

The inclusion criteria for AD were defined as any diagnosis registered according to the ICD-10 classification, as follows: A00: Cholera, A01: Typhoid and paratyphoid fevers, A02: Other salmonella infections, A03: Shigellosis, A04: Other bacterial intestinal infections, A05: Other bacterial foodborne intoxication not elsewhere classified, A06: Amebiasis, A07: Other protozoal intestinal diseases, A08: Viral and other specified intestinal infections, and A09: Other gastroenteritis and colitis of infectious and unspecified origin. We excluded patients with specific diagnosis codes unrelated to AD, such as R10.0: Acute abdomen and chronic diarrhea-related codes, including R19.7: Diarrhea, unspecified, K59.1: Functional diarrhea, K50: Crohn’s disease [regional enteritis], K51: Ulcerative colitis, and K52: Other and unspecified noninfective gastroenteritis and colitis.

A probabilistic sampling technique was employed to select a representative sample for the study. The sample size was derived from the aggregated count of AD cases within the pediatric population under the age of 5, as officially reported by the MOPH for the district in the year 2019, comprising a total of 2148 cases. To account for variability in case distribution across healthcare facilities, a stratified sampling method was utilized. This involved considering the proportion of AD cases treated at each facility when selecting the sample. Random selection was achieved using a random number system to ensure objectivity and fairness. This approach aimed to obtain a sample that accurately reflected the distribution of AD cases across different facilities (see Supplemental Table 1).

The following formula was applied to calculate the sample for a finite universe:

n = N * Z^{2} * p * q / d^{2} * (N - 1) + Z^{2} * p * q .

where N is the population size, Z is the confidence level (95%), p is the probability of success or expected proportion (50%), q is the probability of failure (50%), and d is precision (5% of maximum admissible error in terms of proportion). The subsequently studied sample included 359 EHR.

Statistical Analysis

Descriptive analysis of the qualitative variables involved calculating frequency distributions and proportions, while measures of central tendency and dispersion (mean and standard deviation) were employed for the quantitative variables. Before analyzing the data, distribution tests were performed, including the Shapiro-Wilk test for continuous variables and the chi-square test for categorical variables, to assess the data distribution. To examine the relationship between variables, a stepwise logistic regression analysis was conducted. This regression analysis adjusted for potential confounders and aimed to determine the association between the dependent variable, which was the prescription of antibiotics, and independent factors related to patient and physician characteristics. The selection of independent variables was based on their theoretical relationship to the dependent variable, using bivariate logistic regression models. A significance level of P < .05 was considered to establish statistical significance in the analysis. SPSS v26 was utilized as the statistical software for data analysis.

Results

A total of 359 children under 5 years of age met the inclusion criteria for the study. The characteristics of the sample are described in Table 1. Patients were treated by a total of 91 healthcare professionals, with the majority being female (64.84%, 59/91). Among the healthcare professionals, 62.64% (57/91) were general practitioners, while pediatricians accounted for only 3.30% (3/91). In terms of consultations, general practitioners attended the most, accounting for 49.30% (177/359) of all consultations. Pediatricians followed with 25.91% (93/359) of consultations, and general rural physicians accounted for 15.60% (56/359).

Table 1.

Characteristics of the Sample.

Patients	Total (%)
Total patients	359 (100)
Age in years
Mean	2.01
Standard deviation	1.43
Groups of age
<1 year	69 (19.22)
1-2 years	183 (50.97)
3-5 years	107 (29.81)
Gender
Female	211 (58.77)
Male	148 (41.23)
Comorbidities
Anemia	9 (2.51)
Malnutrition	8 (2.23)
Prematurity history	5 (1.39)
Asthma	1 (0.27)
Clef lip	1 (0.27)
Epilepsy	1 (0.27)
Diarrhea frequency per day
Mean	5.45
Standard deviation	3.36
Days of duration of diarrheal episode
Mean	2.19
Standard deviation	2.06
Fever
Presence	44 (12.26)
Absence	315 (87.74)
Abdominal discomfort
Presence	45 (12.53)
Absence	314 (87.47)
Prescribers	Total (%)
Total prescribers	91 (100)
Age in years
Mean	40.54
Standard deviation	13.40
Gender
Female	59 (64.84)
Male	32 (35.15)
Health professional
General rural physician	5 (5.49)
General practitioner	57 (62.64)
Family physician	26 (28.57)
Pediatrician	3 (3.30)
Consultations by type of physician
General rural physician	56 (15.60)
General practitioner	177 (49.30)
Family physician	33 (9.19)
Pediatrician	93 (25.91)
Physician consultations by age groups
<35 years	189 (52.65)
36-44 years	46 (12.81)
45-54 years	32 (8.91)
>55 years	92 (25.63)

Of the total number of children, girls constituted the majority with 58.77% (211/359) and the mean age of the sample was 2 years. Children aged 1 to 2 years predominated in the sample with 50.97% (183/359). Anemia 2.51% (9/359), malnutrition 2.23% (8/359), and history of prematurity 1.39% (5/359) were the most frequently identified comorbidities.

Of the total of AD cases in the sample, 85.24% (306/359) were gastroenteritis and colitis of infectious and unspecified origin (A09 code), 13.37% (48/359) amebiasis (A06 code), 1.11% (4/359) other protozoal intestinal diseases (A07 code), and 0.28% (1/359) were coded other bacterial foodborne intoxication not elsewhere classified (A05 code). The mean duration of the AD episode was 2.19 days and the mean of the number loose stools per day was 5.45. Fever was reported in 12.26% (44/359) cases, abdominal discomfort in 12.53% (45/359), and blood in stools in 1.95% (7/359) cases.

Blood tests and coprological studies were requested in 6.41% (23/359) and 24.79% (89/359) of the children, respectively. No abnormalities were found in blood tests. Of the coprological test, 28.09% (25/89) were pathological, with the presence of Entamoeba histolytica in 76% (19/25), Giardia lamblia in 12% (3/25), Embadomona intestinalis in 8% (2/25), Ascaris lumbricoides in 4% (1/25), and the presence of the rotavirus antigen in 4% (1/25).

Figure 1 presents the compliance with the IMCI strategy. Among the parameters, the recording of duration of diarrhea, presence of blood in stool, and evidence of sunken eyes showed the highest completion rates, with 100%, 100%, and 87.47% respectively. However, the recording of parameters such as state of consciousness, presence of thirst, and type of diarrhea exhibited the lowest completion rates, at 0.28%, 0.28%, and 0.84% respectively. None of the cases had all parameters fully recorded.

Figure 1.

Compliance of the parameters of the IMCI guidelines.

No significant relationships were found between patient or physician characteristics and the parameters of the IMCI guidelines, except for the prescription of an adequate rehydration plan. Notably, physicians aged 35 to 44 years showed a higher inclination toward recommending an appropriate rehydration plan compared to those over 55 years (OR: 4.13, 95% CI: 1.92-8.91, P < .0001). Furthermore, children who had more than 5 loose stools per day were more likely to receive an adequate rehydration plan (OR: 2.26, 95% CI: 1.46-3.49, P < .0001), as well as those who experienced diarrhea for over 48 h (OR: 2.08, 95% CI: 1.33-3.25, P = .001).

Zinc was prescribed in only 1.95% (7/359) of the children, and our regression model did not reveal any characteristics of the prescriber or clinical presentation of the cases that might be associated with zinc prescription.

Table 2 depicts the medicines used in AD cases in the sample. Antipyretic/analgesic agents were prescribed in 35.93% (129/359) of the children, and acetaminophen was the most prescribed agent 32.31% (116/359). Oral rehydration salts (ORS) were prescribed in 54.87% (197/359) of the cases. Antimicrobials were prescribed in 38.72% (139/359) of the cases, with 2.88% (4/139) comprising a combination of antibacterial and antiparasitic agents (amoxicillin, albend-azole, and metronidazole), 46.76% (65/139) consisting of antiparasitic medications, and 50.36% (70/139) involving antibacterial drugs. Among the antiparasitic medications, 55.39% (36/65) were a combination of albendazole and metronidazole, while no combinations of antibacterial agents were observed. Trimethoprim-sulfamethoxazole was the most prescribed antibiotic 68.57% (48/70) and metronidazole was the most prescribed antiparasitic 35.38% (23/65). Antiemetics and antidiarrheal medicines were prescribed in 0.84% (3/359) of the cases and probiotics in 6.41% (23/359) of the cases.

Table 2.

Medicines Used for Acute Diarrheal Disease in Children.

Medicines	n (%)
Antipyretic analgesic medicines	129 (35.93)
Acetaminophen	116 (89.92)
Ibuprofen	13 (10.08)
Oral rehydration salts	197 (54.87)
Antimicrobial	139 (38.72)
Antibacterial	70 (50.36)
Trimethoprim-sulfamethoxazole	48 (68.57)
Azithromycin	9 (12.86)
Amoxicillin	6 (8.57)
Cephalexin	3 (4.28)
Clarithromycin	2 (2.86)
Fosfomycin	1 (1.43)
Ampicillin-sulbactam	1 (1.43)
Antiparasitic	65 (46.76)
Metronidazole	23 (35.38)
Albendazole	6 (9.23)
Combination metronidazole/albendazole	36 (55.39)
Antibacterial plus antiparasitic (Amoxicillin + metronidazole + albendazole)	4 (2.88)
Antiemetics and antidiarrheal medicines	3 (0.84)
Scopolamine	1 (33.33)
Metoclopramide	2 (66.67)
Probiotics	23 (6.41)
Saccharomyces boulardii	2 (8.70)
Bacillus clausii	21 (91.30)

Antimicrobial prescription rates for the ICD-10 codes were 29.74% (91/306) for code A09, 91.67% (44/48) for code A06, 75% (3/4) for code A07, and 100% (1/1) for code A05. Factors related to antimicrobial prescriptions are presented in Table 3. The results indicate a significant association between the gender and age of the prescriber and antimicrobial prescriptions in AD cases among children. Female health professionals demonstrated a higher rate of antimicrobial prescription compared to males (OR: 2.26, 95% CI: 1.31-3.87, P = .003). Similarly, health professionals aged 25 to 34 years were more likely to prescribe antimicrobials compared to those over 55 years of age (OR: 2.07, 95% CI: 1.22-3.52, P = .007).

Table 3.

Factors Related to Antimicrobial Prescription in AD.

Variable	Category	OR	95% CI	P value
Prescriber’s gender	Female	2.26	1.31-3.87	.003
Prescriber’s gender	Male	1	-	-
Prescriber’s age	25-34 years	2.07	1.22-3.52	.007
	35-44 years	0.71	0.32-1.61	.424
	45-54 years	0.76	0.30-1.90	.560
	>55 years (REF)	1	-	-
Type of professional	General rural physician	1.07	0.55-2.07	.849
	General physician	0.49	0.29-0.83	.007
	Family medicine physician	0.34	0.14-0.84	.018
	Pediatrician (REF)	1	-	-
Patient’s gender	Male	1.37	0.88-2.19	.153
Patient’s gender	Female (REF)	1	-	-
Patient’s age	3-5 years	3.59	1.99-7.85	<.0001
	1-2 years	2.03	1.06-3.87	.032
	<1 year	1	-	-
Loose stools/day	>5	2.60	1.68-4.03	<.0001
Loose stools/day	≤5	1	-	-
Duration of the episode	>48 hours	1.87	1.21-2.89	.005
Duration of the episode	≤48 hours	1	-	-
Fever	Presence	0.72	0.37-1.42	.357
Fever	Absence	1	-	-
Abdominal discomfort	Presence	1.49	0.79-2.80	.211
Abdominal discomfort	Absence	1	-	-
Comorbidity	Presence	1.54	0.68-3.48	.297
Comorbidity	Absence	1	-	-
Variable	Category	aOR	95% CI	P value
Prescriber’s gender	Female	2.24	1.26-4.00	.006
Prescriber’s gender	Male (REF)	1	-	-
Prescriber’s age	25-34 years	1.86	1.06-3.28	.030
	35-44 years	0.65	0.27-1.55	.333
	45-54 years	0.78	0.30-2.07	.625
	>55 years (REF)	1	-	-
Patient’s age	3-5 years	4.42	2.13-9.18	<.0001
	1-2 years	2.04	1.04-4.03	.038
	<1 year	1	-	-
Loose stools/day	>5	2.58	1.60-4.16	<.0001
Loose stools/day	≤5	1	-	-

Abbreviations: REF, reference category; OR, odds ratio; aOR, adjusted odds ratio.

The child’s age showed a significant association with antimicrobial prescription. Children between 1 and 2 years old had 2.03 times higher odds of receiving antimicrobials (95% CI: 1.06-3.87, P = .032), while children between 3 and 5 years old had 3.59 times higher odds (95% CI: 1.99-7.85, P < .0001) compared to children under 1 year old.

Antimicrobial prescription was significantly influenced by the clinical presentation of the patient. The presence of AD with a frequency of more than 5 loose stools per day was associated with higher odds of antimicrobial prescription (OR: 2.60, 95% CI: 1.68-4.03, P < .0001). Similarly, a longer duration of diarrheal symptoms exceeding 48 h also increased the odds of antimicrobial prescription (OR: 1.87, 95% CI: 1.21-2.89, P = .005). Detailed results can be found in Table 3.

After a multivariate analysis through logistic regression, antimicrobial prescription in AD in children under 5 years was 4.42 times higher (95%, CI 2.13-9.18, P < .0001) in children aged 3 to 5 years compared to children under 1 year, adjusted for the number of stools per day of the child, gender and age of the health professional. This adjustment is depicted in Table 3.

Discussion

We conducted this study to investigate the prescribing practices of doctors in the management of AD in children under 5 years of age. In our analysis, the predominant management approach for AD involved the use of ORS. Notably, these findings align with similar studies conducted in different regions, reporting ORS utilization rates of 40.5% in Zimbabwe, 64.7% in Zambia, 64.6% in Malawi, 67% in Ethiopia, and 52.8 in Brazil.^30
-32 These comparative data highlight the consistency of ORS usage as a common practice for AD management across various settings.

According to the IMCI strategy, the recommended treatment for AD involves administering an ORS with a zinc supplementation.²⁹ It is crucial to avoid the use of probiotics, antibiotics, antidiarrheal agents, or antiemetics. In regions where zinc deficiency or malnutrition is prevalent, providing zinc to children aged 6 months and above has the potential to reduce the average duration of the diarrhea and decrease the number of children experiencing persistent diarrhea beyond the seventh day.^33,34 However, our study highlights a concerning finding of significantly low prescription rates of zinc. This finding aligns with a study conducted in Comoros, Madagascar, and Kenya, which reported prescription rates of 0.4%, 1.4%, and 8.2%, respectively.³⁵ Additionally, studies in Nepal and Ethiopia showed similarly low utilization of zinc for AD management, with rates of 15.4% and 16.6% respectively.^36,37 We did not identify any specific prescriber characteristics or clinical presentation factors that could be associated with the lack of zinc prescription in our study. In a previous study, we similarly observed a low prescription rate of zinc (3.61%), likely attributed to issues such as stock unavailability and the high cost of zinc supplementation.³⁸ Existing literature suggests that the prevalence of zincutilization is influenced by factors such as maternal education, a high wealth index, and increased community media exposure to the use of zinc^35,37; however, due to the limitations of our study design, we were unable to assess these factors and their potential impact on zinc prescription rates.

As per the IMCI strategy, antibiotics are typically unnecessary during the initial patient contact for children under the age of 5 with AD. Immediate antibiotic prescription is justified only in a limited number of specific circumstances.^12,29 Our study revealed a prescription rate of 38.7% for antibiotics, which is relatively lower compared to other studies conducted in the field. Notably, higher prescription rates were reported in Ethiopia (86.8%), Nigeria (over 85%), India (71%), and Thailand (61.4%). These findings underscore the variability in prescribing practices across different countries and emphasize the significance of considering regional factors when interpreting the results.^25,39
-41

However, our findings indicate an excessive utilization of antibiotics and a lack of adherence to recommended guidelines, mirroring observations reported in other studies.^42,43 Viral infections are the primary cause of diarrhea in children under the age of 5. In contrast, bacterial infections account for less than 20% of cases, while parasites are responsible for less than 5% of cases.^44
-46 Considering these etiological factors, it is important to note that antimicrobials are not recommended as the initial treatment option for AD in children.^47,48

Our findings suggest that the duration of diarrhea episodes and the frequency of loose stools per day appear to influence physicians in their decision to prescribe antimicrobials. Furthermore, we observed an increased likelihood of antimicrobial prescription the higher the age of the child. A study conducted in Nigeria⁴¹ reported that the odds of antibiotic prescription were nearly 3 times higher in children who had encountered more than 3 episodes of diarrhea per day. Furthermore, a study spanning from 2009 to 2014 conducted in Bangladesh, Brazil, India, Nepal, Pakistan, Peru, South Africa, and the United Republic of Tanzania, demonstrated that higher age at the onset of diarrhea, longer duration of symptoms, and a greater number of loose stools were independently associated with an elevated likelihood of receiving antibiotic treatment.⁴⁹ These findings align with our own research results.

Antimicrobials are recommended in cases of infection caused by specific pathogens, including Salmonella typhi, Vibrio cholerae, Entamoeba histolytica, and Giardia lamblia.⁵⁰ In 2019, Ecuador reported 117 cases of Salmonellosis among children under the age of 5. However, no cases of cholera were reported during that same year.^51,52 While the literature suggests that parasites account for a small proportion of AD cases, our study results indicate that over a quarter of the stool parasite testing orders in the children sampled yielded positive results. However, it is important to note that we cannot definitively attribute these findings as the cause of the diarrhea episodes. It is worth considering that antimicrobial therapy could potentially be beneficial in certain cases of AD, particularly when specific bacteria or parasites are identified, which was not the focus of analysis in our study. Therefore, it cannot be ruled out that some of these children may have derived benefits from antimicrobial treatment.

The IMCI is a comprehensive strategy aimed at enhancing child health and development. This approach plays a crucial role in improving the quality of medical care provided for the prevalent causes of morbidity and mortality among children under the age of five.^53,54 Our study reveals varying adherence levels to recommended practices and documentation within the IMCI framework. While the duration of the AD and the presence of blood were consistently recorded, important parameters such as consciousness, thirst, and diarrhea type were poorly documented. Although signs of dehydration were noted in some cases, the overall documentation of dehydration status was limited. Adequate hydration plans, as per IMCI guidelines, were recommended in only a moderate number of cases. The findings underscore the importance of enhancing adherence to guidelines and ensuring comprehensive documentation in the management of AD, specifically in the assessment of dehydration and the formulation of hydration plans. These results are in line with previous studies investigating adherence to IMCI guidelines, which have consistently revealed significant variations in physician performance.^55
-57

Adhering to guidelines and algorithms is a complex process influenced by contextual factors that impact physicians’ capacity and motivation. These factors include organizational structures, policies, resources, professional norms, and individual attributes.⁵⁸ By focusing on these areas, healthcare systems can promote adherence to guidelines, facilitate consistent and high-quality care, and ultimately enhance children’s overall health outcomes. Although the specific reasons behind these factors were not explored in this study, addressing them is crucial for effective IMCI implementation and improved AD management.

AD in children is influenced by a range of social, political, sanitation, and cultural factors. Socioeconomic disparities, limited access to clean water and sanitation facilities, inadequate healthcare infrastructure, and food insecurity contribute to the burden of diarrhea in many communities.⁵⁹ In Ecuador, waterborne diseases (WBD) remain a significant public health concern, with recent research demonstrating that the indigenous population exhibits a higher susceptibility and mortality rate from WBD compared to other ethnic groups.⁶⁰ Moreover, the same study revealed a heightened likelihood of hospitalization among younger children for such diseases. Comprehensive interventions addressing these multifaceted factors are imperative and should encompass improved sanitation, enhanced access to clean water, strengthened healthcare infrastructure, targeted education initiatives, and cultural sensitivity in order to effectively combat the occurrence and impact of AD in children in Ecuador.

The present study demonstrates several significant strengths that enhance the reliability and validity of the findings. Firstly, data collection was conducted across 21 healthcare facilities, ensuring a diverse and representative sample. Additionally, the utilization of EHR as the source of data acquisition is a notable strength, as it enables the direct retrieval of accurate and authentic information, thereby minimizing the potential for data inaccuracies or recall biases. Furthermore, the design facilitates the generation of comparable results, ensuring consistency and enabling meaningful comparisons with other relevant studies. In addition, the study adheres to the IMCI guidelines, which are officially adopted by the country, providing a standardized framework for assessing the appropriateness of antibiotic prescribing practices. Moreover, it is noteworthy that all variables examined in the study were consistently and comprehensively documented in the EHR of all included patients. This meticulous data collection process ensures the availability of complete and reliable information for thorough analysis, enhancing the internal validity of the study.

However, it is important to acknowledge certain limitations inherent in our study design. Firstly, a primary limitation is the retrospective nature of the data extracted from the EHR, which may introduce biases and potential limitations in the documentation process. Selective recording of symptoms or laboratory data by physicians based on individual judgment or clinical priorities could lead to incomplete documentation or underreporting of variables. This variation in the accuracy and completeness of recorded data within the EHR system may impact the reliability of the findings. This limitation should be taken into consideration when interpreting the results and generalizing the findings.

Another significant limitation is the lack of evaluation of the decision-making process underlying prescribing practices. While we analyzed prescribing patterns, we did not have access to information on specific factors influencing healthcare providers’ decisions, such as familiarity with guidelines, adherence to protocols, patient characteristics, or local policies. This absence of information limits our understanding of contextual factors that could have influenced prescribing practices.

Additionally, it is important to note that our study focused on a specific district in Ecuador, limiting the generalizability of the findings to the entire population of children under 5 with AD in Ecuador or other regions. Prescribing patterns and guideline compliance in different healthcare settings or regions may vary significantly. Furthermore, our analysis was based on data from the year 2019, and prescribing practices may have evolved or changed since then due to updates in treatment guidelines, medication availability, or changes in local policies. Therefore, caution should be exercised when applying the findings to current practices.

Considering these limitations, it is essential to interpret the results of our study within the context of these constraints, and further research is warranted to address these limitations and gain a more comprehensive understanding of prescribing practices for children with AD.

Conclusion

This study identified shortcomings in adherence to treatment guidelines for AD in children under the age of 5 at the health centers of District 17D03 of the MOPH in Ecuador. Significant variations in compliance with the IMCI guidelines were observed, with no instances fully conforming to the guidelines. Remarkably high rates of antimicrobial prescription were noted, particularly among older children. This study underscores the importance of enhancing adherence to the IMCI guidelines and implementing targeted interventions to minimize unnecessary antibiotic prescriptions for AD in children. To enhance the quality of care, relevant contextual determinants should be considered and adherence to established guidelines actively promoted. Further research and targeted interventions are necessary to gain a comprehensive understanding of the determinants contributing to non-compliance with the IMCI guidelines.

Supplemental Material

sj-docx-1-jpc-10.1177_21501319231196110 – Supplemental material for Antibiotic Prescription Patterns in Children Under 5 Years of Age With Acute Diarrhea in Quito-Ecuador

Supplemental material, sj-docx-1-jpc-10.1177_21501319231196110 for Antibiotic Prescription Patterns in Children Under 5 Years of Age With Acute Diarrhea in Quito-Ecuador by Xavier Sánchez, Nathali Calderón, Olga Solis and Ruth Jimbo-Sotomayor in Journal of Primary Care & Community Health

Footnotes

Acknowledgements

None.

Authors’ Contributions

XS, NC, and OS designed the study and participated in the elaboration of the protocol, XS, NC and OS analyzed the results and wrote the manuscript; XS and RJ participated in the statistical analysis and wrote the manuscript; XS, NC and OS participated in fields and bench work; NC, OS and RJ corrected the manuscript. All authors read and approved the final manuscript.

Availability of Data and Materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Consent for Publication

Not applicable.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics approval and consent to participate

All methods were conducted in strict accordance with relevant national guidelines and regulations. Informed consent was obtained from all subjects involved in the study. The data concerning patients and physicians were sourced from secondary data, and the database underwent a rigorous anonymization process to ensure the complete protection of personal information. No identifiable patient or physician information was utilized in the study. The study was approved by the Subcommittee for Research Ethics on Human Beings – Pontificia Universidad Católica del Ecuador (PUCE), with authorization number SB-CEISH-POS-722 dated April 15, 2021.

ORCID iDs

Xavier Sánchez

Ruth Jimbo-Sotomayor

Supplemental Material

Supplemental material for this article is available online.

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