Role of antibiotics in reducing childhood mortality in resource-poor settings.

Abstract

A recent article ‘A quiet revolution in the treatment of childhood diarrhea’ in the New York Times[1] highlights childhood diarrhea, a ‘silent’ killer of infants and children in resource-poor settings, second in magnitude only to pneumonia. Diarrhea treatment guidelines in such settings rely on oral rehydration and reserve antibiotics for the presence of blood in the stool. These guidelines were developed more than 30 years ago. Newer evidence points to the higher than previously thought frequency of bacterial causes, even in the absence of visible blood in the stool [1]. Some experts argue that empiric antibiotic treatment of childhood diarrhea in resource-poor settings is a more cost-effective option than microbiologic testing to determine the cause. Others argue that such use of antibiotics will lead to widespread resistance. Several lines of recent evidence have shown a benefit of administering antibiotics to children in resource-poor settings in which malaria is also prevalent. Use of daily cotrimoxazole prophylaxis in HIV-exposed, uninfected infants in Malawi significantly reduced the risk of infant pneumonia, diarrhea, and malaria, and halved the risk of infant death [2]. Another study in Malawi compared the combination of chloroquine with azithromycin to chloroquine alone as treatment for symptomatic malaria episodes in children [3]; the combination with azithromycin not only treated malaria, but also decreased the incidence of subsequent respiratory infections by 33% and gastrointestinal tract infections by 26%. These data complement those of yet another study in Malawi, which demonstrated a 40% reduction in mortality in children by adding amoxicillin or cefdinir to ready-to-use food for the outpatient treatment of acute severe malnutrition [4], and those of a study of mass treatment for trachoma with azithromycin in Ethiopia [5], which demonstrated a decrease in childhood mortality. These benefits of antibiotics for children in resource-poor settings likely stem from the fact that bacterial diseases are very frequent and the etiologic pathogens are still susceptible to them [6]. We know that resistance can follow indiscriminate use of antibiotics. On the contrary, saving young children's lives cannot wait, and the evidence that antibiotics can help reduce child mortality is compelling. We urgently need to know when and how to treat common childhood infections in resource-poor settings, and whether and how to utilize prophylactic approaches for such infections. Such knowledge stems from finding out the etiologic pathogens of diarrhea and respiratory infections of infants and children in different resource-poor settings using newer methods adaptable to such settings. Based on that knowledge, creative and novel approaches to treatment and prevention can be quickly developed and clinically tested. Such studies need to give us accurate measurements of the effectiveness of each approach, their side-effects, resistance, and also the efficiency and cost-effectiveness of their administration. Pneumonia and diarrhea kill millions of young children, and stunt their growth and development. The time to dedicate efforts on this is now, so updated diagnostic, treatment, and prevention algorithms can be built. Acknowledgements Conflicts of interest The findings and conclusions in this letter are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. .