Adherence and impact of the World Health Organization zinc and antibiotic administration guidelines for diarrhea management among children aged 6-35 months: EFGH study, 2022 - 2024

Abstract Background Diarrheal disease is the second leading cause of under-five mortality and morbidity in Sub-Saharan Africa. The World Health Organization (WHO) has developed treatment guidelines to support clinicians in the management of pediatric diarrhea; however, adherence to, and the impact of, these guidelines are not well described in low- and middle-income countries. Method We conducted a secondary analysis of data from the Enterics for Global Health study to determine whether adherence to WHO diarrhea management guidelines, specifically zinc supplementation and antibiotic administration (when appropriate), shortened the duration of diarrhea among children aged 6-35 months who presented to selected health facilities with diarrhea. Results This analysis includes 9,397 children aged 6 to 35 months with diarrhea enrolled across all seven EFGH sites. The majority (63.3%) of participants were under 18 months of age and 54.4% were male; 1,214 children (12.9%) presented to care with dysentery. Zinc was frequently administered (96.6%), with over 10 days of mean prescribed treatment duration. Of 5,061 children (53.9%) offered antibiotics, 3,082 (60.9%) received a WHO recommended regimen. Among participants who presented with dysentery, 67.6% were prescribed a WHO-recommended antibiotic. Among participants with watery diarrhea without dysentery, 72.4% were not prescribed any of the recommended antibiotics and were thus considered guideline-adherent. Overall, 6,302 (67.1%) children received guideline-adherent care when combining the zinc and appropriate antibiotic use indicators. In children with dysentery, providing WHO-recommended antibiotics was associated with 1.08 (95% CI: 0.53, 1.53) fewer days of diarrhea than those with dysentery who did not receive antibiotics. Children who were given 10+ days of zinc had on average 0.36 (95% CI: 0.03, 0.70) fewer days of diarrhea. Conclusion We found that two-thirds of children in this study received guideline adherent care in terms of zinc and appropriate antibiotic use for the treatment of childhood diarrhea, and that adherent treatment was associated with shorter duration diarrhea.