Etiology and management of hospitalized and outpatient diarrhea among children less than 5 years of age in Lambaréné, Gabon

Objectives: Diarrhea remains a significant cause of global under-5 mortality, particularly in SubSaharan Africa (SSA). To reduce morbidity and mortality, the World Health Organization (WHO) recommends oral rehydration salts (ORS), zinc supplementation, and continued feeding or breastfeeding for all children with diarrhea to prevent dehydration and malnutrition; antibiotics only for bloody diarrhea (i.e. probable shigellosis), suspected cholera, or severe non-intestinal infections (e.g. pneumonia or sepsis); and avoidance of antidiarrheals and antiemetics owing to lack of benefit and potential for harm in young children. Gabon is an upper-middle income country in SSA for which there is a lack of recent, high quality data on the etiology and management of childhood diarrhea. This prospective study aimed to describe the etiology and management of hospitalized and outpatient cases of diarrhea in Gabonese children under five years of age. Methods: Children ≤ 59 months presenting to the Albert Schweitzer or George Rawiri Regional hospitals (February-July 2017) in Lambaréné, Gabon were included if they had ≥ 3 liquid stools per day within the past 3 days. Data was obtained via medical records and standardized questionnaires with caregivers. Diarrheaogenic Escherichia coli, Salmonella enterica, and Shigella spp. were detected using conventional culture techniques. Rotavirus, adenovirus, and Cryptosporidium spp. antigens were detected with commercial rapid immunoassays. Multiplex PCR was used for Cryptosporidium spp., Giardia intestinalis, and Cyclospora cayetanensis detection. Results: Forty-five children were included, 34 of whom were hospitalized. Mean age was 12.2 months; 58% were female. 49% were infected with one or more sought-for pathogens, most commonly with Giardia intestinalis (28.9%) or Cryptosporidium spp. (24.4%). 33% and 36% of hospitalized and outpatient children, respectively, received ORS. Zinc was given to one (3%) hospitalized patient and zero outpatients. Antidiarrheals were frequently given to hospitalized (48%) and outpatient (73%) children. Antibiotics were prescribed in 85% and 36% of hospitalized and outpatient cases, respectively, while only 8 children (18%) presented with bloody stools. 79% of children presented with severe acute malnutrition; 21% had never been breastfed. Conclusions: Ongoing education of healthcare workers and communities regarding WHO-recommended management of childhood diarrhea is needed. The overuse of antibiotics observed in this study is consistent with previous reports and is concerning given high levels of antimicrobial resistance in SSA. Strategies to increase provider awareness of indicated uses of antimicrobials in the setting of childhood diarrhea may help limit the spread of resistance