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Reduction in diarrhoeal rates through interventions that prevent unnecessary antibiotic exposure early in life in an observational birth cohort
  1. Elizabeth T Rogawski1,
  2. Steven R Meshnick1,
  3. Sylvia Becker-Dreps2,
  4. Linda S Adair3,
  5. Robert S Sandler1,4,
  6. Rajiv Sarkar5,
  7. Deepthi Kattula5,
  8. Honorine D Ward5,6,
  9. Gagandeep Kang5,
  10. Daniel J Westreich1
  1. 1Department of Epidemiology, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
  2. 2Department of Family Medicine, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
  3. 3Department of Nutrition, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
  4. 4Department of Medicine, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
  5. 5Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India
  6. 6Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
  1. Correspondence to Elizabeth T Rogawski, Division of Infectious Diseases and International Health, University of Virginia, P.O. Box 801379, Carter Harrison Research Bldg MR-6, 345 Crispell Drive, Room 2525, Charlottesville, VA 22908-1379, USA; etr5m{at}


Background Antibiotic treatment early in life is often not needed and has been associated with increased rates of subsequent diarrhoea. We estimated the impact of realistic interventions, which would prevent unnecessary antibiotic exposures before 6 months of age, on reducing childhood diarrhoeal rates.

Methods In data from a prospective observational cohort study conducted in Vellore, India, we used the parametric g-formula to model diarrhoeal incidence rate differences contrasting the observed incidence of diarrhoea to the incidence expected under hypothetical interventions. The interventions prevented unnecessary antibiotic treatments for non-bloody diarrhoea, vomiting and upper respiratory infections before 6 months of age. We also modelled targeted interventions, in which unnecessary antibiotic use was prevented only among children who had already stopped exclusive breast feeding.

Results More than half of all antibiotic exposures before 6 months (58.9%) were likely unnecessary. The incidence rate difference associated with removing unnecessary antibiotic use before 6 months of age was −0.28 (95% CI −0.46 to −0.08) episodes per 30 child-months. This implies that preventing unnecessary antibiotic exposures in just 4 children would reduce the incidence of diarrhoea by 1 from 6 months to 3 years of age.

Conclusions Interventions to reduce unnecessary antibiotic use among young children could result in an important reduction in diarrhoeal rates. This work provides an example application of statistical methods which can further the aim of presenting epidemiological findings that are relevant to public health practice.

  • Epidemiological methods

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