Prevalence of antibiotic use and household water-sanitation risk factors of acute watery diarrhea among children <5 years: retrospective analysis of multicounty health survey data, 2006-2018

A total 12,69,944 under ve year Childs were included in this study among them 1,80,067 Childs were acute watery diarrhea (AWD) and 19,502 Childs were bloody diarrhea respectively. Among them 47,755 Childs were taken antibiotic treatment for AWD. The overall prevalence of acute watery diarrhea ~ 14% (prevalence = 0.142; 95% CI = 0.141, 0.142). On the other hand the prevalence of bloody diarrhea ~ 2% (prevalence = 0.015; 95% CI = 0.015, 0.016). The prevalence of antibiotic treatment for AWD was ~ 27% (prevalence = 0.27, 95% CI = 0.26, 0.27) among the under ve years old children in DH survey regions in the world. The prevalence of acute watery diarrhea was higher ~ 17% (prevalence = 0.17, 95% CI = 0.16, 0.17) in the Latin America DHS survey region. The minimum prevalence of AWD was almost equal between South East Asia and Central Asia DHS survey regions ~ 12% (prevalence = 0.12, 95% CI = 0.11, 0.12) and ~ 12% (prevalence = 0.12, 95% CI = 0.10, 0.13) respectively. On the other hand the prevalence of AWD between Europe and West North and Central Africa DHS survey regions ~ 16% (prevalence = 0.16, 95% CI = 0.15, 0.16) and ~ 15% (prevalence = 0.15, 95% CI = 0.14, 0.15) correspondingly. In the central Asia of 15,089 under ve Childs were included in the survey. Among them 1,748 Childs were AWD and 967 Childs had taken antibiotic treatment for AWD. The highest prevalence of antibiotic use for AWD in Central Asia ~ 55% (prevalence=(967/1748) = 0.55, 95% CI = 0.52, 0.59) and Europe DH survey region ~ 44% (prevalence=(5483/12502) = 0.44, 95% CI = 0.43, 0.45). The lowest prevalence of antibiotic use for under ve Child AWD was ~ 23% (prevalence=(11918/51328) = 0.23, 95% CI = 0.22, 0.24) in the DH survey region South East Asia. On the other hand the DH survey region Latin America and West North and Central Africa region the prevalence of antibiotic use for AWD were ~ 30% (prevalence=(7887/26396) = 0.30, 95% CI = 0.29, 0.31) and ~ 24% (prevalence=(21500/88093) = 0.24, 95% CI = 0.23, 0.24). The South East Asia DH survey region countries DHS 2007 (Bangladesh), DHS 2014 and 2010 (Cambodia), DHS 2017 and 2012 (Indonesia), DHS 2009 (Maldives), DHS 2015–2016 (Myanmar), DHS 2012–2013 (Pakistan), DHS 2017 and 2013 (Philippines), and DHS 2009–2010 (Timor-Leste) were higher risk of AWD for drinking unimproved water sources. The prevalence of antibiotic use for u5c AWD was shown highest prevalence in DHS 2007 (~ 44%), DHS 2012 (~ 49%), DHS 2016 (~ 40%), and DHS 2017 (~ 65%) from DH survey 2006 to 2018 in South East & Central Asia. The linear trend analysis showed that upward trend for using antibiotic of AWD in the South East & Central Asia DH survey region.


Introduction
Diarrhea is the state of loose, liquid, or watery bowel engagements three times or more a day. [1] If it will be continue for a few days for a result creates severe dehydration. Among the low-and middle-income countries diarrhea is one of the foremost causes of antibiotic use for children. On the other hand vaccine may prevent diarrhea infections but they often consumed antibiotic treatment. [2] Of 13% prevalence for purchasing antibiotics without a prescription, ~ 2% were preferred by the regulars and ~ 11% were suggested by the pharmacists. [3] Cotrimoxazole was the most commonly prescribed drug (51%), followed by colistin sulfate (15.3%), nor oxacin (11%), and nalidixic acid (0.5%). The average number of antimicrobials per case of inpatients was higher than outpatients (1.15 vs 0.84, p < 0.001). There was a trend toward prescribing nor oxacin in childhood diarrhea. [4] The last 20 years shown that the prevalence of antibiotic resistance has increasing remarkably. [5] It is a serious hazard for health among the global people.
[6] The low income and middle income countries are higher threatened than high income countries for depletion of antibiotic, prevalence, and confrontation of antibiotic against the childhood diarrhea or diseases by the record. [7] Aggregate the numbers of peoples for gaining access of antimicrobial resistance not only the formal health care but also increasing the antibiotic treatments by the both formal and informal health care providers. [8,9] Moderately a 3rd of patients admitted to hospital are speci ed by the antibiotic treatment according to the report by the worldwide Point Prevalence Survey. [10] Around 21% antibiotic were used by oral pills or syrups and 3% by injections in the Demographic Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) data. The proportion of antibiotic treatments 3-78% for childhood diarrhea episodes among 38 included studies. [11] The main objective of this paper to estimate the prevalence of antibiotic use for acute watery diarrhea of under ve children (u5c), and retrospectives analysis of household water sanitation risk factors of DHS multi country survey from 2006-2018. Methods Data sources In this paper we used 112 Demographic Health Survey (DHS) data. On period of household surveys mothers were asked detailed questions about management of diarrhea episodes. And those under-5children were included whose 2-weeks diarrhea episodes earlier the survey date. Of 112 countries 12,69,944 under ve Children (u5c) datasets were collected from Demographic and Health Survey (DHS) programmed surveys from 2006 to 2018 (https://dhsprogram.com/Data/). The cross sectional study design used for the DHS survey data collection. The details sampling strategy and methodology discuss in the DHS website and published reports.

Statistical Analysis Method
The dataset was collected from Demographic and Health Survey (DHS) programmed from 2006 to 2018 survey year. There were 12,69,944 under ve Children suffering from acute watery diarrhea (had diarrhea last 24 hours or last two weeks) were analyzed as a study variable or dependent variable. Also analyzed the prevalence of antibiotic use for under ve child acute watery diarrhea. The logistic regression was used to estimate crude odds ratio (COR) of household drinking water (Improved as reference category) sources and sanitation (Improved as reference category) risk factors with 95% con dence interval. The pvalue was estimated for prediction of signi cant risk factors of under-ve childhood watery diarrhea. The multiple logistic regression was used to estimate the adjusted odds ratio (AOR) the age in months and sex of the children with 95% con dence interval. All the statistical analysis implemented using the open sources software R statistical programming language (https://www.r-project.org/). The classi cation of household sanitation and water risk factors are as follows:

Results
Overall Characteristics: A total 12,69,944 under ve year Childs were included in this study among them 1,80,067 Childs were acute watery diarrhea (AWD) and 19,502 Childs were bloody diarrhea respectively. Among them 47,755 Childs were taken antibiotic treatment for AWD. The overall prevalence of acute watery diarrhea ~14% (prevalence=0.142;95% CI=0.141,0.142 Socio-economic and Demographic characteristics: The wealth index is a signi cant measurement of socio-economic status. The median (robust measures of central tendency with 50% outliers tolerate) prevalence of antibiotic use for acute watery diarrhea (AWD) were almost equal among the poorest (~22%) and poorer (~22%) group Childs respectively. But among the richest people prevalence of antibiotic use was ~14% for AWD. Therefore, from the box plot ( Figure-1(A)) showed that the prevalence of antibiotic use trend was decreasing from poorest to richest (Supplementary Table-1).
The mother education plays signi cant roles for under ve childhood acute watery diarrhea. The prevalence of AWD among the primary and secondary education child mother were higher ~31% (median) and ~28% (median) respectively. Comparatively lower prevalence of AWD among the no education child mother group ~20% (median) than the primary and secondary education child mother. However, prevalence of AWD remarkably lowers ~2% among the higher education mother ( Figure-1 (B) and Supplementary Table-2).
The prevalence of AWD was higher among the age group 6-12 months and 12-18 months ~19% (median) and ~18% (median) respectively. The very low prevalence of AWD among the age group 42-48 months and 48-54 months were ~5% (median) and ~5% (median) respectively (Supplementary Table- 3). From the box plot (Figure-1(C)) showed that the prevalence of AWD was decreasing trend from age group 6-12 months to 48-54 months.

and Supplementary
Most of the countries in the South East Asia region were higher risk of u5c AWD for using unimproved sanitation toilet. On the other hand, DHS 2015 in Afghanistan, DHS 2015-2016 in Myanmar, and DHS 2016 in Timor-Leste were lower risk of AWD (Table-2 Figure-3(a)).
All the DH survey in the DH survey region in Latin America was higher risk of AWD for using unimproved sanitation toilet. But the DHS 2016-2017 in Haiti was lower risk of AWD (aOR=0.99; 95% CI=0.99, 0.99) for using unimproved sanitation toilet (Table-2

Declarations Acknowledgement
The author is cordially grateful to the DHS for making the data access available for analysis and publications. This work was done by author won interest, there no funding for this study. The authors had full access to all the data in the study and had nal responsibility for the decision to submit for publication.

Author contributions
All the statistical analysis and write & revised the manuscript and provided important intellectual content. The author approved the nal version of the manuscript.

Competing interests
The author(s) declare no competing interests.

Data Availability
The study data are available upon request from the Demographic and Health Surveys program (https://dhsprogram.com/).