title: Use of antibiotics in children younger than two years in eight countries: a prospective cohort study.
abstract: OBJECTIVE
  To describe the frequency and factors associated with antibiotic use in early childhood, and estimate the proportion of diarrhoea and respiratory illnesses episodes treated with antibiotics.
  
  
  METHODS
  Between 2009 and 2014, we followed 2134 children from eight sites in Bangladesh, Brazil, India, Nepal, Pakistan, Peru, South Africa and the United Republic of Tanzania, enrolled in the MAL-ED birth cohort study. We documented all antibiotic use from mothers' reports at twice-weekly visits over the children's first two years of life. We estimated the incidence of antibiotic use and the associations of antibiotic use with child and household characteristics. We described treatment patterns for diarrhoea and respiratory illnesses, and identified factors associated with treatment and antibiotic class.
  
  
  RESULTS
  Over 1 346 388 total days of observation, 16 913 courses of antibiotics were recorded (an incidence of 4.9 courses per child per year), with the highest use in South Asia. Antibiotic treatment was given for 375/499 (75.2%) episodes of bloody diarrhoea and for 4274/9661 (44.2%) episodes of diarrhoea without bloody stools. Antibiotics were used in 2384/3943 (60.5%) episodes of fieldworker-confirmed acute lower respiratory tract illness as well as in 6608/16742 (39.5%) episodes of upper respiratory illness. Penicillins were used most frequently for respiratory illness, while antibiotic classes for diarrhoea treatment varied within and between sites.
  
  
  CONCLUSIONS
  Repeated antibiotic exposure was common early in life, and treatment of non-bloody diarrhoea and non-specific respiratory illnesses was not consistent with international recommendations. Rational antibiotic use programmes may have the most impact in South Asia, where antibiotic use was highest.
authors.affiliation: Division of Infectious Diseases and International Health, University of Virginia, PO Box 801379, Carter Harrison Research Bldg MR-6, 345 Crispell Drive, Room 2520, Charlottesville, Virginia 22908-1379, United States of America (USA).
authors.forename: Elizabeth T
authors.initials: ET
authors.lastname: Rogawski
authors.affiliation: Division of Infectious Diseases and International Health, University of Virginia, PO Box 801379, Carter Harrison Research Bldg MR-6, 345 Crispell Drive, Room 2520, Charlottesville, Virginia 22908-1379, United States of America (USA).
authors.forename: James A
authors.initials: JA
authors.lastname: Platts-Mills
authors.affiliation: Fogarty International Center, National Institutes of Health, Bethesda, USA .
authors.forename: Jessica C
authors.initials: JC
authors.lastname: Seidman
authors.affiliation: Christian Medical College, Vellore, India .
authors.forename: Sushil
authors.initials: S
authors.lastname: John
authors.affiliation: International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh .
authors.forename: Mustafa
authors.initials: M
authors.lastname: Mahfuz
authors.affiliation: Institute of Medicine, Tribhuvan University, Kathmandu, Nepal .
authors.forename: Manjeswori
authors.initials: M
authors.lastname: Ulak
authors.affiliation: Walter Reed/AFRIMS Research Unit, Kathmandu, Nepal .
authors.forename: Sanjaya K
authors.initials: SK
authors.lastname: Shrestha
authors.affiliation: Aga Khan University, Karachi, Pakistan .
authors.forename: Sajid Bashir
authors.initials: SB
authors.lastname: Soofi
authors.affiliation: Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA .
authors.forename: Pablo Penataro
authors.initials: PP
authors.lastname: Yori
authors.affiliation: Haydom Lutheran Hospital, Haydom, United Republic of Tanzania .
authors.forename: Estomih
authors.initials: E
authors.lastname: Mduma
authors.affiliation: Haukeland University Hospital, Bergen, Norway .
authors.forename: Erling
authors.initials: E
authors.lastname: Svensen
authors.affiliation: International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh .
authors.forename: Tahmeed
authors.initials: T
authors.lastname: Ahmed
authors.affiliation: Clinical Research Unit and Institute of Biomedicine, Federal University of Ceara, Fortaleza, Brazil .
authors.forename: Aldo Am
authors.initials: AA
authors.lastname: Lima
authors.affiliation: Aga Khan University, Karachi, Pakistan .
authors.forename: Zulfiqar A
authors.initials: ZA
authors.lastname: Bhutta
authors.affiliation: Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA .
authors.forename: Margaret N
authors.initials: MN
authors.lastname: Kosek
authors.affiliation: Foundation for the National Institutes of Health, Bethesda, USA .
authors.forename: Dennis R
authors.initials: DR
authors.lastname: Lang
authors.affiliation: Foundation for the National Institutes of Health, Bethesda, USA .
authors.forename: Michael
authors.initials: M
authors.lastname: Gottlieb
authors.affiliation: Aga Khan University, Karachi, Pakistan .
authors.forename: Anita Km
authors.initials: AK
authors.lastname: Zaidi
authors.affiliation: Christian Medical College, Vellore, India .
authors.forename: Gagandeep
authors.initials: G
authors.lastname: Kang
authors.affiliation: University of Venda, Thohoyandou, South Africa .
authors.forename: Pascal O
authors.initials: PO
authors.lastname: Bessong
authors.affiliation: Division of Infectious Diseases and International Health, University of Virginia, PO Box 801379, Carter Harrison Research Bldg MR-6, 345 Crispell Drive, Room 2520, Charlottesville, Virginia 22908-1379, United States of America (USA).
authors.forename: Eric R
authors.initials: ER
authors.lastname: Houpt
authors.affiliation: Division of Infectious Diseases and International Health, University of Virginia, PO Box 801379, Carter Harrison Research Bldg MR-6, 345 Crispell Drive, Room 2520, Charlottesville, Virginia 22908-1379, United States of America (USA).
authors.forename: Richard L
authors.initials: RL
authors.lastname: Guerrant
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D003906:Developing Countries; D003967:Diarrhea / Q000188:drug therapy*; D004363:Drug Utilization / Q000706:statistics & numerical data*; D005260:Female; D014943:Global Health; D019983:Guideline Adherence; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D017410:Practice Guidelines as Topic; D012140:Respiratory Tract Diseases / Q000188:drug therapy*; D012959:Socioeconomic Factors
chemical_list: D000900:Anti-Bacterial Agents