Prevalence of co-trimoxazole resistance against bacterial isolates from children with diarrhea in Ethiopia: Systematic review and Meta-analysis

Abstract

Background: South Asia and Sub-Saharan Africa account for about 90% of all diarrheal fatalities in children worldwide. The World Health Organization guideline suggests the use of co-trimoxazole in the management of bloody diarrhea, cholera, and invasive bacterial diarrhea in children. However, there are reports on the inappropriate and empirical use of co-trimoxazole for the management of diarrhea in Ethiopia. Our objective was to estimate the prevalence of bacterial resistance against co-trimoxazole from stool isolates of diarrheic children in Ethiopia and to identify the factors associated with it. Methods:We conducted a comprehensive database search in PubMed and Embase electronic databases to retrieve studies published between 2000 and 2021. We assessed heterogeneity across studies using Higgin's I² test statistic and Cochrane Q test. We used a random-effects model to pool the proportion of bacterial resistance. We evaluated publication bias using a funnel plot and Egger's regression test. The Joanna Briggs Institute (JBI) critical appraisal tool was used to measure the quality of the papers included. Results: We included 20 eligible studies (1040 isolates) reporting the antimicrobial resistance of Shigella, Salmonella, E.coli,and Campylobacter against co-trimoxazole. The pooled proportion of co-trimoxazole resistance to the four diarrheagenic enteropathogens was 50.3 % with (95%CI: 41.7%-58.8%). We carried out a subgroup analysis based on four factors; bacterial species, participants’ age, region, study setting and sample size. The highest resistance was E. coli, 62.3 % (95%CI; 38%-83%) followed by Shigella 51.4% (95%CI; 38%-64%). There was a significant difference in the co-trimoxazole resistance of studies that had a sample size above 250 participants (58.5%) versus studies having a sample size below 250 (34.2%). However, there was no significant difference in co-trimoxazole resistance between children aged below 5 years compared with children above 5 years. Conclusion: Bacterial isolates from the stool of diarrheic Ethiopian children have shown resistance to co-trimoxazole. E. coli showed the highest resistance among the isolates. Therefore, we need to exercise caution in the over-the-counter use of co-trimoxazole and promote the rational use and prescribing practice of co-trimoxazole by healthcare providers. Prevention interventions such as safe drinking water, improved sanitation, and handwashing with soap can reduce disease risk and the use of antibiotic use. Additionally, breastfeeding and rotavirus vaccination can also reduce the incidence of acute gastroenteritis in young children. Systematic review registration PROSPERO CRD42023281838.