Global burden of childhood pneumonia and diarrhoea.

Diarrhoea and pneumonia are the leading infectious causes of childhood morbidity and mortality. We comprehensively reviewed the epidemiology of childhood diarrhoea and pneumonia in 2010-11 to inform the planning of integrated control programmes for both illnesses. We estimated that, in 2010, there were 1·731 billion episodes of diarrhoea (36 million of which progressed to severe episodes) and 120 million episodes of pneumonia (14 million of which progressed to severe episodes) in children younger than 5 years. We estimated that, in 2011, 700,000 episodes of diarrhoea and 1·3 million of pneumonia led to death. A high proportion of deaths occurs in the first 2 years of life in both diseases--72% for diarrhoea and 81% for pneumonia. The epidemiology of childhood diarrhoea and that of pneumonia overlap, which might be partly because of shared risk factors, such as undernutrition, suboptimum breastfeeding, and zinc deficiency. Rotavirus is the most common cause of vaccine-preventable severe diarrhoea (associated with 28% of cases), and Streptococcus pneumoniae (18·3%) of vaccine-preventable severe pneumonia. Morbidity and mortality from childhood pneumonia and diarrhoea are falling, but action is needed globally and at country level to accelerate the reduction.

Haemolytic-uraemic syndrome as a sequela of diarrhoeal disease.

Haemolytic-uraemic syndrome (HUS) is a serious sequela of diarrhoea and results in a high mortality rate. This systematic review aimed at estimating the proportion of HUS cases that are linked to prior infection due to Shiga toxin-producing Escherichia coli (STEC) or Shigella dysenteriae type 1. A systematic review of the existing literature was done to identify cohort and case-control studies that examined the relationship between STEC and S. dysenteriae type 1 and HUS. After screening 2,516 articles, 11 studies were found that met the inclusion/exclusion criteria. Findings of case-control studies suggest that 60.8% of the HUS cases may be attributable to a previous infection with STEC. In cohort studies, 7.8% of participants with STEC and 8% of participants with S. dysenteriae type 1 developed HUS during follow-up. HUS is linked to diarrhoea due to both STEC and S. dysenteriae type 1. Thus, preventing infections caused by both pathogens is critical for the prevention and control of HUS, especially in areas where timely and effective treatment is not available.

Quantifying the association between Campylobacter infection and Guillain-Barré syndrome: a systematic review.

Guillain-Barré Syndrome (GBS) is a neurologic disease that causes ascending paralysis and is triggered by a preceding bacterial or viral infection. Several studies have shown that patients with GBS have a recent history of infection due to Campylobacter jejuni. A literature review of published studies that reported rates of Campylobacter infection before or in conjunction with GBS was done. These reported data were used for calculating the proportion of GBS cases who tested positive for Campylobacter compared to the control population and the incidence of GBS among patients infected with Campylobacter. Results of the analysis suggest that 31% of 2,502 GBS cases included in these papers are attributable to Campylobacter infection.

Variation in clinical presentation of childhood group A streptococcal pharyngitis in four countries.

We conducted a cross-sectional study from September 2001 to August 2003 during which children between 2 and 12 years of age presenting with complaint of sore throat were recruited from urban pediatric clinics in Brazil, Croatia, Egypt and Latvia. The objective of the study was to compare clinical signs and symptoms of children presenting to urban pediatric clinics with sore throat in and between countries and to identify common clinical criteria predicting group A beta hemolytic streptococcal (GAS) pharyngitis. Using a single standard protocol in all four sites, clinical data were recorded and throat swabs obtained for standard GAS culture in 2040 children. Signs and symptoms were tested for statistical association with GAS positive/negative pharyngitis, and were compared using chi(2) tests, ANOVA and Odds Ratios. Clinical signs of GAS pharyngitis in children presenting to clinics varied significantly between countries, and there were few signs or symptom that could statistically be associated with GAS pharyngitis in all four countries, though several were useful in two or three countries. Our results indicate that the clinical manifestations of pharyngitis in clinics may vary by region. It is therefore critical that clinical decision rules for management of pharyngitis should have local validation.

Zinc during and in convalescence from diarrhea has no demonstrable effect on subsequent morbidity and anthropometric status among infants <6 mo of age.

BACKGROUND: Preventing illness and improving growth in the first 6 mo of life is critical to reducing infant mortality. Zinc given for 14 d at the start of diarrhea has been shown to decrease the incidence and prevalence of diarrhea and pneumonia and improve growth in the 2-3 mo after, but no trial has been done in infants <6 mo of age. OBJECTIVE: This study sought to assess the effect of 14 d of zinc supplementation on subsequent morbidity and growth among infants 1-5 mo of age living in Pakistan, India, and Ethiopia. DESIGN: Infants with acute diarrhea were randomly assigned to receive zinc (10 mg/d; n = 538) or placebo (n = 536) for 2 wk. Weekly follow-up visits were conducted for 8 wk after the diarrhea episode. Incidence and prevalence of diarrhea and prevalence of respiratory infections including pneumonia were compared between the groups. Changes in weight, length, and corresponding z scores during the 8 wk of follow-up were also compared. RESULTS: One thousand seventy-four infants were enrolled at the start of follow-up. The groups did not differ significantly in the proportion of infants with at least one episode of diarrhea or respiratory infections. Infants who received zinc had more days of diarrhea (rate ratio = 1.20) than did the infants who received placebo. The groups had similar prevalences of pneumonia and overall respiratory infections. No significant differences in the mean changes in weight-for-age, length-for-age, and weight-for-length z scores were observed between the groups overall or in stratified analyses. CONCLUSION: Young infants do not appear to benefit from 2 wk of zinc, unlike what has been observed among older children.

A Systematic Review of the Effect of Rotavirus Vaccination on Diarrhea Outcomes Among Children Younger Than 5 Years.

BACKGROUND: Rotavirus is the leading cause of vaccine-preventable diarrhea among children under 5 globally. Rotavirus vaccination has been shown to prevent severe rotavirus infections with varying efficacy and effectiveness by region. METHODS: We sought to generate updated region-specific estimates of rotavirus vaccine efficacy and effectiveness. We systematically reviewed published vaccine efficacy and effectiveness studies to assess the region-specific effect of rotavirus vaccination on select diarrheal morbidity and mortality outcomes in children under 5 years of age. We employed meta-analytic methods to generate pooled effect sizes by Millennium Development Goal region. RESULTS: Rotavirus vaccination was both efficacious and effective in preventing rotavirus diarrhea, severe rotavirus diarrhea and rotavirus hospitalizations among children under 5 across all regions represented by the 48 included studies. Efficacy against severe rotavirus diarrhea ranged from 90.6% [95% confidence interval (CI): 82.3-95.0] in the developed region to 88.4% (95% CI: 67.1-95.9) in Eastern/Southeastern Asia, 79.6% (95% CI: 71.3-85.5) in Latin America and the Caribbean, 50.0% (95% CI: 34.4-61.9) in Southern Asia and 46.1% (95% CI: 29.1-59.1) in sub-Saharan Africa. Region-specific effectiveness followed a similar pattern. There was also evidence of vaccine efficacy against severe diarrhea and diarrheal hospitalizations. CONCLUSION: Our findings confirm the protective efficacy and effectiveness of rotavirus vaccination against rotavirus diarrheal outcomes among children under 5 globally.

An external evaluation of the Diarrhea Alleviation through Zinc and ORS Treatment (DAZT) program in Gujarat and Uttar Pradesh, India.

BACKGROUND: To address inadequate coverage of oral rehydration salts (ORS) and zinc supplements for the treatment of diarrhea among children under-five, the Diarrhea Alleviation through Zinc and ORS Treatment (DAZT) program was carried out from 2011-2013 in Gujarat and from 2011-2014 in Uttar Pradesh (UP), India. The program focused on improving the diarrhea treatment practices of public and private sector providers. METHODS: We conducted cross-sectional household surveys in program districts at baseline and endline and constructed state-specific logistic regression models with generalized estimating equations to assess changes in ORS and zinc treatment during the program period. RESULTS: Between baseline and endline, zinc coverage increased from 2.5% to 22.4% in Gujarat and from 3.1% to 7.0% in UP; ORS coverage increased from 15.3% to 39.6% in Gujarat but did not change in UP. In comparison to baseline, children with diarrhea in the two-weeks preceding the endline survey had higher odds of receiving zinc treatment in both Gujarat (odds ratio, OR = 11.2; 95% confidence interval (CI) 6.4-19.3) and UP (OR = 2.4; 95% CI 1.4-3.9), but the odds of receiving ORS only increased in Gujarat (OR = 3.6; 95% CI 2.7-4.8; UP OR = 0.9; 95% CI 0.7-1.2). Seeking care outside the home, especially from a public sector source, was associated with higher odds of receiving ORS and zinc. CONCLUSIONS: During the duration of the DAZT program, there were modest improvements in the treatment of diarrhea among young children. Future programs should build upon and accelerate this trend with continued investment in public and private sector provider training and supply chain sustainability, in addition to targeted caregiver demand generation activities.

Adherence to zinc supplementation guidelines for the treatment of diarrhea among children under-five in Uttar Pradesh, India.

BACKGROUND: There is limited evidence on adherence to the recommended dose and duration of zinc supplementation for diarrheal episodes in children under five years of age. In selected districts of Uttar Pradesh, India, we sought to assess adherence to the nationally advised zinc treatment regimen (ie, 10 mg/day for ages 2-6 months and 20 mg/day for ages 7-59 months for 14 days) among caregivers of zinc-prescribed children. METHODS: We identified and conducted follow-up visits to children advised zinc for the treatment of diarrhea. At the initial visit, we collected data on the treatment instructions received from providers. Caregivers were asked to record treatments administered on a pictorial tracking form and were asked to retain all packaging for collection at follow-up. We quantified the average dose and duration of zinc therapy and built logistic regression models to assess the factors associated with caregiver adherence to national guidelines. RESULTS: Caregivers administered zinc for an average of 10.7 days (standard deviation (SD) = 3.9 days; median = 13 days), and 47.8% continued treatment for the complete 14 days. Among children receiving zinc syrups and tablets respectively, the age appropriate dose was received by 30.8% and 67.3%. Adherence to age appropriate dose and continuation of zinc for 14 days were highly associated with having received appropriate provider instructions. CONCLUSIONS: Our results indicate moderate-to-good adherence to national zinc treatment guidelines for diarrhea among caregivers in rural India. Our findings also highlight the importance of provider guidance in ensuring adherence to zinc dose and duration. Programs aiming to scale-up zinc treatment for childhood diarrhea should train providers to successfully communicate dosing instructions to caregivers, while also addressing the tendency of caregivers to terminate treatment once a child appears to have recovered from an acute diarrheal episode.

Appropriate Management of Acute Diarrhea in Children Among Public and Private Providers in Gujarat, India: A Cross-Sectional Survey.

Diarrhea remains a leading cause of morbidity and mortality among children under 5 years of age in low- and middle-income countries. In 2006, the Indian government formally endorsed the World Health Organization guidelines that introduced zinc supplementation and low-osmolarity oral rehydration salts (ORS) for the treatment of diarrhea. Despite this, zinc is rarely prescribed and has not been available in the public sector in India until very recently. The Diarrhea Alleviation Through Zinc and ORS Treatment (DAZT) project was implemented in Gujarat between 2011 and 2013 to accelerate the uptake of zinc and ORS among public and private providers in 6 rural districts. As part of an external evaluation of DAZT, we interviewed 619 randomly selected facility- and community-based public and private providers 2-3 months after a 1-day training event had been completed (or, in the case of private providers, after at least 1 drug-detailing visit by a pharmaceutical representative had occurred) and supplies were in place. The purpose of the interviews was to assess providers' knowledge of appropriate treatment for diarrhea in children, reported treatment practices, and availability of drugs in stock. More than 80% of all providers interviewed reported they had received training or a drug-detailing visit on diarrheal treatment in the past 6 months. Most providers in all cadres (range, 68% to 100%) correctly described how to prepare ORS and nearly all (range, 90% to 100%) reported routinely prescribing it to treat diarrhea in children. Reported routine prescription of zinc was lower, ranging from 62% among private providers to 96% among auxiliary nurse-midwives. Among providers who reported ever not recommending zinc (n = 242), the 2 most frequently reported reasons for not doing so were not completely understanding zinc for diarrhea treatment and not having zinc in stock at the time of contact with the patient. In a multiple logistic regression analysis, recent training or drug-detailing visits and having zinc in stock were associated with reported zinc prescribing (P<.05). Recent training among public providers was significantly associated with having correct knowledge of zinc treatment duration and dosage, but the same was not true of drug-detailing visits among private providers. Treating diarrhea with zinc and low-osmolarity ORS is new for public and private providers in India and other low- and middle-income countries. Sufficient training and logistics support to ensure consistent supplies are critical if providers are to begin routinely treating all diarrhea episodes with zinc and ORS.

Public sector scale-up of zinc and ORS improves coverage in selected districts in Bihar, India.

BACKGROUND: In Bihar, India, a new initiative to enhance diarrhea treatment with zinc and ORS in the public sector was rolled out in selected districts. We conducted an external evaluation to measure changes in diarrhea careseeking and treatment in intervention districts. METHODS: We conducted baseline and endline household surveys among caregivers of children 2-59 months of age. We calculated summary statistics for household characteristics, knowledge, careseeking and treatments given to children with a diarrhea episode in the last 14 days and built logistic regression models to compare baseline and endline values. RESULTS: Caregivers named a public health center as an appropriate source of care for childhood diarrhea more often at endline (71.3%) compared to baseline (38.4%) but did not report increased careseeking to public sector providers for the current diarrhea episode. In logistic regression analyses, the odds of receiving zinc, with or without oral rehydration salts (ORS), increased at endline by more than 2.7 as compared to baseline. Children who were taken to the public sector for care were more likely to receive zinc (odds ratio, OR = 3.93) and zinc in addition to ORS (OR = 6.10) compared to children who were not taken to the public sector. CONCLUSION: Coverage of zinc and ORS can improve with public sector programs targeted at training and increasing product availability, but demand creation may be needed to increase public sector careseeking in areas where the private sector has historically provided much of the care.

Protocol for the economic evaluation of the diarrhea alleviation through zinc and oral rehydration salt therapy at scale through private and public providers in rural Gujarat and Uttar Pradesh, India.

BACKGROUND: Child diarrhea persists as a leading public health problem in India despite evidence supporting zinc and low osmolarity oral rehydration salts as effective treatments. Across 2 years in 2010-2013, the Diarrhea Alleviation using Zinc and Oral Rehydration Salts Therapy (DAZT) program was implemented to operationalize delivery of these interventions at scale through private and public sector providers in rural Gujarat and Uttar Pradesh, India. METHODS/DESIGN: This study evaluates the cost-effectiveness of DAZT program activities relative to status quo conditions existing before the study, comparing a Monte Carlo simulation method with net-benefit regression, discussing the strengths and weaknesses of each approach. A control group was not included in the 'before and after' study design as zinc has proven effectiveness for diarrhea treatment. Costs will be calculated using a societal perspective including program implementation and household out-of-pocket payments for care seeking, as well as estimates of wages lost. Outcomes will be measured in terms of episodes averted in net-benefit regression and in terms of the years of life lost component of disability-adjusted life years in the method based on Monte Carlo simulation. The Lives Saved Tool will be used to model anticipated changes in mortality over time and deaths averted based on incremental changes in coverage of oral rehydration salts and zinc. Data will derive from cross-sectional surveys at the start, midpoint, and endpoint of the program. In addition, Lives Saved Tool (LiST) projections will be used to define the reference case value for the ceiling ratio in terms of natural units. DISCUSSION: This study will be useful both in its application to an economic evaluation of a public health program in its implementation phase but also in its comparison of two methodological approaches to cost-effectiveness analysis. Both policy recommendations and methodological lessons learned will be discussed, recognizing the limitations in drawing strong policy conclusions due to the uncontrolled study design. It is expected that this protocol will be useful to researchers planning what method to use for the evaluation of similar before and after studies.

Diarrhea as a risk factor for acute lower respiratory tract infections among young children in low income settings.

BACKGROUND: Diarrhea and acute lower respiratory tract infections (ALRI) are leading causes of morbidity and mortality among children under 5 years of age. We sought to quantify the correlation of diarrhea and respiratory infections within an individual child and to determine if infection with one illness increases the risk of infection with the other during the same time period. METHODS: We quantified the likelihood of an ALRI and a diarrhea episode occurring during the same week compared to the likelihood of each occurring independently in two cohorts of children under 3 years of age using a bivariate probit regression model. We also quantified the likelihood of an ALRI episode conditioned on a child's diarrhea history and the likelihood of a diarrhea episode conditioned on a child's ALRI history using Cox Proportional Hazard models. RESULTS: In Indian and Nepali children, diarrhea and ALRI occurred simultaneously more than chance alone. Incidence of ALRI increased in both cohorts as the number of days with diarrhea in the prior 28 days increased; the greatest incident rate ratio was reported among children with 20 or more days of diarrhea (1.02, 95% confidence interval (CI) 1.01 - 1.03 in Nepal and 1.07, 95% CI 1.05 - 1.09 in South India). Incidence of diarrhea was affected differently by ALRI prevalence depending on season. CONCLUSIONS: Diarrhea may be a direct risk factor for ALRI among children under 3 years of age. The risk of comorbidity increases as disease severity increases, providing additional rationale for prompt community case-management of both diarrhea and pneumonia.

Oral zinc supplementation for the treatment of acute diarrhea in children: a systematic review and meta-analysis.

Evidence supporting the impact of therapeutic zinc supplementation on the duration and severity of diarrhea among children under five is largely derived from studies conducted in South Asia. China experiences a substantial portion of the global burden of diarrhea, but the impact of zinc treatment among children under five has not been well documented by previously published systematic reviews on the topic. We therefore conducted a systematic literature review, which included an exhaustive search of the Chinese literature, in an effort to update previously published estimates of the effect of therapeutic zinc. We conducted systematic literature searches in various databases, including the China National Knowledge Infrastructure (CNKI), and abstracted relevant data from studies meeting our inclusion and exclusion criteria. We used STATA 12.0 to pool select outcomes and to generate estimates of percentage difference and relative risk comparing outcomes between zinc and control groups. We identified 89 Chinese and 15 non-Chinese studies for the review, including studies in 10 countries from all WHO geographic regions, and analyzed a total of 18,822 diarrhea cases (9469 zinc and 9353 control). None of the included Chinese studies had previously been included in published pooled effect estimates. Chinese and non-Chinese studies reported the effect of therapeutic zinc supplementation on decreased episode duration, stool output, stool frequency, hospitalization duration and proportion of episodes lasting beyond three and seven days. Pooling Chinese and non-Chinese studies yielded an overall 26% (95% CI: 20%-32%) reduction in the estimated relative risk of diarrhea lasting beyond three days among zinc-treated children. Studies conducted in and outside China report reductions in morbidity as a result of oral therapeutic zinc supplementation for acute diarrhea among children under five years of age. The WHO recommendation for zinc treatment of diarrhea episodes should be supported in all low- and middle-income countries.

Typhoid fever and paratyphoid fever: Systematic review to estimate global morbidity and mortality for 2010.

BACKGROUND: Typhoid and paratyphoid fever remain important causes of morbidity worldwide. Accurate disease burden estimates are needed to guide policy decisions and prevention and control strategies. METHODS: We conducted a systematic literature review of the PubMed and Scopus databases using pre-defined criteria to identify population-based studies with typhoid fever incidence data published between 1980 and 2009. We also abstracted data from annual reports of notifiable diseases in countries with advanced surveillance systems. Typhoid and paratyphoid fever input data were grouped into regions and regional incidence and mortality rates were estimated. Incidence data were extrapolated across regions for those lacking data. Age-specific incidence rates were derived for regions where age-specific data were available. Crude and adjusted estimates of the global typhoid fever burden were calculated. RESULTS: Twenty-five studies were identified, all of which contained incidence data on typhoid fever and 12 on paratyphoid fever. Five advanced surveillance systems contributed data on typhoid fever; 2 on paratyphoid fever. Regional typhoid fever incidence rates ranged from <0.1/100 000 cases/y in Central and Eastern Europe and Central Asia to 724.6/100 000 cases/y in Sub-Saharan Africa. Regional paratyphoid incidence rates ranged from 0.8/100 000 cases/y in North Africa/Middle East to 77.4/100 000 cases/y in Sub-Saharan Africa and South Asia. The estimated total number of typhoid fever episodes in 2010 was 13.5 million (interquartile range 9.1-17.8 million). The adjusted estimate accounting for the low sensitivity of blood cultures for isolation of the bacteria was 26.9 million (interquartile range 18.3-35.7 million) episodes. These findings are comparable to the most recent analysis of global typhoid fever morbidity, which reported crude and adjusted estimates of 10.8 million and 21.7 million typhoid fever episodes globally in 2000. CONCLUSION: Typhoid fever remains a significant health burden, especially in low- and middle-income countries. Despite the availability of more recent data on both enteric fevers, additional research is needed in many regions, particularly Africa, Latin America and other developing countries.

Estimating diarrhea mortality among young children in low and middle income countries.

BACKGROUND: Diarrhea remains one of the leading causes of morbidity and mortality among children under 5 years of age, but in many low and middle-income countries where vital registration data are lacking, updated estimates with regard to the proportion of deaths attributable to diarrhea are needed. METHODS: We conducted a systematic literature review to identify studies reporting diarrhea proportionate mortality for children 1-59 mo of age published between 1980 and 2009. Using the published proportionate mortality estimates and country level covariates we constructed a logistic regression model to estimate country and regional level proportionate mortality and estimated uncertainty bounds using Monte-Carlo simulations. FINDINGS: We identified more than 90 verbal autopsy studies from around the world to contribute data to a single-cause model. We estimated diarrhea proportionate mortality for 84 countries in 6 regions and found diarrhea to account for between 10.0% of deaths in the Americas to 31.3% of deaths in the South-east Asian region. DISCUSSION: Diarrhea remains a leading cause of death for children 1-59 mo of age. Published literature can be used to create a single-cause mortality disease model to estimate mortality for countries lacking vital registration data.

Zinc for the treatment of diarrhoea: effect on diarrhoea morbidity, mortality and incidence of future episodes.

BACKGROUND: Zinc supplementation for the treatment of diarrhoea has been shown to decrease the duration and severity of the diarrhoeal episode, diarrhoea hospitalization rates and, in some studies, all-cause mortality. Using multiple outcome measures, we sought to estimate the effect of zinc for the treatment of diarrhoea on diarrhoea mortality and subsequent pneumonia mortality. METHODS: We conducted a systematic review of efficacy and effectiveness studies. We used a standardized abstraction and grading format and performed meta-analyses for all outcomes with >or=2 data points. The estimated effect on diarrhoea mortality was determined by applying the standard Child Health Epidemiology Reference Group rules for multiple outcomes. RESULTS: We identified 13 studies for abstraction. Zinc supplementation decreased the proportion of diarrhoeal episodes which lasted beyond 7 days, risk of hospitalization, all-cause mortality and diarrhoea mortality. Using diarrhoea hospitalizations as the closest and most conservative possible proxy for diarrhoea mortality, zinc for the treatment of diarrhoea is estimated to decrease diarrhoea mortality by 23%. CONCLUSION: Zinc is an effective therapy for diarrhoea and will decrease diarrhoea morbidity and mortality when introduced and scaled-up in low-income countries.

The effect of rotavirus vaccine on diarrhoea mortality.

BACKGROUND: Approximately 39% of the global diarrhoea deaths in children aged 5 years may be attributable to rotavirus infection. Two rotavirus vaccines were recently introduced to the market, with evidence of efficacy in the USA, Europe and Latin America. We sought to estimate the effectiveness of these vaccines against rotavirus morbidity and mortality. METHODS: We conducted a systematic review of published efficacy and effectiveness trials of rotavirus vaccines. Study descriptors and outcome measures were abstracted into standardized tables and the quality of each study was graded. We performed meta-analyses for any outcome with two or more data points, and used child health epidemiology reference group (CHERG) Rules for Evidence Review to estimate the effect of the vaccine on rotavirus mortality. RESULTS: We identified six papers for abstraction, reporting results from four studies. No studies reported diarrhoea or rotavirus deaths, but all studies showed reductions in hospitalizations due to rotavirus or diarrhoea of any aetiology, severe and any rotavirus infections and diarrhoea episodes of any aetiology in children who received rotavirus vaccine compared with placebo. Effectiveness against very severe rotavirus infection best approximated effectiveness against the fraction of diarrhoea deaths attributable to rotavirus, and was estimated to be 74% (95% confidence interval: 35-90%). CONCLUSIONS: Rotavirus vaccines are efficacious against rotavirus morbidity and mortality and have the potential to substantially reduce child mortality in low-income countries if implemented appropriately.

Antibiotics for the treatment of dysentery in children.

BACKGROUND: Ciprofloxacin, ceftriaxone and pivmecillinam are the antibiotics currently recommended by the World Health Organization (WHO) for the treatment of dysentery in children; yet there have been no reviews of the clinical effectiveness of these antibiotics in recent years. METHODS: We reviewed all literature reporting the effect of ciprofloxacin, ceftriaxone and pivmecillinam for the treatment of dysentery in children in the developing countries. We used a standardized abstraction and grading format and performed meta-analyses to determine the effect of treatment with these antibiotics on rates of treatment failure, bacteriological failure and bacteriological relapse. The CHERG Standard Rules were applied to determine the final effect of treatment with these antibiotics on diarrhoea mortality. RESULTS: Eight papers were selected for abstraction. Treatment with ciprofloxacin, ceftriaxone or pivmecillinam resulted in a cure rate of >99% while assessing clinical failure, bacteriological failure and bacteriological relapse. CONCLUSIONS: The antibiotics recommended by the WHO--ciprofloxacin, ceftriaxone and pivmecillinam--are effective in reducing the clinical and bacteriological signs and symptoms of dysentery and thus can be expected to decrease diarrhoea mortality attributable to dysentery.