Shigellosis remains underdiagnosed due to the lack of rapid, reliable diagnostics. Although Shigella spp. is known for causing dysentery, over 50% of Shigella -associated cases are watery diarrhea. Identifying and treating these cases of watery diarrhea caused by Shigella could be lifesaving, which would require a point-of-care (POC) Shigella test. Evidence-based treatment could also reduce the overuse of antibiotics. We evaluated the feasibility and applicability of the Rapid LAMP-based Diagnostic Test (RLDT) assay for detecting shigellosis in a healthcare facility. Stool samples (n=228) were collected from children seeking facility care during diarrhea and on their follow-up visits from an ongoing case-control study, INSIGHT. The stool samples were tested by the INSIGHT lab personnel using the RLDT for Shigella spp. The lab personnel at a rural primary healthcare facility, Mirzapur Upazila Health Complex (MUHC) in Bangladesh, received training in RLDT and retested the stool samples with RLDT at the MUHC; the results were compared. The acceptance of RLDT at MUHC was also evaluated through questionnaires. After training, the MUHC lab personnel independently performed RLDT. The RLDT tests performed by the MUHC showed sensitivity of 98% and specificity of 99%, with an almost perfect agreement (Kappa = 0.96) compared with the pre-tested RLDT results. The RLDT assay was well received by the MUHC, despite the general challenges of limited manpower and resources at rural health care facilities. This study demonstrates the potential of using RLDT as a POC test in Shigella -endemic countries to support evidence-based treatment, saving lives and reducing inappropriate antibiotic use. Keypoints: RLDT, as a simple and accurate diagnostic tool, offers a practical solution for Shigella detection in low-resource settings. Scaling up RLDT will empower health systems by enabling timely diagnoses to guide treatment and reduce antimicrobial resistance.

Background: Antimicrobial resistance, driven by inappropriate use and overuse of antibiotics, is a major public health threat. Diarrhea and respiratory illness are the leading causes of pediatric healthcare visits in low- and middle-income countries like Bangladesh. Despite clear WHO guidelines recommending limited use of antibiotics for these conditions, potentially inappropriate or non-prescription antibiotic use remains a concern. Methods: We interviewed caregivers of 3025 under-5 children via cellphones to assess common illnesses, associated care-seeking practices, and antibiotic use for diarrhea and respiratory illnesses experienced by their children in the prior 14 days. Caregivers were identified through hospital outpatient screening and were contacted over the phone for the interview at least two months after that hospital visit. Results: Among the participants, 116 (3.8%) reported diarrheal disease and 570 (18.8%) experienced respiratory illness during the preceding 2-week recall period. Among the children with diarrhea, 52.6% received antibiotics, and 73.8% obtained them over the counter from pharmacies. Among those with respiratory illness, 26.3% received antibiotics, and 58% procured them from local drugstores without a prescription from a registered physician. For diarrhea, azithromycin and metronidazole were the commonly used antibiotics, while for respiratory illness, cefixime and azithromycin were frequently used. Notably, 68% of the diarrheal children either sought care from local drugstores, were self-medicated, or did not receive any formal treatment. Conventional practice, long wait times at healthcare facilities, distance, and poverty were the main reasons for not seeking care from a registered healthcare provider. Conclusions: Understanding community-level antibiotic use and care-seeking behavior is essential to strengthening antibiotic stewardship and child health programs. Our findings suggest the need for context-sensitive community education, improved access to appropriate care, and enforcement of regulations restricting the over-the-counter sale of antibiotics to curb irrational and excessive antibiotic use.

Background: Misuse and overuse of antibiotics in childhood diarrhea pose a high risk of antimicrobial resistance (AMR), which is a public health threat globally, and Bangladesh is no exception. This study aims to describe urban-rural differences and determine the factors associated with antibiotic use at home in children before seeking care for diar-rhea at the health care facilities. Methods: This cross-sectional study, over an 18-month period, included 5,894 children aged 1-59 months from two large health facilities: a rural secondary-level district hospital, located in Tangail, and an urban diarrhea specialized facility, icddr,b Dhaka hospital. Following clinical care, trained staff used a pre-validated structured questionnaire to collect data on child demographics, clinical symptoms, feeding practices, and treatment received prior to hospital visit. The primary outcome was antibiotic use at home before hospital presentation. Multivariable logistic regression models analyzed factors linked to home antibiotic use. Results: The preva-lence of antibiotic use at home before seeking care among diarrheal children was sig-nificantly higher in children visiting a rural facility as compared to that of the urban facility (90.0% vs. 68.4%). Pharmacies were the primary source of antibiotics for children in both rural and urban areas (64.1% vs. 61.2%). Multivariable analysis showed that in urban settings, children with diarrhea for 1-3 days were more than twice as likely (aOR:2.39, 95% CI:1.66.4), and those sick for 4 or more days were three times as likely (aOR:3.09, 95% CI: 2.21–4.43) to receive antibiotics at home compared to children who had less than one day of diarrhea. Children with no history of a prior hospital visit for diarrhea were also 1.86 times at higher risk of using antibiotics (aOR: 1.86, 95% CI:1.28–2.72). In a rural setting, children with diarrhea for 1–3 days had five times (aOR:5.11, 95% CI: 3.6–7.1), and those who had diarrhea for 4 days or more had two times higher odds (aOR: 1.97, 95% CI: 1.43–2.73) for antibiotic use. Moreover, children whose caregivers used ORS were 2.8 times more likely to use antibiotics at home (aOR:2.80, 95% CI: 1.06-7.35). Conclusions: This study demonstrates that antibiotic use at home before seeking care is alarmingly high among children with diarrhea in Bangladesh, particu-larly in rural settings, driven by informal pharmacy access and symp-tom-duration-driven decision-making in urban areas. This emphasizes the need to en-hance awareness in both sectors of the public and healthcare providers. Moreover, im-plementing and monitoring strict regulations for antibiotic sales over-the-counter in pharmacies is essential to impede escalating trends of AMR in Bangladesh.

Background: Antimicrobial resistance, driven by inappropriate and overuse of antibiotics, is a major public health threat. Diarrhea and respiratory illness are the leading causes of pediatric healthcare visits in low- and middle-income countries like Bangladesh. Despite clear WHO guidelines recommending limited use of antibiotics for these conditions, misuse is widespread. Methods: We interviewed caregivers of 3025 under-5 children via cellphones to assess common illnesses, associated care-seeking practices, and antibiotic use for diarrhea and respiratory illnesses experienced by their children in prior 14 days. Results: Among the participants, 116 (8.83%) reported diarrheal disease and 570 (18.84%) experienced respiratory illness during the preceding 2-week recall period. Among the children with diarrhea, 52.59% received antibiotics, and 73.77% obtained them over-the-counter from pharmacies. Among those with respiratory illness, 26.32% received antibiotics, with 58% procured them from local drugstores without a prescription from a registered physician. For diarrhea, azithromycin and metronidazole were the commonly used antibiotics; while for respiratory illness cefixime and azithromycin were frequently used. Notably, 68% of the diarrheal children either sought care from local drugstores, self-medicated, or did not receive any formal treatment. Conventional practice, long wait times at healthcare facilities, distance, and poverty were the main reasons for not seeking care from a registered healthcare provider. Conclusion: Understanding community-level antibiotic use and care-seeking behavior is essential to strengthen antibiotic stewardship and child health programs. Our findings highlight the urgent need for community awareness and enforcement of regulations restricting the over-the-counter sale of antibiotics to curb irrational and excessive antibiotic use.

: The rapid loop-mediated isothermal amplification-based diagnostic test (RLDT) has been validated as a simple, sensitive, and rapid tool for detecting Shigella spp. from fresh or frozen stool. When stool is unavailable or difficult to transport, rectal swabs (RSs) in Cary–Blair medium, stool collected in buffered glycerol saline (BGS), or stool-dipped swabs (SDSs) in Cary–Blair medium offer alternatives that can be easily collected and transported without maintaining a cold chain. This study evaluated the performance of RLDTs for detecting Shigella spp. from RSs, stool collected in BGS, and SDSs compared with fresh stool (FS). Paired RSs and FS were collected from 105 children younger than 5 years old at two hospitals in Bangladesh. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were determined along with the agreement between assays using kappa statistics. The RLDTs detected Shigella in approximately 38–40% of samples across all sample types. Rectal swabs in Cary–Blair medium and SDS each showed 97.6% sensitivity and 100% specificity, with PPVs of 100% and NPVs of 98.5% (RSs) and 98.4% (SDSs) compared with FS; stool collected in BGS samples demonstrated the highest sensitivity (100%) and NPV (100%), with 98.4% specificity and 97.6% PPV. All alternative specimen types showed almost perfect agreement with FS. The RLDT performed well using RSs, indicating a practical alternative to stool for detecting Shigella . The assay was also reliable with stool collected in BGS and SDSs. Broader adoption of RLDTs could improve diagnostic capacity and strengthen surveillance and control efforts.