{"doi":"10.1101/2021.07.31.21261145","title":"External Validation of a Mobile Clinical Decision Support System for Diarrhea Etiology Prediction in Children: A Multicenter Study in Bangladesh and Mali","abstract":"Abstract Background Diarrheal illness is a leading cause of antibiotic use for children in low- and middle-income countries. Determination of diarrhea etiology at the point-of-care without reliance on laboratory testing has the potential to reduce inappropriate antibiotic use. Methods This prospective observational study aimed to develop and externally validate the accuracy of a mobile software application (“App”) for the prediction of viral-only etiology of acute diarrhea in children 0-59 months in Bangladesh and Mali. The App used previously derived and internally validated models using combinations of “patient-intrinsic” information (age, blood in stool, vomiting, breastfeeding status, and mid-upper arm circumference), pre-test odds using location-specific historical prevalence and recent patients, climate, and viral seasonality. Diarrhea etiology was determined with TaqMan Array Card using episode-specific attributable fraction (AFe) >0.5. Results Of 302 children with acute diarrhea enrolled, 199 had etiologies above the AFe threshold. Viral-only pathogens were detected in 22% of patients in Mali and 63% in Bangladesh. Rotavirus was the most common pathogen detected (16% Mali; 60% Bangladesh). The viral seasonality model had an AUC of 0.754 (0.665-0.843) for the sites combined, with calibration-in-the-large α=-0.393 (−0.455 – -0.331) and calibration slope β=1.287 (1.207 – 1.367). By site, the pre-test odds model performed best in Mali with an AUC of 0.783 (0.705 - 0.86); the viral seasonality model performed best in Bangladesh with AUC 0.710 (0.595 - 0.825). Conclusion The App accurately identified children with high likelihood of viral-only diarrhea etiology. Further studies to evaluate the App’s potential use in diagnostic and antimicrobial stewardship are underway.","journal":"medRxiv","year":2021,"id":221346,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":1,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9419,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2021-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":280903,"name":"Eric J. Nelson","orcid":"0000-0003-2649-2624","position":1,"is_corresponding":false},{"id":713144,"name":"Sabiha Nasrin","orcid":"0000-0001-9618-7081","position":2,"is_corresponding":false},{"id":585554,"name":"Adama Mamby Keita","orcid":"0000-0002-0315-0632","position":3,"is_corresponding":false},{"id":455317,"name":"Ben J. Brintz","orcid":"0000-0003-4695-0290","position":4,"is_corresponding":false},{"id":713143,"name":"Monique Gainey","orcid":"0000-0002-2860-9104","position":5,"is_corresponding":false},{"id":821364,"name":"Henry Badji","orcid":"0000-0003-3681-5976","position":6,"is_corresponding":false},{"id":821941,"name":"Dilruba Nasrin","orcid":null,"position":7,"is_corresponding":false},{"id":487623,"name":"Joel Howard","orcid":null,"position":8,"is_corresponding":false},{"id":330180,"name":"Mami Taniuchi","orcid":null,"position":9,"is_corresponding":false},{"id":289244,"name":"James A Platts-Mills","orcid":"0000-0002-4956-0418","position":10,"is_corresponding":false},{"id":242121,"name":"Karen L. Kotloff","orcid":"0000-0003-1808-6431","position":11,"is_corresponding":false},{"id":289251,"name":"Rashidul Haque","orcid":"0000-0001-5100-136X","position":12,"is_corresponding":false},{"id":374570,"name":"Adam C. Levine","orcid":"0000-0003-3982-3824","position":13,"is_corresponding":false},{"id":299788,"name":"Samba O. Sow","orcid":"0000-0002-6335-5066","position":14,"is_corresponding":false},{"id":713146,"name":"Nur Alam","orcid":"0000-0002-7591-9033","position":15,"is_corresponding":false},{"id":352714,"name":"Daniel T. Leung","orcid":"0000-0001-8401-0801","position":16,"is_corresponding":false},{"id":436468,"name":"Stephanie C. Garbern","orcid":"0000-0002-0919-2841","position":0,"is_corresponding":true}],"reference_count":32,"raw_metadata":null,"created_at":"2026-07-18T23:53:55.215284Z","pmid":null,"pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}