Can drinking water, sanitation, handwashing, and nutritional interventions reduce antibiotic use in young children?

Frequent antibiotic use in areas with high infection burdens can lead to antimicrobial resistance and microbiome alterations. Reducing pathogen exposure and child undernutrition can reduce infections and subsequent antibiotic use. We assessed effects of water, sanitation, handwashing (WSH) and nutrition interventions on pediatric antibiotic use in Bangladesh and Kenya, using longitudinal data from birth cohorts (at ages 3-28 months) enrolled in the WASH Benefits cluster-randomized trials. Over 50% of children used antibiotics at least once in the last 90 days. In Bangladesh, the prevalence of using antibiotics at least once was 10-14% lower in groups receiving WSH (prevalence ratio [PR]=0.90 (0.82-0.99)), nutrition (PR=0.86 (0.78-0.94)), and nutrition+WSH (PR=0.86 (0.79-0.93)) interventions. The prevalence of using antibiotics multiple times was 24-35% lower in intervention arms. Intervention effects were strongest when the birth cohort was younger. In Kenya, interventions did not affect antibiotic use. Improving WSH and nutrition can reduce antibiotic use in some low- and middle-income settings. Studies should assess whether such reductions translate to reduced carriage of antimicrobial resistance. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial NCT01590095, [NCT01704105][1] ### Clinical Protocols ### Funding Statement This research was financially supported by a global development grant (OPPGD759) from the Bill & Melinda Gates Foundation to the University of California, Berkeley, CA, USA. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study protocol was approved by human subjects committees at the International Centre for Diarrhoeal Disease Research, Bangladesh (PR11063), Kenya Medical Research Institute (SSC-2271), University of California, Berkeley (2011-09-3652), and Stanford University (25863). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Upon publication, all data will be available on Open Science Framework at https://osf.io/t7fmw/ [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01704105&atom=%2Fmedrxiv%2Fearly%2F2024%2F05%2F10%2F2024.05.10.24307069.atom