Anna T Nguyen, Gabby Barratt Heitmann, Andrew Mertens, Sania Ashraf, Md Ziaur Rahman, Shahjahan Ali, Mahbub Rahman, Benjamin F Arnold, Jessica A Grembi, Audrie Lin, Ayse Ercumen, Jade Benjamin-Chung
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Among a subsample of children within the WASH, nutrition, nutrition + WASH, and control arms (N = 1409 children; 267 clusters), we recorded caregiver-reported antibiotic use at ages 14 and 28 months and collected stool at age 14 months. Our primary outcome was any caregiver-reported antibiotic use by index children within the past 30 or 90 days measured at age 14 and 28 months. Mediators included caregiver-reported child diarrhea, acute respiratory infection (ARI), and fever; and enteric pathogen carriage in stool measured by qPCR. Both intervention-mediator and mediator-outcome models were controlled for mediator-outcome confounders.</p><p><strong>Findings: </strong>The receipt of any WASH or nutrition intervention reduced caregiver-reported antibiotic use through all pathways in the past month by 5.5 percentage points (95% CI 1.2, 9.9), from 49.5% (95% CI 45.9%, 53.0%) in the control group to 45.0% (95% CI 42.7%, 47.2%) in the pooled intervention group. When separating this effect into different pathways, we found that interventions reduced antibiotic use by 0.6 percentage points (95% CI 0.1, 1.3) through reduced diarrhea, 0.7 percentage points (95% CI 0.1, 1.5) through reduced ARI with fever, and 1.5 percentage points (95% CI 0.4, 3.0) through reduced prevalence of enteric viruses. Interventions reduced antibiotic use through any of these measured mediators by 2.1 percentage points (95% CI -0.3, 4.5).</p><p><strong>Interpretation: </strong>WASH and nutrition interventions reduced pediatric antibiotic use through the prevention of enteric and respiratory infections in a rural, low-income population. 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引用次数: 0
摘要
背景：低成本、家庭层面的水、环境卫生和个人卫生（WASH）和营养干预措施可以减少儿科抗生素的使用，但干预措施减少抗生素使用的机制尚未得到调查。方法：我们使用2013年9月至2015年10月收集的数据进行了因果中介分析，这些数据来自WASH Benefits孟加拉国集群随机试验（NCT01590095）中的队列。在WASH、营养组、营养+ WASH组和对照组的儿童子样本中(N = 1409名儿童；267组)，我们记录了护理人员在14个月和28个月时报告的抗生素使用情况，并在14个月时收集了粪便。我们的主要结局是在过去的30天或90天内，在14个月和28个月的时间里，任何看护人报告的指数儿童使用抗生素的情况。调节因子包括照顾者报告的儿童腹泻、急性呼吸道感染（ARI）和发烧；qPCR检测粪便中肠道病原菌携带情况。干预-中介和中介-结果模型均受中介-结果混杂因素控制。结果：在过去一个月里，接受任何WASH或营养干预使护理人员报告的所有途径的抗生素使用减少了5.5个百分点（95% CI 1.2, 9.9），从对照组的49.5% （95% CI 45.9%, 53.0%）降至联合干预组的45.0% （95% CI 42.7%, 47.2%）。当将这种影响分成不同的途径时，我们发现干预措施通过减少腹泻减少了抗生素使用0.6个百分点（95% CI 0.1, 1.3），通过减少伴有发烧的ARI减少了0.7个百分点（95% CI 0.1, 1.5），通过减少肠道病毒的流行减少了1.5个百分点（95% CI 0.4, 3.0）。干预措施通过任何这些测量介质减少了2.1个百分点的抗生素使用（95% CI -0.3, 4.5）。解释：在农村低收入人群中，WASH和营养干预通过预防肠道和呼吸道感染减少了儿科抗生素的使用。鉴于这些感染中许多是由病毒或寄生虫引起的，讲卫生运动和营养干预措施可能有助于减少在类似环境中不适当使用抗生素。资助：比尔和梅林达·盖茨基金会，国家过敏和传染病研究所。
Pathways through which water, sanitation, hygiene, and nutrition interventions reduce antibiotic use in young children: a mediation analysis of a cohort nested within a cluster-randomized trial.
Background: Low-cost, household-level water, sanitation, and hygiene (WASH) and nutrition interventions can reduce pediatric antibiotic use, but the mechanism through which interventions reduce antibiotic use has not been investigated.
Methods: We conducted a causal mediation analysis using data collected between September 2013 and October 2015 from a cohort nested within the WASH Benefits Bangladesh cluster-randomized trial (NCT01590095). Among a subsample of children within the WASH, nutrition, nutrition + WASH, and control arms (N = 1409 children; 267 clusters), we recorded caregiver-reported antibiotic use at ages 14 and 28 months and collected stool at age 14 months. Our primary outcome was any caregiver-reported antibiotic use by index children within the past 30 or 90 days measured at age 14 and 28 months. Mediators included caregiver-reported child diarrhea, acute respiratory infection (ARI), and fever; and enteric pathogen carriage in stool measured by qPCR. Both intervention-mediator and mediator-outcome models were controlled for mediator-outcome confounders.
Findings: The receipt of any WASH or nutrition intervention reduced caregiver-reported antibiotic use through all pathways in the past month by 5.5 percentage points (95% CI 1.2, 9.9), from 49.5% (95% CI 45.9%, 53.0%) in the control group to 45.0% (95% CI 42.7%, 47.2%) in the pooled intervention group. When separating this effect into different pathways, we found that interventions reduced antibiotic use by 0.6 percentage points (95% CI 0.1, 1.3) through reduced diarrhea, 0.7 percentage points (95% CI 0.1, 1.5) through reduced ARI with fever, and 1.5 percentage points (95% CI 0.4, 3.0) through reduced prevalence of enteric viruses. Interventions reduced antibiotic use through any of these measured mediators by 2.1 percentage points (95% CI -0.3, 4.5).
Interpretation: WASH and nutrition interventions reduced pediatric antibiotic use through the prevention of enteric and respiratory infections in a rural, low-income population. Given that many of these infections are caused by viruses or parasites, WASH and nutrition interventions may help reduce inappropriate antibiotic use in similar settings.
Funding: Bill & Melinda Gates Foundation, National Institute of Allergy and Infectious Diseases.
期刊介绍：
eClinicalMedicine is a gold open-access clinical journal designed to support frontline health professionals in addressing the complex and rapid health transitions affecting societies globally. The journal aims to assist practitioners in overcoming healthcare challenges across diverse communities, spanning diagnosis, treatment, prevention, and health promotion. Integrating disciplines from various specialties and life stages, it seeks to enhance health systems as fundamental institutions within societies. With a forward-thinking approach, eClinicalMedicine aims to redefine the future of healthcare.
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