Targeting community-level drivers of antimicrobial resistance in sub-Saharan Africa: the effect of a community-based intervention bundle on household transmission of extended spectrum beta-lactamase-producing E. coli in rural Burkina Faso - a cluster randomised trial

Preprint

Background 
In sub-Saharan Africa (sSA), invasive antimicrobial-resistant infections often originate from community-level acquisition. We assessed whether a behavioural intervention bundle targeting sub-optimal antibiotic use and hygiene practices reduced household-level acquisition of extended-spectrum beta-lactamase–producing E. coli (ESBL-E).

Methods 
We conducted a cluster-randomised controlled trial in 22 village clusters in Nanoro district, Burkina Faso. We enrolled 12 randomly selected households per cluster to assess intervention impact on ESBL-E household-transmission. The intervention comprised three rounds at three-month intervals and combined WHO AWaRe–based educational feedback for formal and informal medicine providers with a community-wide WASH and antibiotic-use behaviour change campaign. Consenting household members provided stool samples before, during, and after intervention rollout, alongside a pre–post household WASH survey. We estimated intervention effects on ESBL-E acquisition using Bayesian Markov models. Cox frailty models assessed associations between WASH exposures and acquisition. ClinicalTrials.gov, NCT05378880.

Findings 
Between Oct 11, 2022, and Feb 19, 2024, 1203 individuals were enrolled. At baseline, 57·3% (346/604) of control and 48·6% (291/599) of intervention household members were colonised. Pre-intervention acquisition incidence was 3·8 per 100 person-days (95% credible interval [CrI] 2·0–9·9) in the intervention group and 3·5 (95% CrI 1·8–9·6) in the control group. The intervention did not change the risk of ESBL-E acquisition in months 1–6 (hazard ratio [HR] 1·02, 95% CrI 0·78–1·31), while we estimated a reduction in ESBL-E acquisition from months 6–9 (HR 0·82, 95% CrI 0·56–1·14). Acquisition risk was higher in the rainy season (peak HR 1·73, 95% CI 1·49–2·00), while improved sanitation was associated with lower risk (HR 0·77, 95% CI 0·59–1·00).

Interpretation 
Findings, though inconclusive, were consistent with a modest intervention-related reduction in ESBL-E incidence. Higher acquisition rates associated with the rainy season and poor sanitation highlight the need to tackle environmental drivers of AMR transmission in addition to antibiotic use in rural sSA.

Funding 
JPI-AMR CABU EICO grant number: JPIAMR2021-053

Authors: Aizouk, R; Sibidou, Y; Valia, D; Ingelbeen, B; Campbell, L

• Publication status: Published
• Peer review status: Not peer reviewed
• Preprint server: medRxiv
• Publication date: 2025-12-18
• DOI: 10.64898/2025.12.15.25342269
• Language: English
• Keywords: antimicrobial resistance; behavioural community intervention; antimicrobial stewardship; WaSH; extended-spectrum beta-lactamase-producing E. coli community-acquisition; sub-Saharan Africa