# WASH-nutrition integration as a global policy priority for antimicrobial stewardship in low- and middle-income countries

## TL;DR

This paper argues that improving water, sanitation, hygiene, and nutrition can reduce antibiotic overuse and combat antimicrobial resistance in low- and middle-income countries.

## Contribution

It introduces WASH-nutrition integration as a novel, community-level strategy for antimicrobial stewardship.

## Key findings

- Low-cost WASH and nutrition interventions reduce pediatric antibiotic use through multiple biological pathways.
- These interventions transform prevention into a measurable defense strategy against antimicrobial resistance.
- The findings support redefining antimicrobial stewardship as part of global health policy and environmental conservation.

## Abstract

Antimicrobial resistance (AMR) is a global health threat predicted to hit 10 million deaths per year by 2050. Most conventional antimicrobial stewardship (AMS) strategies focus on clinical settings, failing to address community-level overuse, a primary driver of AMR in low- and middle-income countries. This commentary leverages novel evidence to argue for the prioritization of water, sanitation, and hygiene (WASH)-nutrition integration as a global health policy and first-line defense strategy against AMR. This argument is grounded on a target article that utilized causal mediation analysis to establish how low-cost household level WASH and nutrition interventions reduced pediatric antibiotic use via multiple biological pathways. This transforms prevention into a measurable antimicrobial defense strategy through antibiotic doses averted and limits antibiotic demand. These findings provide an empirical basis for integrated preventive measures, a quantifiable scorecard for securing political and fiscal commitment and redefinition of AMS as an element of global health policy and environmental conservation.