Gastrointestinal Carriage of Antimicrobial Resistance in School-Aged Children in Three Municipalities of Timor-Leste
, Brandon Le 2, Virginia da Conceicao 1, Ian Marr 3, Carolina Maia 4, Messias Soares 1, Joana Correia Belo 1, Nevio Sarmento 1, Endang da Silva 4, Salvador Amaral 1, Susana Vaz Nery 3, Sarah Lynar 1,5, Joshua R. Francis 1,5 and Jennifer Yan 1,5
Round 1
Reviewer 1 Report
This study by Tessa Oakley et al describes the colonic carriage of fluoroquinolone, and aminoglycoside resistant Enterobacterales in school children from three cities Dili, Ermera, and Manufahi in the Timor-Leste area. The study utilized stool samples from 621 children to determine antibiotic resistance and followed by MADI-TOF and /or AST analysis. The number of participants is high to gain an understanding of Antimicrobial resistance among the population in a geographical area. However,
1) There is no description of the medical history of the participants.
2) Authors could provide an explanation about what factors could attribute to higher AMR in samples from Dili municipality than Ermera and Manufahi.
3) The study is limited to a specific age group and sample collection is not widely distributed.
Author Response
Please see the attachment.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
I congratulate the authors for the study conducted. I only recommend moving the materials and methods after the introduction. English should be improved.
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
Reviewer 3 Report
It is an interesting study. However, some improvements can be made to increase the scientific value of the manuscript:
I would suggest some changes in the Introduction:
line 38: problem -> issue
line 49: ESBLs -> ESBL organisms/bacteria
I would suggest to place the Timor-related data at the beginning of the introduction (lines from 62)
Methods
I would suggest to place the Methods before Results section
The aim of the study was to determine colonic carriage of ESBL+ bacteria, not scabies and filariasis incidence in children. Why did you choose to determine this carriage only in children tested for scabies and filariasis? Is this group representative enough for your Country?
Results
You have stated in the methods that stool samples were obtained in 3 different days. These 621 children have provided stool samples every day that were required by the study design or some samples were missing?
Are these 621 the sum of 3-days samples taken?
For the children population I would suggest providing the median age including months.
Conclusions
The conclusions should be the last paragraph of the discussion.
“This study is the first from Timor-Leste demonstrating rates of ESBL, fluoroquinolone and aminoglycoside resistance carriage amongst school-aged children.” - This is not the conclusion that can be based on the study results I would suggest to delete it or place in a different part of discussion
“The improved understanding of AMR carriage rates across different geographical areas in this study can be used to guide public health strategies, better inform empirical antibiotic guidelines, and be utilised as a baseline to monitor changing AMR trends.” This conclusion does not answer the study aim “The aim of this study was to determine colonic carriage of ESBL- producing, fluoroquinolone, and aminoglycoside resistant Enterobacterales in healthy children in three municipalities of Timor-Leste. “
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
Round 2
Reviewer 1 Report
None.
Reviewer 3 Report
The manuscript has been sufficiently improved. The authors have implemented all my suggestions.
