Given the absence of temporal data and the observational nature of the analysis, how can the authors confidently disentangle whether the identified household and individual-level characteristics (such as frequent antibiotic use, treatment failures, or poor WASH access) are genuine upstream drivers of MDR infection, rather than downstream consequences of prior exposure to MDR pathogens or healthcare interactions? Without longitudinal or temporally anchored data, isn’t there a substantial risk that some of the high-risk profiles identified may conflate cause with effect, thus undermining the directionality and utility of the intervention targets proposed?
