PONE-D-25-30050Public Perceptions and Support for Introduced Microbes to Combat Hospital-Acquired Infections and Antimicrobial ResistancePLOS ONE

Dear Dr. Cummings,

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Reviewer #1: The work by Cummings and collogues encapsulates an interesting investigation of the factors influencing one’s attitudes to using microbes as a preventative in preventing hospital acquired infections. There are many errors in the introduction where papers are cited that do not accurately support their claims. This reduces the reviewer’s enthusiasm for the work and their trust in the author’s presented results.

- Personally, I would reduce the number of abbrevations. It makes the text overly verbose. Too many to keep track of.

- Reference to Rodrigues et al 2025 does not support using engineered bacteria, at no point in the cited study were probiotics used, however it was noted that women who were hospitalized were at a higher risk of acquiring an infection.

- Reference to Fady once again does not support the claim being made "For example, bioengineered waste lignocellulosic biochars have been shown to sequester MDR bacteria, reducing hospital contamination and minimizing antibiotic- resistant outbreaks (Fady et al., 2024).”

- This paper is not about phages at all. Discusses nanoparticles to treat infections but does not mention either of the points it is meant to support “Additionally, phage therapy and microbiome restoration techniques have gained traction as alternative interventions, showing promise in targeting antimicrobial-resistant bacterial strains without relying on traditional antibiotics (Ahmed et al., 2025).” Phage therapy has existed as a concept since the early 1900s, there should be at least a few references which would be better used to support this claim.

- Another instance of an improper citation: “Recurrent bacteremia in the setting of Pseudomonas endocarditis of the tricuspid valve and indwelling medical devices”, cited work is case report, regarding biofilm formation on a medical device. No review of supplying probiotics to outcompete pathogens as suggested by the quoted line.

- There is no Cummings 2025 in the works cited. I assume that this is in reference to the manuscript itself, which seems odd if not misleading: “So far there have been limited studies of U.S. public attitudes on microbiome engineering in the built environment. In the first survey of built microbiome engineering and public attitudes, attitudes toward microbes and microbiome engineering were discovered to be shaped by a complex interplay of scientific literacy, emotional responses, media influence, and demographic factors (Cummings, Landreville, & Kuzma, 2024; Cummings, Landreville, & Kuzma, 2025)”.

- It would be interesting to see if one’s prior scientific knowledge was in anyway predictive of their thoughts on the microbiome in therapy, perhaps including this information in the model would provide interesting insights as to whether education is actually helpful in increasing the public’s perception of microbiome based therapeutics

Reviewer #2: Cummings and colleagues present a very thorough, well written, and interesting assessment of Americans’ attitudes towards introducing engineered microbiomes into hospital sinks to combat antimicrobial resistance and hospital associated infections. The study is timely as AMR and HAI are major issues facing the US healthcare system and innovative strategies are needed to combat them. Additionally, deploying engineered microbiomes in the built environment is in early stages, making now an ideal time for assessing public attitudes so that they may inform future implementation strategies and promote success. I think the manuscript can be improved by adding some detail/clarifying information, tightening up some of the language to describe survey respondent characteristics, and including a discussion of the study’s limitations. My specific suggestions are below.

Major comments

1. I think it would be nice to give a little detail/context on why the study/survey focused on introduced microbiomes specifically deployed in sinks (as opposed to other parts of the hospital built environment).

2. I think the last sentence of the introduction – very clearly stating the overall research question – is really great and sets the reader up nicely for the rest of the manuscript! (no revisions requested here)

3. Are there any notable examples/success stories of deploying engineered/introduced microbiomes in other built environment settings (healthcare or otherwise)? If yes, I would consider giving a brief overview of these in the literature review section, along with any lessons learned that may be relevant to the current study. Alternatively, are there any notable failures with relevant lessons learned?

4. The language used to describe sex/gender, political orientation/party identification, and religiosity/church attendance is not internally consistent throughout the manuscript, and the alternative terms that are used have meaningful differences. Here are some specific clarifying questions and suggestions I have:

a. I really like that you give a full description of all participants’ reported gender in the methods! From those data, it seems like the survey asked about gender and not sex? If yes, terminology used later in the manuscript to refer to ‘females’ and ‘biological sex’ should be revised to refer to women and gender. If the survey assessed gender and sex, that should be stated in the methods, and the manuscript should clearly identify which variable is being discussed and use congruent terminology (e.g., ‘female’ to describe sex and ‘woman’ to describe gender).

b. The methods section defines the bounds of the party identification scale as ‘strong Republican coded’ and ‘strong Democrat coded’. Later, the results refer to ‘conservative political orientation’. In the current (and recent) American sociopolitical context, ‘Republican’ and ‘conservative’ are not interchangeable, and I think whichever language is intended to be used with the party identification scale should be used throughout the manuscript.

c. Did the church attendance scale explicitly assess ‘church’ attendance, or did it ask about attending any variety of religious/worship service or any variety of house of worship? If it only asked about church, I don’t think ‘religiosity’ or ‘religious attendance’ should be used to describe this independent variable, and it should instead be referred to as church attendance.

5. In the methods or results, can you state how age and gender were operationalized in the models? Specifically, was age continuous or binned? How were individuals who did not share their gender and individuals identifying as nonbinary, genderqueer, trans, and ‘no label’ included in models?

6. Did you examine relationships among the dependent variables? I’m curious if any of the dependent variables are significant predictors of each other.

7. Given the partial overlap of significant predictors between the three models, have you considered including a venn diagram of which ones are/aren’t shared across models, perhaps as a panel b for Figure 1? I think this could be a nice visualization, but also it may get clunky with more text than a typical venn diagram.

8. Can you include a limitations paragraph in the discussion? A couple limitations that I think deserve some discussion are: the survey doesn’t speak to hospital workers’ attitudes (out of the scope of this study but nonetheless important); the survey population has a higher proportion of respondents over 65 and of white respondents than the census estimate; and people’s personal histories related to hospital stays (e.g., recent/frequent/long hospital stays, death of a loved one in hospital) may meaningfully impact their attitudes, but these data were not collected (alternatively, if these data were collected, I think it would be really interesting to include them in the current analysis!).

Minor comments

1. Can you add line numbers in the revised draft?

2. Can you include interquartile ranges in the text alongside standard deviations?

3. There are a few spots where I’d like a bit of clarification:

a. When the methods refer to a ‘composite item’ of multiple questions, does this just mean that response values were averaged across those questions, and the average was used as a predictor?

b. You define the bounds of the 6-point scale used to assess church attendance (1 – rarely attends; 6 – attends weekly). For other scales, it may be easy to assume what the rest of the scale values are defined as, but I’m not sure it’s as intuitive for church attendance. Can you define all six scale values in the methods?

c. Can you state the p value cutoff for determining significance in the methods or results?

d. In the results, does ‘strongest predictor’ refer to the predictor with the largest-magnitude beta estimate or the smallest p value?

e. In the methods or Table 1 footnotes, can you state what test was used to determine significance of changes in R2 across successive blocks of predictors?

f. In the methods, can you state what software programs, packages, functions, and versions were used in the analyses?

4. I’m not sure ‘change’ is the best word to use in Table 1 to describe increases in R2 across successive blocks of predictors. My understanding is that R2 should increase (or stay the same) with each successive block of predictors (i.e., monotonic increases in R2). ‘Change’ implies that R2 may decline with added blocks of predictors, and only presenting the change in R2 for blocks 2-5 may be a bit confusing. I’d suggest either using a different word than ‘change’, or presenting the overall R2 for each block alongside the change from the prior block.

5. The bottom of Figure 1 appears to be cut off.

6. In the first paragraph of the discussion, can you either add a citation for the last part following sentence (starting at ‘potentially’), or state that it is a hypothesis: ‘Interestingly, prior information-seeking and familiarity with ME were often negatively associated with support, suggesting that surface-level or critical exposure may lead to skepticism, potentially due to the framing of microbiome interventions or conflation with genetic modification and synthetic biology.’

Signed: Kayla A. Carter

Reviewer #3: Well-written manuscript highlighting the importance of microbiome engineering to combat HAI. Authors investigated (with an RRI) approach, how people perceive the use of microbes in these "sterile" hospital environments to promote the growth of beneficial microbes.

1. If the participants wanted to know the exact science behind the introduction of beneficial microbes to hospital sinks, were they provided an explanation?

2. Were the surveys completed in person (at a hospital, clinic, at home, etc)?

3. Is it possible to gain more insight into societal value and ethical considerations of microbiome engineering/HAI by surveying individuals in predominately Black, AA and/or Latinx communities?

4. Historically, how influential has the public perception been on developing novel techniques in hospitals?

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Reviewer #1: No

Reviewer #2: Yes:  Kayla A. Carter

Reviewer #3: No

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Public Perceptions and Support for Introduced Microbes to Combat Hospital-Acquired Infections and Antimicrobial Resistance

PONE-D-25-30050R1

Dear Dr. Cummings,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Assoc. Prof. Phakkharawat Sittiprapaporn, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewer #2:

Reviewer #3:

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: No

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

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6. Review Comments to the Author

Reviewer #2: Thank you for your thoughtful and thorough responses and revisions! I have no further comments.

Signed: Kayla A. Carter

Reviewer #3: The authors answered all of my questions thoughtfully and thoroughly. The provided easy-to-understand explanations about the statistical analysis. This helped me understand their approach. The manuscript reads very well.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #2: Yes:  Kayla A. Carter

Reviewer #3: No

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