TY - JOUR T1 - Mass azithromycin administration: considerations in an increasingly resistant world JF - BMJ Global Health JO - BMJ Global Health DO - 10.1136/bmjgh-2020-002446 VL - 5 IS - 6 SP - e002446 AU - Yogesh Hooda AU - Arif M Tanmoy AU - Mohammad Saiful Islam Sajib AU - Senjuti Saha Y1 - 2020/06/01 UR - http://gh.bmj.com/content/5/6/e002446.abstract N2 - Summary boxRecent studies have shown that mass administration of azithromycin in some areas can lead to reduction in childhood mortality, which in turn has led to additional large-scale trials in many parts of the world.We provide evidence for the emergence of novel azithromycin resistance mechanisms in common bacterial pathogens like Salmonella, arguing that the appealing positive effects of mass drug administration might diminish with increasing azithromycin resistance.While a silver bullet against childhood mortality is highly desirable, given the alarming rise in antimicrobial resistance and the drying pipeline of novel drugs, the opportunity costs of mass administration should be considered with utmost caution.Future studies and trials of mass azithromycin administration should include methods for early detection of azithromycin resistance such that preventative measures can be implemented, in case azithromycin resistance begins to spread.Azithromycin is an oral macrolide discovered in 1980 and approved for medical use in 1988.1 This relatively inexpensive antibiotic is often deemed as a wonder drug due to its safety and effectiveness against parasitic and helminth infections, in addition to a wide range of bacterial infections. In the early 2000s, biannual administration of azithromycin (mass drug administration, MDA) for trachoma control was found to reduce all-cause mortality by almost 49%.2 These encouraging results, presumably due to reduction in respiratory and diarrhoeal infections3 4 and malaria,5 led to the placebo-controlled, double-blinded, cluster-randomised MORDOR-I trial (Macrolides Oraux pour Réduire les Décès avec un Oeil sur la Résistance) in Niger, Malawi and Tanzania covering 190 238 children.6 An overall 13.5% reduction in child mortality was observed in azithromycin versus placebo communities; however, the effect was largely driven by findings in Niger (18.1%), with minimal impact in Malawi (5.7%) and Tanzania (3.4%). While the mechanism of azithromycin’s effect on childhood mortality is not fully understood, … ER -