Mass azithromycin administration: considerations in an increasingly resistant world

Abstract

► Recent 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.