Paper Information

The World Health Organization recommends mass drug administration (MDA) of the antibiotic azithromycin for children 1-11 months of age in areas with high infant and child mortality. Notwithstanding the substantial potential benefits in lowering childhood mortality, MDA raises understandable concerns about exacerbating antibiotic resistance.

Here we aim to evaluate the use of MDA, using both quantitative and ethical considerations.

While better data on antibiotic use and resistance are needed, efforts to reduce antibiotic use and resistance should not start with halting mass drug administration of azithromycin in the areas with the highest childhood mortality. Improving the data to inform this decision is critical. However, based on the best evidence available, we believe that resistance concerns should not thwart MDA, accompanied by robust plans to monitor its efficacy and changes in resistance levels. Similar considerations could be included in a framework for evaluating benefits of antibiotics against resistance risk in other contexts.

We first compare MDA with other uses of antibiotics, using the standard metric of "number needed to treat," and five additional criteria: 1) other widely accepted uses of anti-infectives; 2) absolute use (i.e, total number) of antibiotics; 3) risk-benefit tradeoff; 4) availability of short-term alternatives; and 5) the precedent for implementing similar interventions. We find that MDA falls well within a justifiable range when compared to widely accepted uses of antibiotics in terms of the number needed to treat. The other five criteria we consider provide further support for use of MDA to prevent childhood mortality.

We performed a series of literature searches between July 2019 and June 2022.