03169nas a2200193   4500000000100000008004100001260004400042653002400086653005700110653002100167100001300188700001300201700002000214245009900234856008200333490000700415520253900422022001402961       2022                            d  bSpringer Science and Business Media LLC10aInfectious Diseases10aPublic Health, Environmental and Occupational Health10aGeneral Medicine1 aRolfe RJ1 aShaikh H1 aTillekeratne LG00aMass drug administration of antibacterials: weighing the evidence regarding benefits and risks  uhttps://idpjournal.biomedcentral.com/track/pdf/10.1186/s40249-022-00998-6.pdf0 v113 a<p>Background</p>

<p>Mass drug administration (MDA) is a strategy to improve health at the population level through widespread delivery of medicine in a community. We surveyed the literature to summarize the benefits and potential risks associated with MDA of antibacterials, focusing predominantly on azithromycin as it has the greatest evidence base.</p>

<p>Main body</p>

<p>High-quality evidence from randomized controlled trials (RCTs) indicate that MDA-azithromycin is effective in reducing the prevalence of infection due to yaws and trachoma. In addition, RCTs suggest that MDA-azithromycin reduces under-five mortality in certain low-resource settings that have high childhood mortality rates at baseline. This reduction in mortality appears to be sustained over time with twice-yearly MDA-azithromycin, with the greatest effect observed in children &lt; 1&nbsp;year of age. In addition, observational data suggest that infections such as skin and soft tissue infections, rheumatic heart disease, acute respiratory illness, diarrheal illness, and malaria may all be treated by azithromycin and thus incidentally impacted by MDA-azithromycin. However, the mechanism by which MDA-azithromycin reduces childhood mortality remains unclear. Verbal autopsies performed in MDA-azithromycin childhood mortality studies have produced conflicting data and are underpowered to answer this question. In addition to benefits, there are several important risks associated with MDA-azithromycin. Direct adverse effects potentially resulting from MDA-azithromycin include gastrointestinal side effects, idiopathic hypertrophic pyloric stenosis, cardiovascular side effects, and increase in chronic diseases such as asthma and obesity. Antibacterial resistance is also a risk associated with MDA-azithromycin and has been reported for both gram-positive and enteric organisms. Further, there is the risk for cross-resistance with other antibacterial agents, especially clindamycin.</p>

<p>Conclusions</p>

<p>Evidence shows that MDA-azithromycin programs may be beneficial for reducing trachoma, yaws, and mortality in children &lt; 5&nbsp;years of age in certain under-resourced settings. However, there are significant potential risks that need to be considered when deciding how, when, and where to implement these programs. Robust systems to monitor benefits as well as adverse effects and antibacterial resistance are warranted in communities where MDA-azithromycin programs are implemented. Graphical Abstract</p>
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