What is the impact of mass and systematic antibiotic administration on antibiotic resistance in low- and middle-income countries? A systematic review

Antibiotic consumption is a key driver of antibiotic resistance (AR), particularly in low- and middle-income countries, where risk factors for AR emergence and spread are rife. However, the potential contribution of mass and systematic antibiotic administration (MDA/SDA) to AR spread is unknown. We conducted a systematic review to provide an overview of MDA/SDA in low- and middle-income countries, including indications, antibiotics used and, if investigated, levels of AR over time. This systematic review is reported in accordance with the PRISMA statement. Of 2438 identified articles, 63 were reviewed: indications for MDA/SDA were various, and targeted populations were particularly vulnerable, including pregnant women, children, HIV-infected populations and communities in outbreak settings. Available data suggest MDA/SDA may lead to significant AR increase, especially after azithromycin administration. However, only 40% of studies evaluated AR. Integrative approaches that evaluate AR in addition to clinical outcomes are needed to understand consequences of MDA/SDA implementation, combined with standardized AR surveillance for timely detection of antibiotic resistance emergence.