Editorial Commentary: Mass Azithromycin Distribution and Emerging Resistance: Taking a Minimum Harms Approach

(See the Major Article by Coles et al on pages 1519–26.) Trachoma is the leading cause of infectious blindness in the world affecting approximately 21.4 million people, causing visual impairment in 2.2 million and clinical blindness in 1.2 million individuals [1]. Blinding trachoma is endemic in 53 countries covering predominantly sub-Saharan Africa, the Middle East, and Asia, where children under 10 years of age are the core reservoir of the causative organism, Chlamydia trachomatis, and also most vulnerable to infection. The International Coalition on Trachoma Control was established in 2004 (http://www.trachomacoalition.org), which, together with the World Health Organization (WHO), has successfully engaged international governmental and nongovernmental agencies in trying to eliminate blinding trachoma by advocating and implementing the Surgery, Antibiotics, Face-washing, and Environmental change (SAFE) strategy. Mass administration of azithromycin (MDA) to children <10 years of age in endemic areas is an integral part of the SAFE program, and a recent Cochrane review assessing the evidence supporting the antibiotic arm of the SAFE strategy concluded that mass antibiotic treatment with single-dose oral azithromycin was associated with a 20% reduced relative risk of active trachoma and ocular infection [2]. Furthermore, MDA also decreased overall mortality in children 1–5 years of age by 65% [3], possibly because of azithromycin's activity against common respiratory and gastrointestinal pathogens that often have a lethal outcome in children in trachoma-endemic areas. However, any ancillary benefits of MDA should outweigh the risks. Azithromycin use is not only associated with the emergence of macrolide resistance, but also with selection of strains resistant to β-lactams [4–6] that represent the most commonly used antibiotic group for respiratory infections.