Amongst intense attention on stimulating innovation and enforcing stewardship of antibiotics, a recent study—a cluster-randomised trial—highlights just how critical ensuring access to antibiotics is.

Published in the New England Journal of Medicine, Keenan et al. reported the efficacy of mass administration of azithromycin, which is known to be effective in reducing rates of trachoma, malaria and pneumonia, in lowering all-cause mortality in children of 1 to 59 months in age in some of the poorest countries in sub-Saharan Africa in Malawi, Niger and Tanzania.

Having monitored 190,238 children and 323,302 person-years over five census visits between 2014 and 2017, the authors found that mass administration of azithromycin could effectively reduce mortality in all three countries, with the greatest effect seen in Niger (18.1% lower in under-five mortality compared with placebo group) and children in the age group of 1 to 5 months (24.9% lower in mortality compared with placebo group).

Findings of the study can seem controversial at first glance. In an age where antibiotic stewardship is firmly recognised as a cornerstone for the fight against AMR, just the suggestion of mass administration of antibiotics seems totally out of place.

However, in addition to cautioning the “potential effect of such a strategy on antibiotic resistance”, authors of the study reminded readers of the importance of understanding the dire country context in which the study took place. Dr Tom Lietman, who ran the study, explained that children in these countries didn’t have access to healthcare and often die at home from common infections; given this life-threatening pretext of lack of access, excess and its consequence of AMR were secondary concerns.

AMR is a global health crisis, but this study is a stark reminder of the fact that there are places in the developing world that are still too deprived to afford it.