Impact of prophylactic oral azithromycin during labor on Azithromycin Resistance (AMR) in nasal Staphylococcus aureus and Streptococcus pneumoniae in women and infants in the multi-country Azithromycin Prevention in Labor Use Study (A-PLUS)

Patricia L. Hibberd; Jean H. Kim; Marissa Trotta; Sixto M. Leal; Anna Aceituno; Doyle V. Ward; Archana Patel; Akila Subramaniam; Waldemar A. Carlo; Imran Ahmed; Sarah Saleem; Sk Masum Billah; Rashidun Haque; Manolo Mazariegos; Fabian Esamai; Manjunath S. Somannavar; Shivaprasad S. Goudar; Elwyn Chomba; Muska Mwenchanya; Adrien Lokangaka; Antoinette Tshefu; Robert L. Goldenberg; Melissa Bauserman; Nancy F. Krebs; Sherri Bucher; Richard J. Derman; William A. Petri; Marion Koso-Thomas; Denise C. Babineau; Elizabeth M. McClure; Alan T. N. Tita

doi:10.1371/journal.pone.0346174

Peer Review History

Original SubmissionSeptember 9, 2025
26 Nov 2025 Decision Letter - Tebelay Dilnessa, Editor Dear Dr. Hibberd, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jan 10 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. 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Read more information on sharing protocols at . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.... We look forward to receiving your revised manuscript. Kind regards, Tebelay Dilnessa, MSc Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1.Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. 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Thank you for stating the following financial disclosure: “The A-PLUS AMR sub-study was supported through grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Boston University (U10 HD078439), RTI International (U01 HD040636), University of North Carolina at Chapel Hill (U10 HD076465), University of Alabama at Birmingham (U10 HD078437), University of Colorado (U10 HD076474), Thomas Jefferson University (U10 HD076457), Columbia University (U10 HD078438), Indiana University (U10 HD076461), and a grant from the Foundation for the National Institutes of Health [MCCL19APT] through the Maternal, Newborn & Child Health Discovery & Tools initiative of the Bill & Melinda Gates Foundation (BMGF) [INV-008973]. The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the NICHD, the National Institutes of Health, or the U.S. Department of Health and Human Services or the BMGF.” Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. 4. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. 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[Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: As the statistical reviewer I will focus on methods and reporting. Major 1) Please discuss that the recruitment target was not met as a limitation in the relevant section, which has power implications. 2) the focal point of the analysis should be the logistic regression model. if the model allows I would be keen to include a random intercept for site. I am not sure the interaction is needed, I would suggest removing it if it is found not to add anything, to simplify the model. 3) there is no information in the methods section as to how the authors dealt with missing data. why weren't multiple imputation approaches considered? 4) I would move away for all p-value focused analyses, since it is impossible to evaluate p-values as descriptive. they are either adjusted and informative or not. Please move all analyses to a regression framework and focus reporting effect/association sizes and their confidence intervals, still keeping the explanatory label. Minor 1) the authors mention 125 women per site before they explain the power calculations. please mention the power calculation alongside the recruitment targets per site. Reviewer #2: This is an important and timely manuscript reporting antimicrobial resistance (AMR) outcomes from the multicountry A-PLUS randomized controlled trial. The study examines azithromycin resistance among nasal Staphylococcus aureus and Streptococcus pneumoniae isolates from mothers and infants following intrapartum azithromycin administration across seven low- and middle-income countries. The work is scientifically rigorous, methodologically sound, and highly relevant to global efforts to balance the benefits of prophylactic antibiotic interventions with their AMR risks. The multicountry scope, standardized methods, and longitudinal sampling represent major strengths. However, certain aspects of clarity, methodological detail, and interpretative depth should be improved before publication. Major Comments 1. The introduction outlines three AMR assessments (nasal, rectal, genomic), but this paper focuses only on nasal carriage. In the last paragraph, specify that this manuscript reports findings from the nasal S. aureus and S. pneumoniae analysis. 2. The culture yield for S. pneumoniae is low, with over 90% undetermined samples at several time points. This raises concerns about representativeness and statistical power. Discuss potential reasons for example sample transport, viability, timing, etc and possible implications for bias in prevalence estimates. 3. Baseline resistance rates are not negligible and may reflect pre-existing macrolide exposure. Expand discussion on background community azithromycin use and acknowledge its potential confounding effect. Minor Comments 1. Consider revising the first line of the abstract line 65 - 66 emphasising the balance between mortality/sepsis prevention and AMR risk. for example .. Prophylactic intrapartum azithromycin reduces maternal mortality/sepsis but may promote antimicrobial resistance (AMR) in commensal bacteria. 2. Aside from mothers giving consent where there any other inclusion criteria to join for the AMR sub study 3. were the laboratory team blinded to treatment allocation? 4. what was the concentration of azithromycin in azithromycin containing agar use to select organisms for identification and susceptibility testing 5. what does resistant undetermined mean? 6.Highlight that the rebound to baseline resistance levels by 6–12 months aligns with previous evidence from The Gambia and Kenya. 7. Be consistent in the use of American or UK English for example labor or labour 8. Where possible, provide absolute prevalence percentages in-text when comparing treatment arms (e.g., “Azithromycin-resistant S. aureus was X% vs. Y% at 6 weeks”). ****** what does this mean?). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? 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Revision 1
8 Jan 2026 Author Response Reviewer #1: As the statistical reviewer I will focus on methods and reporting. Major Comment #1: Please discuss that the recruitment target was not met as a limitation in the relevant section, which has power implications. Response: Thank you for this comment, we have updated the text in limitations in order to address this issue as a limitation. Comment #2: the focal point of the analysis should be the logistic regression model. if the model allows I would be keen to include a random intercept for site. I am not sure the interaction is needed, I would suggest removing it if it is found not to add anything, to simplify the model. Response: The logistic regression model was used solely to compare estimates between Africa and Asia. The primary analysis was the Cochran-Mantel-Haenszel test stratified by region, which was used to test for association between resistance and treatment. To clarify this, we have updated the text regarding the statistical analysis to make it clearer. Comment #3: there is no information in the methods section as to how the authors dealt with missing data. why weren't multiple imputation approaches considered? Response: No differences in baseline characteristics were noted between mothers and infants with and without a nasal swab over time so we chose to do a complete case analysis at each time point. We have added a line in the methods to emphasize this. Comment #4: I would move away for all p-value focused analyses, since it is impossible to evaluate p-values as descriptive. they are either adjusted and informative or not. Please move all analyses to a regression framework and focus reporting effect/association sizes and their confidence intervals, still keeping the explanatory label. Response: Our objective was just to test association between arm and resistance controlling for region, our analysis was not an attempt to get estimates of association. We have adjusted the text to make the intended statistical analysis clearer. Minor Comment #1: the authors mention 125 women per site before they explain the power calculations. please mention the power calculation alongside the recruitment targets per site. Response: We have moved the sample size discussion to before we mention the 125 women per site in order to clarify the sample upfront. Reviewer #2: This is an important and timely manuscript reporting antimicrobial resistance (AMR) outcomes from the multicountry A-PLUS randomized controlled trial. The study examines azithromycin resistance among nasal Staphylococcus aureus and Streptococcus pneumoniae isolates from mothers and infants following intrapartum azithromycin administration across seven low- and middle-income countries. The work is scientifically rigorous, methodologically sound, and highly relevant to global efforts to balance the benefits of prophylactic antibiotic interventions with their AMR risks. The multicountry scope, standardized methods, and longitudinal sampling represent major strengths. However, certain aspects of clarity, methodological detail, and interpretative depth should be improved before publication. Major Comments Comment #1: The introduction outlines three AMR assessments (nasal, rectal, genomic), but this paper focuses only on nasal carriage. In the last paragraph, specify that this manuscript reports findings from the nasal S. aureus and S. pneumoniae analysis. Response: Thank you for this comment. This change has been made in the last paragraph of the introduction. Comment #2: The culture yield for S. pneumoniae is low, with over 90% undetermined samples at several time points. This raises concerns about representativeness and statistical power. Discuss potential reasons for example sample transport, viability, timing, etc and possible implications for bias in prevalence estimates. Response: We agree that low culture yield for S. pneumoniae is a concern and is a study limitation. We have added 3 sentences to the Conclusions/Discussion section addressing this, particularly highlighting difficulty in culturing this bacteria as well as small variations in collection, transport, and laboratory methods that can result in no viable recovery. We also note that all laboratory staff were trained in the same standard operating procedures and used the same recommended consumables. We also used ongoing quality control and validation procedures for all sties as described in the methods and results. Comment #3: Baseline resistance rates are not negligible and may reflect pre-existing macrolide exposure. Expand discussion on background community azithromycin use and acknowledge its potential confounding effect. Response: We agree with this concern and have added more detail in the first paragraph of the Discussion about use of azithromycin for treatment of COVID, particularly in the Asian sites. Minor Comments Comment #1: Consider revising the first line of the abstract line 65 - 66 emphasizing the balance between mortality/sepsis prevention and AMR risk. for example .. Prophylactic intrapartum azithromycin reduces maternal mortality/sepsis but may promote antimicrobial resistance (AMR) in commensal bacteria. Response: Thank you for this suggestion and we have made this change as suggested. Comment #2: Aside from mothers giving consent where there any other inclusion criteria to join for the AMR sub study Response: We have added that there were no additional eligibility criteria for women selected for the AMR sub-study other than willing ness to participate and signing of the AMR sub-study consent form. Comment #3: were the laboratory team blinded to treatment allocation? Response: The laboratory staff were blinded to treatment allocation and we have updated the text to address. Comment #4: What was the concentration of azithromycin in azithromycin containing agar used to select organisms for identification and susceptibility testing? Response: The concentration of azithromycin added to the agar was dependent on the bacterial species and determined based on the recommended MIC breakpoints for resistance (CLSI , 2024 – reference 13). Comment #5: what does resistant undetermined mean? Response: Thank you for noticing that there are minor discrepancies in the text when resistance undetermined is mentioned. We have reviewed all instances of “resistance undetermined” and now the consistently are clarified as “because the cultures failed to grow or had incomplete laboratory testing”. Comment #6: Highlight that the rebound to baseline resistance levels by 6–12 months aligns with previous evidence from The Gambia and Kenya. Response: We already have indicated that our results are similar to the Gambia study in paragraph 3 of the conclusions/discussion. We have clarified that the Gambian results returned to baseline in paragraph 3 in the conclusions/discussion section. I think the Kenyan study refers to our Kenya site so that is already included in our date. Comment #7: Be consistent in the use of American or UK English for example labor or labour. Response: We did a search for English vs. US spellings and noted that all mentions of “labour” were in the references (8, 10 and 20). We believe that there are no outstanding instances to UK English references other than in the references, which we hesitate to change. Similarly, we have not changed institution names that use the English spelling. Comment #8: Where possible, provide absolute prevalence percentages in-text when comparing treatment arms (e.g., “Azithromycin-resistant S. aureus was X% vs. Y% at 6 weeks”). Response: We have provided this information in the text (RESULTS under Section “Cross sectional Analyses of Prevalence of Azithromycin Resistance in S. aureus at Each Time Point” as requested Attachments Attachment Submitted filename: 2 Rebuttal Letter.docx https://doi.org/10.1371/journal.pone.0346174.r002
1 Feb 2026 Decision Letter - Tebelay Dilnessa, Editor Dear Dr. Hibberd, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. ============================== Please submit your revised manuscript by Mar 18 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. 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Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.... We look forward to receiving your revised manuscript. Kind regards, Tebelay Dilnessa, MSc Academic Editor PLOS One Journal Requirements: If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments: Place the ‘Author Contributions’ in the declaration sectionin the declaration sectionin the declaration sectionin the declaration section Include ‘Key words’ in the abstract part. The author should minimize the use of pronoun ‘We/our’. Unnecessary bolding of texts from lines 283-291 should be avoided. The discussion should be revised; some of the paragraphs cannot stand by themselves; for example, lines 434-437. Some of them was also too wide; for example; lines from 455-479 (it requires revision). Conclusion: ‘Despite these limitations………………..’ Which limitation? The conclusion should not contain the limitation and discussion. The author should revise it to make a concrete conclusion that emanates from the main findings. The figure titles should not be embedded within figures. They should be left within the main manuscript where they are cited. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: All comments have been addressed Reviewer #3: All comments have been addressed Reviewer #4: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: Yes Reviewer #3: Yes Reviewer #4: Partly ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #3: Yes Reviewer #4: No ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #3: Yes Reviewer #4: Yes ****** Reviewer #1: I am satisfied with the authors' responses and the resulting changes to the paper. All comments have been addressed. Reviewer #3: (No Response) Reviewer #4: The thematic message in the article is good. However, the presentation needs to be improved. Below are some suggestions for improvement. 1. Methods The study design should include that … the study used both longitudinal and cross-sectional approach. State where these were applied as well. A section on data analysis should be added to know the tools used for statistical analysis and how the data were represented. 2. Results This section is not very robust as one will expect. For instance, the data in Table 1 would have looked better if the bacterial carriage was used with their respective statistical comparison instead of only enumerating the number of participants enrolled. 3. Discussion One serious limitation of this study is the confirmation with molecular techniques which is the gold standard. This should be explained in the discussion. This is because upon molecular confirmation, these isolates may not be the same. Line 434 is incomplete. The paragraph beginning at 436 should not be a stand-alone sentence. You could possibly further explain this sentence. The discussion section is poorly written. Focus should be given to the interpretation of the results obtained and compared to literature. Overall, the author has adopted the corrections suggested by previous reviewers. However, grammar check, and some of the above recommendation should are highly recommended prior to publication. ****** what does this mean?). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our Privacy Policy..--> Reviewer #1: No Reviewer #3: No Reviewer #4:Yes:Tombari Pius MonsiTombari Pius MonsiTombari Pius MonsiTombari Pius Monsi ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation. NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. https://doi.org/10.1371/journal.pone.0346174.r003
Revision 2
5 Mar 2026 Author Response Associate Editor: 1. Place “Author Contributions’ in the Declaration Section. Response: A Declaration Section has been created at the end of the manuscript after Supporting Information- please see lines in the track changes word document 617-624. 2. Include “Key Words” in the abstract part Response: Key words were included in the PLOS One submission portal. They are now added to the end of the abstract as requested (lines 105-112 in the tracked changes word document). 3. The author should minimize the use of pronoun “We/our” Response: We have removed “we” and “our” from the entire manuscript. Thank you for your advice on this matter. These changes are present in multiple locations and required minor wording changes for the passive voice – lines 147, 160, 162, 166, 170, 288, 439, 449, 450, 452, 455, 463, 466, 471, 476, 478, 482, 501 in the tracked changes word document). 4. Unnecessary bolding of texts from lines 283-291 should be avoided Response: The bolding of text has been removed in lines 297-308 in the tracked changes word document). 5. The Discussion should be revised Response: The discussion has been revised to address multiple suggestions and paragraphs that cannot stand on their own have been removed. Please see all the changes in the tracked changes word document). 6. Conclusions should not contain the limitation and discussion Response: The conclusion in the abstract and discussion section has been revised as requested. Thank you for this guidance. (Please see lines 96-104 and 501-509 in the tracked changes word document). 7. Figure titles should not be embedded within figures Response: Updated Figures are provided without the Figure titles. Thank you for this guidance. Please find updated Figures 1, 2, 3a and 3b without any title including Fig x. Reviewer Comments Reviewer 1 and 3 had no additional comments. Reviewer 4 had suggestions for improving the presentation, all of which are addressed below. Reviewer 4 (statistical): 1. Methods 1. The study design should include that … the study used both longitudinal and cross-sectional approach. State where these were applied as well. Response: We did not use longitudinal analyses in this paper, this was strictly cross-sectional. We have edited the text as requested (please see lines 339 in the tracked changes word document). 2. A section on data analysis should be added to know the tools used for statistical analysis and how the data were represented. Response: We have added a sentence clarifying that we used SAS version 9.4 for our analysis (please see line 349 in the tracked changes word document). We have also added a sentence to clarify that we reported out the distribution of culture resistance as percentages (please see line 339-340 in the tracked changes word document). 2. Results Section 1. This section is not very robust as one will expect. For instance, the data in Table 1 would have looked better if the bacterial carriage was used with their respective statistical comparison instead of only enumerating the number of participants enrolled. Response: The bacterial carriage with their respective statistical comparisons are displayed in Figure 3. Supplemental Table 1 is intended to show the percentage of samples collected over time. We have included a track changes and clean copy version of the Supplemental Tables. 3. Discussion Section 1. One serious limitation of this study is the confirmation with molecular techniques which is the gold standard. This should be explained in the discussion. This is because upon molecular confirmation, these isolates may not be the same. Response: We agree with the reviewer, but unfortunately, the global network microbiology laboratories used morphological and biochemical tests to identify bacteria. They did not have capabilities for molecular identification. This is described in our study methods paper (Reference 6). We have added this clarification to the results section (please see line 429-432 in the results section) as well as the to line 495-498 in the discussion section in the tracked changes word document). 2. Line 434 is incomplete. Response: This typographical error has been removed. 3. The paragraph beginning at 436 should not be a stand-alone sentence. You could possibly further explain this sentence. Response: This stand alone sentence has been added to the subsequent paragraph (please see line 466 in the tracked changes word document). 4. The discussion section is poorly written. Focus should be given to the interpretation of the results obtained and compared to literature. Response: Thank you for this suggestion. The discussion section has multiple revisions as shown in the track changes manuscript to address this concern. Un-numbered comment Overall, the author has adopted the corrections suggested by previous reviewers. However, grammar check, and some of the above recommendation should are highly recommended prior to publication. Response: This comment is appreciated. A complete grammar check has been performed resulting in additional changes in the track changes manuscript throughout the entire manuscript. It was difficult to list each line that had these changes but it can be provided if helpful. Attachments Attachment Submitted filename: 2 Rebuttal Letter 2 25 26.docx https://doi.org/10.1371/journal.pone.0346174.r004
16 Mar 2026 Decision Letter - Tebelay Dilnessa, Editor Impact of Prophylactic Oral Azithromycin during Labor on Azithromycin Resistance (AMR) in Nasal Staphylococcus aureus and Streptococcus pneumoniae in Women and Infants in the Multi-Country Azithromycin Prevention in Labor Use Study (A-PLUS) PONE-D-25-38518R2 Dear Dr. Hibberd, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support.... If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Tebelay Dilnessa, MSc Academic Editor PLOS One Additional Editor Comments (optional): - Avoid lines 413 and 415 (they create a mixation of method and result). -Line 423: Azithromycin Susceptibility Pattern - The 'Declaration' section should be placed above the reference list, but below the conclusion. Reviewers' comments: https://doi.org/10.1371/journal.pone.0346174.r005
Formally Accepted
Acceptance Letter - Tebelay Dilnessa, Editor PONE-D-25-38518R2 PLOS One Dear Dr. Hibberd, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Tebelay Dilnessa Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0346174.r006

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