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During her time as director general of the World Health Organization, a former leader famously remarked that all of the “easy” antibiotics had already been found. The argument was that in addressing the pressing danger of drug-resistant bacterial infections, we would struggle to find new treatments – or conserve the current arsenal – without finding novel approaches of working. This view proved accurate.

A Sluggish and Unprofitable Pipeline

Since the late 2010s, only 16 antimicrobial agents have received broad regulatory approval – mostly close relatives of medicines already in use and thus unlikely to evade bacterial resistance for an extended period. The creation of novel compounds is a lengthy and unprofitable endeavor, given that curative treatments are less lucrative as those managing longer-term conditions. The scientific outlook continues to be bleak.

A Spark of Optimism and a Novel Approach

Nevertheless, the recent announcement of two new FDA-approved antibiotics against gonorrhoea is good news and, crucially, confirms a innovative method of incentivising development. A particular of the recently approved medications, Zoliflodacin, is the product of a novel kind of collaboration between a global health organization and a drug firm. The public health partnership provided financial support and managed clinical trials to defray costs and navigate approval processes. This sort of support in advance helps direct the sector towards areas of greatest public health necessity.

This approach and another praised “subscription model” – launched to guarantee revenue to companies investing in certain antibiotics – constitute the best hope of sustaining a trickle of novel treatments from the existing system.

The Inevitable Challenge of Drug Resistance

But even hurrying the development of drugs currently in development is not enough. The new drug is at times described as a new class of antimicrobial, indicating it targets a part of the infectious bacteria that no other drug does, in principle compelling the pathogen to start from zero in evolving a defense to it. Researchers and doctors are relieved to have a new option for gonorrhoea – which has strains resistant to all existing treatments – but warn that eventual drug resistance to this compound is certain.

As has grown customary with recent antimicrobials, there is therefore an argument about whether it should be held in reserve, restricted to extremely drug-resistant cases only – confining its use to settings where high‑end lab testing is available. This kind of rational approach should be the global standard, but often cannot be implemented easily in many regions.

A Diminishing Pipeline of Innovation

On a wider scale, it is difficult to see where the flow of additional novel antimicrobials we require could possibly originate. The former official's comment nodded to the fact that surveying the natural world for biological compounds – as with the first antibiotic – has had declining success. Use of AI has been mooted to speed up the search, although a highly-touted initial discovery identified in 2020 has not yet advanced past animal trials. Fully lab-created compounds, which are largely or entirely lab-created, are continually in development, but often run up against the fundamental rules of molecular science – the fact that we envision a molecule does not guarantee we can synthesise it easily.

Moving Quickly to Stand Still

The dominant expert assessment is that when it comes to antibiotics, we must run very fast truly just to remain in the current position. Prudent, globally managed deployment is the sole method to preserve our therapeutic edge. Regrettably, the scale of future breakthroughs is likely to seem meager in contrast to the therapeutic revolution of the previous century.