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During her tenure as head of the WHO, a former leader famously stated that all of the “simple” antimicrobials had already been found. The argument was that in addressing the urgent threat of drug-resistant bacterial infections, we would struggle to find new treatments – or preserve the current arsenal – without finding novel approaches of operating. This assessment proved accurate.

A Slow and Unprofitable Development Path

Since the late 2010s, just 16 antibiotics have received broad regulatory approval – primarily close relatives of medicines already in use and thus unlikely to evade resistance for long. The development of new ones is a slow and unprofitable business, given that one-off treatments are less lucrative as ones treating longer-term conditions. The overall prospect remains grim.

A Spark of Optimism and a New Model

Nevertheless, the recent announcement of two new regulator-approved drugs against gonorrhoea is good news and, crucially, confirms a innovative method of encouraging research. One of the recently approved medications, a compound called Zoliflodacin, is the result of a novel kind of collaboration between a Swiss non‑profit and a pharmaceutical company. The public health partnership provided funding and managed clinical trials to defray costs and navigate approval processes. This sort of support upfront helps steer the sector towards fields of most pressing global need.

This approach and a separate praised “subscription model” – launched to ensure income to firms investing in certain antibiotics – constitute the best hope of maintaining a dripfeed of new drugs from the current framework.

The Inevitable Problem of Drug Resistance

But even hurrying the production of drugs currently in development is not enough. Zoliflodacin is sometimes described as a new class of antibiotic, meaning it targets a component of the infectious bacteria that existing treatments does, in principle forcing the pathogen to start from zero in developing a countermeasure to it. Researchers and doctors are grateful to have a new drug for gonorrhea – which has resistant strains to every known antibiotic – but caution that eventual drug resistance to it is inevitable.

As has grown customary with new antibiotics, there is consequently an debate about whether it should be stockpiled, rationed to highly resistant infections only – limiting its application to situations where sophisticated diagnostics is accessible. This sort of prudent strategy should be the worldwide norm, but often can't be implemented easily in many parts of the world.

A Dwindling Pipeline of Discovery

On a wider scale, it is hard to see where the flow of additional new antibiotics we need could realistically come from. The aforementioned statement nodded to the fact that surveying the living world for natural sources – as with penicillin – has had diminishing returns. Use of artificial intelligence has been mooted to speed up the discovery process, although a highly-touted early candidate found in recent years has not yet progressed past preclinical studies. Synthetic drugs, which are largely or entirely lab-created, are constantly in development, but often confront the iron laws of chemistry – the fact that we imagine a molecule does not guarantee we can create it without great difficulty.

Running Fast to Stay in Place

The dominant scientific evaluation is that when it comes to antimicrobials, we must run very fast truly just to remain in the same place. Prudent, internationally coordinated deployment is the sole method to maintain our therapeutic edge. Regrettably, the scale of forthcoming breakthroughs is likely to seem meager compared with the curative bonanza of the 20th century.