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During a tenure as head of the WHO, a past official famously stated that all of the “simple” antimicrobials had already been found. The point was that in tackling the urgent threat of drug-resistant bacterial infections, we would struggle to find new medicines – or conserve the current arsenal – without developing new ways of operating. This assessment proved correct.

A Sluggish and Challenging Pipeline

Since the late 2010s, just sixteen antibiotics have received widespread official clearance – mostly similar derivatives of drugs currently available and thus unlikely to evade bacterial resistance for an extended period. The creation of new ones is a lengthy and unprofitable endeavor, given that curative treatments are less lucrative as ones managing longer-term conditions. The overall prospect continues to be bleak.

A Glimmer of Hope and a New Model

Nevertheless, the recent announcement of two new regulator-approved antibiotics for gonorrhea is a welcome development and, crucially, validates a innovative method of encouraging research. A particular of the recently approved medications, a compound called Zoliflodacin, is the product of a novel kind of partnership between a global health organization and a drug firm. The public health partnership supplied funding and organised testing phases to defray expenses and clear approval processes. This sort of assistance upfront helps direct the sector towards fields of most pressing public health necessity.

This model and a separate praised revenue guarantee scheme – initiated to ensure revenue to companies investing in specific antibiotics – constitute the strongest chance of sustaining a trickle of novel treatments from the existing framework.

The Unavoidable Challenge of Drug Resistance

But even accelerating the production of drugs currently in development isn't sufficient. Zoliflodacin is sometimes described as a new class of antimicrobial, indicating it attacks a part of the infectious bacteria that existing treatments does, theoretically compelling the bacterium to start from zero in developing a defense to it. Researchers and physicians are relieved to have a new drug for gonorrhea – which has resistant strains to every known antibiotic – but warn that future resistance to it is inevitable.

As has grown customary with recent antimicrobials, there is therefore an debate about whether it should be held in reserve, restricted to extremely drug-resistant infections only – confining its use to situations where high‑end lab testing is accessible. This kind of rational strategy should be the worldwide norm, but often cannot be deployed readily in many regions.

A Diminishing Stream of Discovery

On a wider scale, it is hard to see where the stream of additional novel antimicrobials we require could possibly come from. The aforementioned comment nodded to the fact that searching the living world for natural sources – as with the first antibiotic – has had diminishing returns. The application of artificial intelligence has been mooted to accelerate the search, although a highly-touted early candidate identified in 2020 has not yet advanced past animal trials. Fully lab-created compounds, which are mainly or fully lab-created, are constantly in development, but often confront the fundamental rules of chemistry – just because we envision a compound doesn't mean we can synthesise it without great difficulty.

Moving Quickly to Stay in Place

The prevailing expert assessment is that when it comes to antimicrobials, we must run very fast indeed just to remain in the current position. Careful, globally managed deployment is the only way to preserve our therapeutic edge. Sadly, the scale of future discoveries is going to seem miserly compared with the therapeutic revolution of the 20th century.