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During her time as director general of the WHO, a past official famously remarked that all of the “easy” antibiotics had already been found. The argument was that in addressing the urgent threat of antibiotic-resistant bacterial infections, we would struggle to discover new treatments – or preserve the current arsenal – without finding new ways of operating. This assessment proved correct.

A Sluggish and Unprofitable Pipeline

Since 2017, only sixteen antimicrobial agents have gained broad official clearance – mostly similar derivatives of drugs already in use and thus unlikely to overcome bacterial resistance for an extended period. The creation of novel compounds is a lengthy and financially unattractive endeavor, given that one-off treatments are less lucrative as those managing longer-term conditions. The scientific outlook remains bleak.

A Glimmer of Optimism and a Novel Approach

Nevertheless, the news this month of two new regulator-approved drugs for gonorrhea is good news and, crucially, validates a innovative method of encouraging research. A particular of the recently approved medications, Zoliflodacin, is the result of a unique type of partnership between a Swiss non‑profit and a pharmaceutical company. The public health partnership provided financial support and managed testing phases to offset costs and clear approval processes. This type of support upfront helps steer the industry towards areas of greatest global need.

This model and another praised “subscription model” – initiated to ensure income to companies investing in specific antibiotics – represent the strongest chance of sustaining a dripfeed of novel treatments from the current system.

The Inevitable Problem of Drug Resistance

But even accelerating the development of compounds currently in development isn't enough. The new drug is at times described as a new class of antimicrobial, meaning it attacks a component of the infectious bacteria that existing treatments does, in principle forcing the pathogen to begin anew in evolving a countermeasure to it. Scientists and doctors are relieved to have a new option for gonorrhoea – which has strains resistant to all existing treatments – but caution that eventual drug resistance to it is inevitable.

As has grown customary with recent antimicrobials, exists therefore an debate about whether it should be held in reserve, restricted to extremely drug-resistant infections only – confining its application to settings where high‑end lab testing is accessible. This sort of prudent approach should be the worldwide norm, but often can't be deployed easily in many regions.

A Diminishing Pipeline of Innovation

More broadly, it is difficult to see where the stream of other novel antimicrobials we require could realistically come from. The former official's statement nodded to the fact that surveying the natural world for natural sources – as with the first antibiotic – has had declining success. Use of artificial intelligence has been proposed to speed up the discovery process, although a much-celebrated initial discovery found in recent years has not yet advanced past preclinical studies. Fully lab-created compounds, which are largely or entirely synthesized, are constantly in development, but often run up against the fundamental rules of molecular science – just because we imagine a molecule does not guarantee we can create it easily.

Running Fast to Stay in Place

The prevailing expert assessment is that when it comes to antibiotics, we must run very fast truly just to remain in the current position. Careful, internationally coordinated deployment is the sole method to maintain our therapeutic edge. Sadly, the magnitude of future breakthroughs is going to seem meager compared with the therapeutic revolution of the previous century.