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During her tenure as head of the WHO, a past official famously stated that all of the “easy” antimicrobials had long since been discovered. The point was that in tackling the urgent threat of antibiotic-resistant infections, we would struggle to find new treatments – or conserve the existing ones – without finding novel approaches of working. This assessment proved correct.

A Sluggish and Challenging Pipeline

Since the late 2010s, only 16 antibiotics have gained widespread official clearance – mostly similar derivatives of medicines already in use and thus unlikely to overcome bacterial resistance for long. The creation of novel compounds is a slow and unprofitable business, given that curative treatments are less lucrative as ones managing chronic ailments. The overall prospect remains grim.

A Glimmer of Hope and a Novel Approach

Nevertheless, the news this month of two new regulator-approved antibiotics for 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 unique type of partnership between a global health organization and a drug firm. The non-profit provided financial support and managed testing phases to offset expenses and navigate regulatory hurdles. This type of support in advance helps direct the industry towards areas of most pressing global need.

This approach and a separate praised revenue guarantee scheme – initiated to ensure revenue to firms investing in specific antimicrobials – constitute the best hope of maintaining a trickle of novel treatments from the current framework.

The Inevitable Challenge of Drug Resistance

But even accelerating the development of drugs in the pipeline is not enough. Zoliflodacin is at times described as a new class of antibiotic, indicating it attacks a component of the pathogen that no other drug does, in principle compelling the bacterium to start from zero in developing a defense to it. Researchers and physicians are grateful to have a new drug for gonorrhea – which has resistant strains to all existing treatments – but caution that eventual drug resistance to it is certain.

As has grown customary with recent antimicrobials, exists therefore an argument about whether it should be stockpiled, rationed to extremely drug-resistant cases only – confining its use to situations where sophisticated diagnostics is available. This sort of prudent approach should be the worldwide norm, but often can't be implemented easily in many parts of the world.

A Diminishing Stream of Discovery

On a wider scale, it is difficult to see where the stream of additional novel antimicrobials we need could realistically originate. The aforementioned comment acknowledged the fact that searching the natural world for biological compounds – as with penicillin – has had declining success. The application of AI has been mooted to accelerate the discovery process, although a highly-touted initial discovery found in recent years hasn't yet progressed past animal trials. Fully lab-created compounds, that are largely or entirely lab-created, are constantly in development, but often run up against the iron laws of chemistry – the fact that we envision a compound doesn't mean we can create it easily.

Moving Quickly 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. Prudent, internationally coordinated use is the sole method to preserve our therapeutic edge. Regrettably, the scale of forthcoming breakthroughs is likely to seem miserly compared with the therapeutic revolution of the previous century.