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During a tenure as head of the WHO, a past official famously stated that all of the “simple” antibiotics had already been found. The point was that in addressing the pressing danger of antibiotic-resistant bacterial infections, we would face difficulties to find new treatments – or conserve the current arsenal – without finding new ways of working. This view proved correct.

A Sluggish and Challenging Development Path

Since 2017, only sixteen antimicrobial agents have received broad regulatory approval – primarily similar derivatives of medicines currently available and thus not expected to overcome bacterial resistance for long. The creation of novel compounds is a lengthy and financially unattractive business, given that curative medicines are not as profitable as ones managing chronic ailments. The scientific outlook continues to be bleak.

A Spark of Optimism and a Novel Approach

However, the news this month of a pair of novel regulator-approved antibiotics against gonorrhea is a welcome development and, importantly, validates a new way of incentivising development. One of the new drugs, a compound called Zoliflodacin, is the result of a unique type of collaboration between a global health organization and a pharmaceutical company. The public health partnership provided funding and organised testing phases to defray expenses and navigate approval processes. This type of support in advance helps steer the sector towards areas of greatest global need.

This model and another praised revenue guarantee scheme – initiated to guarantee revenue to firms investing in specific antibiotics – represent the strongest chance of sustaining a trickle of new drugs from the current framework.

The Unavoidable Challenge of Drug Resistance

But even accelerating the production of drugs currently in development is not enough. The new drug is sometimes described as a novel type of antimicrobial, meaning it attacks a component of the pathogen that existing treatments does, theoretically compelling the bacterium to begin anew in developing a defense to it. Researchers and physicians are relieved to have a new drug for gonorrhoea – which has resistant strains to all existing treatments – but caution that eventual drug resistance to this compound is certain.

As has become the norm with recent antimicrobials, there is therefore an debate about whether it should be stockpiled, restricted to highly resistant infections only – limiting its use to situations where sophisticated diagnostics is available. This kind of rational strategy should be the worldwide norm, but often can't be implemented readily in many regions.

A Diminishing Pipeline of Innovation

More broadly, it is difficult to see where the flow of other novel antimicrobials we need could possibly come from. The aforementioned statement acknowledged 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 mooted to accelerate the discovery process, although a much-celebrated initial discovery identified in recent years has not yet progressed past animal trials. Fully lab-created compounds, which are largely or entirely lab-created, are constantly in development, but often confront the iron laws of molecular science – just because we envision a compound doesn't mean we can create it without great difficulty.

Moving Quickly to Stand Still

The dominant scientific evaluation is that when it comes to antimicrobials, we must move with great speed truly just to stay in the current position. Prudent, internationally coordinated deployment is the sole method to preserve our advantage. Regrettably, the scale of forthcoming breakthroughs is going to seem miserly compared with the therapeutic revolution of the 20th century.