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During a time as head of the World Health Organization, a past official famously remarked that all of the “simple” antibiotics had long since been discovered. The point was that in tackling the urgent danger of antibiotic-resistant bacterial infections, we would struggle to find new treatments – or preserve the current arsenal – without finding new ways of working. This view proved accurate.

A Slow and Challenging Development Path

Since 2017, just 16 antibiotics have gained widespread official clearance – primarily close relatives of medicines already in use and thus not expected to evade bacterial resistance for long. The creation of novel compounds is a slow and unprofitable business, given that curative treatments are not as profitable as those treating longer-term ailments. The overall prospect remains grim.

A Spark of Optimism and a Novel Approach

Nevertheless, the recent announcement of a pair of novel regulator-approved antibiotics against gonorrhea is a welcome development and, crucially, validates a new way of encouraging development. A particular of the recently approved medications, Zoliflodacin, is the result of a novel kind of collaboration between a global health organization and a drug firm. The non-profit supplied funding and managed testing phases to offset expenses and clear approval processes. This type of assistance upfront helps direct the sector towards fields of greatest public health necessity.

This approach and another praised “subscription model” – launched to guarantee income to companies that invest in specific antimicrobials – constitute the strongest chance of sustaining a dripfeed of new drugs from the current framework.

The Unavoidable Challenge of Resistance

But even accelerating the production of drugs currently in development isn't sufficient. Zoliflodacin is at times described as a novel type of antibiotic, indicating it attacks a part of the pathogen that existing treatments does, in principle compelling the pathogen to start from zero in developing a defense to it. Scientists and doctors are grateful to have a new option for gonorrhoea – which has resistant strains to all existing treatments – but warn that future resistance to it is inevitable.

As has grown customary with new antibiotics, exists therefore an argument about whether it should be stockpiled, rationed to highly resistant infections only – limiting its use to situations where sophisticated diagnostics is available. This sort of rational strategy should be the worldwide norm, but often cannot be implemented readily in many parts of the world.

A Diminishing Stream of Discovery

More broadly, it is hard to see where the stream of other novel antimicrobials we need could possibly come from. The former official's statement acknowledged the fact that searching the natural world for biological compounds – as with penicillin – has had declining success. Use of AI has been mooted to accelerate the search, although a highly-touted early candidate identified in recent years hasn't yet progressed past preclinical studies. Fully lab-created compounds, which are mainly or fully lab-created, are constantly in research, but often confront the fundamental rules of molecular science – just because we imagine a compound doesn't mean we can synthesise it easily.

Running Fast to Stand Still

The dominant expert assessment is that when it comes to antimicrobials, we must run very fast truly just to stay in the current position. Careful, globally managed deployment is the sole method to preserve our therapeutic edge. Sadly, the scale of future breakthroughs is going to seem miserly compared with the curative bonanza of the 20th century.