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During her time as head of the World Health Organization, a past official famously stated that all of the “simple” antimicrobials had already been found. The point was that in tackling the pressing danger of antibiotic-resistant infections, we would face difficulties to discover new treatments – or preserve the current arsenal – without finding novel approaches of operating. This view proved correct.

A Slow and Unprofitable Development Path

Since the late 2010s, just 16 antibiotics have received widespread regulatory approval – primarily close relatives of medicines already in use and thus not expected to evade resistance for long. The creation of new ones is a slow and financially unattractive business, given that curative treatments are not as profitable as those managing longer-term conditions. The scientific outlook remains bleak.

A Spark of Optimism and a Novel Approach

However, the recent announcement of two new regulator-approved antibiotics against gonorrhoea is a welcome development and, crucially, confirms a new way of encouraging development. One of the recently approved medications, Zoliflodacin, is the result of a unique type of collaboration between a Swiss non‑profit and a pharmaceutical company. The public health partnership supplied funding and organised testing phases to defray expenses and navigate approval processes. This sort of assistance upfront helps direct the industry towards areas of greatest public health necessity.

This approach and a separate lauded revenue guarantee scheme – initiated to ensure revenue to companies that invest in certain antibiotics – constitute the best hope of sustaining a trickle of new drugs from the current system.

The Unavoidable Challenge of Drug Resistance

But even hurrying the development of compounds currently in development is not sufficient. The new drug is at times described as a new class of antimicrobial, meaning it attacks a component of the pathogen that no other drug does, in principle forcing the pathogen to start from zero in evolving a countermeasure to it. Scientists and doctors are relieved to have a new option for gonorrhea – which has strains resistant to all existing treatments – but warn that eventual drug resistance to this compound is inevitable.

As has grown customary with recent antimicrobials, exists consequently an argument about whether it should be held in reserve, rationed to highly resistant infections only – confining its use to settings where sophisticated diagnostics is accessible. This sort of prudent strategy should be the global standard, but frequently can't be implemented easily in many parts of the world.

A Diminishing Stream of Discovery

More broadly, it is difficult to see where the stream of other new antibiotics we require could possibly originate. The aforementioned statement nodded to the fact that searching the natural world for biological compounds – as with the first antibiotic – has had diminishing returns. Use of artificial intelligence has been mooted to speed up the discovery process, although a much-celebrated early candidate identified in recent years has not yet advanced past animal trials. Fully lab-created compounds, that are mainly or fully synthesized, are continually in research, but often run up against the iron laws of chemistry – just because we imagine a compound doesn't mean we can create it without great difficulty.

Moving Quickly to Stand Still

The dominant expert assessment is that when it comes to antibiotics, we must run very fast truly just to remain in the current position. Careful, globally managed deployment is the sole method to maintain our advantage. Sadly, the magnitude of future breakthroughs is likely to seem meager compared with the therapeutic revolution of the 20th century.