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During a time as director general of the WHO, a former leader famously stated that all of the “simple” antimicrobials had long since been discovered. The argument was that in tackling the pressing threat of antibiotic-resistant bacterial infections, we would face difficulties to find new medicines – or conserve the existing ones – without developing novel approaches of working. This view proved accurate.

A Slow and Unprofitable Pipeline

Since the late 2010s, only sixteen antibiotics have received widespread regulatory approval – primarily similar derivatives of drugs currently available and thus unlikely to evade resistance for long. The development of novel compounds is a lengthy and unprofitable endeavor, given that curative treatments are less lucrative as ones treating longer-term ailments. The scientific outlook continues to be bleak.

A Spark of Optimism and a New Model

However, the recent announcement of two new FDA-approved antibiotics for gonorrhea is good news and, importantly, confirms a innovative method of incentivising research. A particular of the new drugs, Zoliflodacin, is the result of a novel kind of partnership between a global health organization and a pharmaceutical company. The public health partnership provided financial support and managed testing phases to defray costs and clear approval processes. This sort of assistance in advance helps steer the sector towards fields of most pressing global need.

This approach and another praised revenue guarantee scheme – initiated to guarantee income to companies investing in specific antibiotics – constitute the strongest chance of sustaining a trickle of new drugs from the existing system.

The Unavoidable Challenge of Drug Resistance

But even hurrying the development of drugs currently in development is not sufficient. Zoliflodacin is at times categorized as a novel type of antimicrobial, indicating it targets a part of the pathogen that no other drug does, theoretically compelling the pathogen to start from zero in evolving a countermeasure to it. Scientists and doctors are grateful to have a new drug for gonorrhea – which has resistant strains to every known antibiotic – but caution that eventual drug resistance to this compound is certain.

As has grown customary with recent antimicrobials, there is consequently an debate about whether it should be held in reserve, rationed to extremely drug-resistant infections only – limiting its use to situations where high‑end lab testing is available. This sort of prudent approach should be the global standard, but often can't be implemented readily in many parts of the world.

A Dwindling Stream of Discovery

More broadly, it is difficult to see where the flow of other novel antimicrobials we require could realistically come from. The aforementioned statement nodded to the fact that searching the natural world for biological compounds – as with penicillin – has had declining success. The application of artificial intelligence has been proposed to accelerate the search, although a much-celebrated early candidate found in recent years hasn't yet progressed past preclinical studies. Fully lab-created compounds, that are mainly or fully lab-created, are continually in research, but often run up against the iron laws of molecular science – just because we imagine a compound doesn't mean we can synthesise it without great difficulty.

Running Fast to Stand Still

The dominant expert assessment is that when it comes to antibiotics, we must move with great speed indeed just to remain in the current position. Careful, internationally coordinated deployment is the sole method to maintain our advantage. Sadly, the magnitude of forthcoming discoveries is likely to seem miserly in contrast to the curative bonanza of the previous century.