🔗 Share this article

During a time as head of the WHO, a past official famously remarked that all of the “easy” antimicrobials had long since been discovered. The argument was that in addressing the urgent threat of drug-resistant bacterial infections, we would face difficulties to discover new treatments – or preserve the existing ones – without developing new ways of operating. This assessment was accurate.

A Slow and Unprofitable Pipeline

Since the late 2010s, only 16 antibiotics have received broad regulatory approval – mostly close relatives of drugs already in use and thus unlikely to overcome bacterial resistance for long. The creation of new ones is a lengthy and financially unattractive endeavor, given that one-off treatments are not as profitable as those managing longer-term ailments. The overall prospect continues to be bleak.

A Glimmer of Hope and a New Model

Nevertheless, the news this month of two new regulator-approved antibiotics for gonorrhoea is a welcome development and, importantly, validates a innovative method of incentivising development. A particular of the new drugs, a compound called Zoliflodacin, is the product of a novel kind of collaboration between a Swiss non‑profit and a drug firm. The public health partnership supplied funding and organised clinical trials to offset costs and clear regulatory hurdles. This sort of support in advance helps steer the industry towards areas of greatest public health necessity.

This model and another praised revenue guarantee scheme – launched to guarantee revenue to companies investing in certain antibiotics – represent the strongest chance of maintaining a trickle of new drugs from the current system.

The Unavoidable Problem of Resistance

But even accelerating the production of compounds in the pipeline isn't enough. The new drug is sometimes described as a new class of antibiotic, indicating it attacks a component of the infectious bacteria that existing treatments does, theoretically forcing the bacterium to start from zero in developing a countermeasure to it. Scientists and doctors are grateful to have a new option for gonorrhea – which has resistant strains to all existing treatments – but warn that eventual drug resistance to this compound is certain.

As has grown customary with recent antimicrobials, there is therefore an debate about whether it should be held in reserve, restricted to extremely drug-resistant infections only – confining its use to settings where sophisticated diagnostics is available. This sort of prudent strategy should be the worldwide norm, but often cannot be deployed easily in many regions.

A Diminishing Stream of Discovery

On a wider scale, it is hard to see where the stream of additional novel antimicrobials we require could possibly originate. The aforementioned comment acknowledged the fact that surveying the living world for natural sources – as with the first antibiotic – has had declining success. The application of artificial intelligence has been proposed to speed up the search, although a much-celebrated initial discovery found in 2020 has not yet advanced past animal trials. Fully lab-created compounds, which are mainly or fully lab-created, are constantly in development, but often run up against the iron laws of chemistry – the fact that we envision a molecule doesn't mean we can synthesise it without great difficulty.

Running Fast to Stand Still

The dominant scientific evaluation is that when it comes to antibiotics, we must run very fast truly just to remain in the same place. Prudent, globally managed use is the sole method to preserve our therapeutic edge. Regrettably, the scale of forthcoming discoveries is going to seem miserly in contrast to the curative bonanza of the 20th century.