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During her tenure as head of the WHO, a past official famously stated that all of the “simple” antimicrobials had already been found. The point was that in tackling the urgent threat of antibiotic-resistant infections, we would face difficulties to discover new medicines – or preserve the current arsenal – without finding new ways of operating. This view proved correct.

A Sluggish and Challenging Pipeline

Since 2017, only 16 antimicrobial agents have received broad regulatory approval – primarily close relatives of medicines currently available and thus not expected to evade bacterial resistance for long. The development of novel compounds is a lengthy and financially unattractive business, given that curative medicines are not as profitable as ones treating chronic ailments. The overall prospect remains grim.

A Glimmer of Hope and a Novel Approach

However, the recent announcement of two new regulator-approved drugs against gonorrhoea is a welcome development and, crucially, confirms a innovative method of incentivising research. One of the recently approved medications, Zoliflodacin, is the product of a novel kind of partnership between a Swiss non‑profit and a drug firm. The non-profit supplied financial support and organised testing phases to offset costs and navigate regulatory hurdles. This type of assistance in advance helps steer the industry towards areas of greatest public health necessity.

This approach and a separate lauded revenue guarantee scheme – initiated to guarantee revenue to companies that invest in specific antimicrobials – constitute the best hope of maintaining a trickle of new drugs from the existing framework.

The Inevitable Challenge of Drug Resistance

But even accelerating the development of compounds currently in development is not sufficient. Zoliflodacin is sometimes categorized as a new class of antimicrobial, meaning it targets a component of the infectious bacteria that existing treatments does, theoretically compelling the pathogen to begin anew in evolving a countermeasure to it. Scientists and doctors are grateful to have a new option for gonorrhoea – which has resistant strains to all existing treatments – but caution that future resistance to this compound is certain.

As has become the norm with new antibiotics, exists consequently an debate about whether it should be held in reserve, restricted to extremely drug-resistant infections only – limiting its use to settings where high‑end lab testing is accessible. This sort of rational strategy should be the global standard, but frequently can't be implemented easily in many parts of the world.

A Diminishing Pipeline of Innovation

More broadly, it is hard to see where the flow of other new antibiotics we require could possibly originate. The aforementioned statement nodded to the fact that searching the living world for biological compounds – as with penicillin – has had diminishing returns. Use of artificial intelligence has been proposed to accelerate the discovery process, although a highly-touted initial discovery identified in 2020 has not yet progressed past animal trials. Fully lab-created compounds, that are mainly or fully lab-created, are continually in research, but often confront the iron laws of chemistry – just because we imagine a compound doesn't mean we can synthesise it without great difficulty.

Moving Quickly to Stay in Place

The prevailing scientific evaluation is that when it comes to antimicrobials, we must run very fast truly just to stay in the same place. Careful, globally managed deployment is the only way to maintain our therapeutic edge. Sadly, the scale of forthcoming discoveries is likely to seem meager in contrast to the therapeutic revolution of the previous century.