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During a time as head of the World Health Organization, a past official famously stated that all of the “simple” antibiotics had already been found. The argument was that in tackling the pressing threat of drug-resistant infections, we would struggle to discover new treatments – or conserve the existing ones – without finding novel approaches of working. This assessment proved accurate.

A Slow and Challenging Pipeline

Since the late 2010s, only 16 antibiotics have received widespread official clearance – primarily close relatives of medicines already in use and thus not expected to overcome bacterial resistance for an extended period. The development of new ones is a lengthy and unprofitable business, given that one-off treatments are not as profitable as ones managing longer-term conditions. The overall prospect remains bleak.

A Glimmer of Hope and a New Model

Nevertheless, the recent announcement of a pair of novel FDA-approved drugs for gonorrhoea is a welcome development and, crucially, confirms a new way of incentivising research. One of the new drugs, Zoliflodacin, is the product of a unique type of collaboration between a Swiss non‑profit and a pharmaceutical company. The non-profit supplied financial support and organised testing phases to offset costs and clear approval processes. This sort of assistance in advance helps steer the industry towards fields of most pressing global need.

This approach and another praised “subscription model” – initiated to ensure income to companies investing in specific antimicrobials – represent the strongest chance of sustaining a dripfeed of new drugs from the current framework.

The Unavoidable Challenge of Drug Resistance

But even hurrying the production of compounds in the pipeline isn't enough. Zoliflodacin is at times categorized as a novel type of antimicrobial, indicating it targets a component of the pathogen that existing treatments does, in principle compelling the bacterium to begin anew in developing a countermeasure to it. Scientists and doctors are grateful to have a new drug for gonorrhea – which has strains resistant to every known antibiotic – but warn that eventual drug resistance to this compound is inevitable.

As has grown customary with recent antimicrobials, exists therefore an argument about whether it should be held in reserve, restricted to extremely drug-resistant infections only – confining its application to situations where sophisticated diagnostics is available. This sort of prudent approach should be the global standard, but frequently can't be implemented easily in many parts of the world.

A Dwindling Pipeline of Innovation

More broadly, it is hard to see where the stream of additional novel antimicrobials we require could realistically come from. The aforementioned statement acknowledged the fact that surveying the living world for biological compounds – as with penicillin – has had declining success. Use of AI has been proposed to accelerate the discovery process, although a much-celebrated initial discovery found in recent years has not yet advanced past preclinical studies. Fully lab-created compounds, that are mainly or fully lab-created, are constantly in research, but often confront the fundamental rules of molecular science – the fact that we envision a compound does not guarantee we can synthesise it without great difficulty.

Moving Quickly to Stay in Place

The dominant expert assessment is that when it comes to antibiotics, we must move with great speed truly just to stay in the same place. Careful, globally managed use is the only way to maintain our advantage. Sadly, the magnitude of future discoveries is likely to seem miserly in contrast to the therapeutic revolution of the previous century.