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During a time as head of the World Health Organization, a former leader famously stated that all of the “easy” antimicrobials had long since been discovered. The argument was that in tackling the urgent danger of antibiotic-resistant infections, we would struggle to find new medicines – or conserve the current arsenal – without developing novel approaches of operating. This assessment was accurate.

A Slow and Unprofitable Development Path

Since 2017, just sixteen antimicrobial agents have received widespread official clearance – primarily close relatives of drugs already in use and thus not expected to evade resistance for an extended period. The development of novel compounds is a lengthy and financially unattractive endeavor, given that curative treatments are less lucrative as ones treating chronic conditions. The overall prospect remains bleak.

A Glimmer of Optimism and a New Model

However, the recent announcement of a pair of novel regulator-approved antibiotics against gonorrhea is a welcome development and, importantly, confirms a innovative method of incentivising development. One of the recently approved medications, a compound called Zoliflodacin, is the result of a novel kind of collaboration between a global health organization and a drug firm. The non-profit supplied funding and organised testing phases to defray expenses and clear approval processes. This sort of support in advance helps steer the industry towards fields of greatest global need.

This approach and a separate lauded “subscription model” – launched to guarantee income to companies that invest in specific antimicrobials – represent the best hope of maintaining a trickle of new drugs from the existing system.

The Inevitable Challenge of Drug Resistance

But even hurrying the production of drugs in the pipeline is not sufficient. The new drug is at times described as a new class of antimicrobial, meaning it attacks a part of the pathogen that existing treatments does, theoretically compelling the pathogen to begin anew in evolving a defense to it. Scientists and doctors are relieved to have a new drug for gonorrhoea – 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, exists consequently an debate about whether it should be stockpiled, restricted to highly resistant cases only – limiting its use to settings where sophisticated diagnostics is available. This kind of rational strategy should be the global standard, but frequently cannot be deployed easily in many parts of the world.

A Diminishing Stream of Discovery

More broadly, it is hard to see where the flow of other new antibiotics we need could possibly originate. The former official's comment nodded to the fact that searching the living world for biological compounds – as with the first antibiotic – has had declining success. Use of artificial intelligence has been proposed to speed up the search, although a highly-touted early candidate found in recent years hasn't yet advanced past animal trials. Synthetic drugs, 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 create it easily.

Moving Quickly to Stand Still

The prevailing scientific evaluation is that when it comes to antibiotics, we must run very fast truly just to stay in the same place. Careful, internationally coordinated use is the only way to maintain our therapeutic edge. Regrettably, the scale of future breakthroughs is likely to seem miserly in contrast to the curative bonanza of the 20th century.