Antibiotics: Recent Breakthroughs Provide Great News, But We Are Losing the Larger Race

During a tenure as director general of the WHO, a former leader famously stated that all of the “simple” antimicrobials had already been found. The point was that in tackling the urgent threat of drug-resistant bacterial infections, we would face difficulties to find new medicines – or preserve the existing ones – without finding new ways of operating. This assessment was correct.

A Sluggish and Challenging Development Path

Since 2017, just sixteen antibiotics have gained broad regulatory approval – mostly close relatives of medicines already in use and thus not expected to evade bacterial resistance for an extended period. The development of novel compounds is a slow and financially unattractive business, given that curative treatments are not as profitable as ones managing longer-term conditions. The overall prospect remains bleak.

A Spark of Optimism and a Novel Approach

Nevertheless, the news this month of two new FDA-approved antibiotics for gonorrhea is a welcome development and, importantly, confirms a new way of encouraging research. One of the new drugs, a compound called Zoliflodacin, is the result of a unique type of collaboration between a global health organization and a pharmaceutical company. The public health partnership supplied funding and managed clinical trials to offset costs and clear regulatory hurdles. This type of assistance upfront helps steer the sector towards fields of greatest public health necessity.

This model and another praised revenue guarantee scheme – launched to guarantee income to companies investing in specific antimicrobials – represent the strongest chance of sustaining a dripfeed of new drugs from the current system.

The Unavoidable Challenge of Resistance

But even accelerating the production of compounds in the pipeline isn't sufficient. Zoliflodacin is sometimes categorized as a novel type of antibiotic, indicating it targets a part of the pathogen that existing treatments does, theoretically compelling the bacterium to begin anew in developing a defense to it. Scientists and doctors are grateful to have a new drug for gonorrhea – which has resistant strains to all existing treatments – but caution 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 situations where high‑end lab testing is available. This sort of rational strategy should be the global standard, but frequently can't be deployed easily in many parts of the world.

A Dwindling Pipeline of Innovation

More broadly, it is hard to see where the flow of other new antibiotics we require could realistically originate. The aforementioned statement nodded to the fact that surveying the living world for biological compounds – as with the first antibiotic – has had diminishing returns. Use of AI has been proposed to accelerate the search, although a highly-touted initial discovery identified in 2020 hasn't yet advanced past animal trials. Fully lab-created compounds, which are mainly or fully lab-created, are constantly in research, but often run up against the iron laws of molecular science – just because we imagine a molecule does not guarantee we can synthesise it easily.

Moving Quickly 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. Careful, globally managed deployment is the sole method to maintain our therapeutic edge. Regrettably, the magnitude of forthcoming discoveries is likely to seem miserly in contrast to the curative bonanza of the previous century.