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During her tenure as head of the WHO, a past official famously stated that all of the “simple” antibiotics had long since been discovered. The argument was that in addressing the pressing threat of antibiotic-resistant infections, we would face difficulties to find new treatments – or preserve the existing ones – without developing novel approaches of operating. This assessment was correct.

A Slow and Challenging Development Path

Since the late 2010s, only sixteen antimicrobial agents have received broad regulatory approval – mostly similar derivatives of drugs already in use and thus unlikely to evade bacterial resistance for an extended period. The development of novel compounds is a lengthy and unprofitable endeavor, given that one-off medicines are not as profitable as those managing chronic ailments. The scientific outlook remains grim.

A Glimmer of Hope and a New Model

However, the news this month of a pair of novel FDA-approved antibiotics for gonorrhoea is a welcome development and, importantly, confirms a new way of encouraging development. A particular of the recently approved medications, Zoliflodacin, is the result of a novel kind of collaboration between a global health organization and a drug firm. The non-profit provided financial support and organised testing phases to offset costs and navigate approval processes. This sort of assistance in advance helps direct the industry towards fields of greatest public health necessity.

This approach and a separate praised revenue guarantee scheme – launched to ensure income to companies investing in specific antimicrobials – constitute the strongest chance of maintaining a trickle of novel treatments from the existing framework.

The Unavoidable Problem of Drug Resistance

But even hurrying the production of compounds currently in development is not enough. The new drug is at times categorized as a novel type of antibiotic, meaning it targets a component of the infectious bacteria that no other drug does, in principle compelling the pathogen to begin anew in evolving a countermeasure to it. Scientists and physicians are relieved to have a new option for gonorrhea – which has strains resistant to every known antibiotic – but warn that future resistance to it is certain.

As has grown customary with new antibiotics, there is therefore an argument about whether it should be stockpiled, restricted to extremely drug-resistant infections only – limiting its application to settings where sophisticated diagnostics is available. This kind of prudent approach should be the worldwide norm, but frequently cannot be implemented easily in many parts of the world.

A Diminishing Pipeline of Discovery

On a wider scale, it is hard to see where the stream of other new antibiotics we require could possibly originate. The former official's 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 accelerate the search, although a highly-touted early candidate identified in recent years hasn't yet advanced past animal trials. Fully lab-created compounds, which are mainly or fully synthesized, are constantly in development, but often confront the iron laws of molecular science – the fact that we envision a compound does not guarantee we can create 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 remain in the same place. Careful, internationally coordinated use is the only way to maintain our advantage. Sadly, the magnitude of forthcoming discoveries is likely to seem meager compared with the therapeutic revolution of the previous century.