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During her tenure as head of the WHO, a past official famously remarked that all of the “easy” antibiotics had long since been discovered. The argument was that in tackling the urgent threat of antibiotic-resistant bacterial infections, we would struggle to find new medicines – or preserve the current arsenal – without developing new ways of working. This view was accurate.

A Slow and Challenging Pipeline

Since the late 2010s, just sixteen antimicrobial agents have gained widespread regulatory approval – mostly similar derivatives of medicines currently available and thus not expected to evade resistance for long. The creation of novel compounds is a lengthy and unprofitable business, given that curative treatments are not as profitable as those treating longer-term ailments. The overall prospect remains grim.

A Glimmer of Hope and a Novel Approach

Nevertheless, the recent announcement of a pair of novel regulator-approved antibiotics for gonorrhoea is a welcome development and, crucially, confirms a innovative method of encouraging research. A particular of the new drugs, a compound called Zoliflodacin, is the result of a unique type of collaboration between a Swiss non‑profit and a pharmaceutical company. The non-profit provided financial support and organised testing phases to defray costs and clear regulatory hurdles. This sort of assistance in advance helps steer the industry towards fields of most pressing public health necessity.

This approach and another lauded “subscription model” – initiated to ensure revenue to firms that invest in specific antibiotics – constitute the best hope of maintaining a trickle of new drugs from the current framework.

The Inevitable Challenge of Resistance

But even hurrying the production of drugs currently in development isn't enough. Zoliflodacin is at times described as a new class of antibiotic, meaning it attacks a component of the infectious bacteria that no other drug does, theoretically compelling the bacterium to start from zero in evolving a countermeasure to it. Researchers and physicians are grateful to have a new drug for gonorrhoea – which has strains resistant to all existing treatments – but caution that future resistance to this compound 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 cases only – confining its application to situations where high‑end lab testing is accessible. This kind of prudent strategy should be the global standard, but frequently cannot be deployed easily in many regions.

A Dwindling Stream of Innovation

On a wider scale, it is difficult to see where the stream of additional novel antimicrobials we require could possibly come from. The aforementioned comment nodded to the fact that searching the living world for biological compounds – as with penicillin – has had declining success. Use of artificial intelligence has been proposed to speed up the discovery process, although a much-celebrated early candidate found in 2020 hasn't yet progressed past animal trials. Synthetic drugs, which are largely or entirely lab-created, are constantly in development, but often run up against the iron laws of molecular science – the fact that we envision a compound doesn't mean we can create it without great difficulty.

Moving Quickly to Stay in Place

The prevailing expert assessment is that when it comes to antimicrobials, we must run very fast indeed just to remain in the same place. Prudent, internationally coordinated use is the only way to maintain our therapeutic edge. Sadly, the magnitude of future discoveries is going to seem miserly in contrast to the curative bonanza of the previous century.