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During her time as head of the WHO, a former leader famously stated that all of the “easy” antibiotics had already been found. The point was that in addressing the pressing danger of antibiotic-resistant infections, we would struggle to find new medicines – or preserve the current arsenal – without developing new ways of working. This view was accurate.

A Sluggish and Challenging Development Path

Since 2017, only sixteen antimicrobial agents have received widespread official clearance – mostly similar derivatives of medicines currently available and thus unlikely to overcome resistance for long. The development of new ones is a slow and unprofitable business, given that curative medicines are less lucrative as those managing longer-term conditions. The scientific outlook continues to be bleak.

A Spark of Hope and a New Model

However, the news this month of a pair of novel regulator-approved antibiotics against gonorrhea is a welcome development and, crucially, validates a new way of encouraging research. One of the new drugs, Zoliflodacin, is the result of a novel kind of partnership between a Swiss non‑profit and a drug firm. The non-profit provided funding and managed testing phases to offset expenses and navigate regulatory hurdles. This sort of assistance in advance helps direct the sector towards fields of most pressing public health necessity.

This approach and a separate lauded revenue guarantee scheme – initiated to guarantee revenue to companies that invest in specific antibiotics – constitute the strongest chance of sustaining a trickle of novel treatments from the existing framework.

The Unavoidable Challenge of Drug Resistance

But even hurrying the production of compounds currently in development is not enough. Zoliflodacin is at times described as a new class of antibiotic, meaning it attacks a component of the pathogen that existing treatments does, theoretically compelling the bacterium to begin anew in evolving a countermeasure to it. Researchers and physicians are relieved to have a new option for gonorrhoea – which has strains resistant to all existing treatments – but caution that future resistance to this compound is inevitable.

As has grown customary with new antibiotics, there is consequently an argument about whether it should be stockpiled, restricted to highly resistant infections only – confining its use to settings where high‑end lab testing is available. This sort of rational strategy should be the worldwide norm, but often can't be implemented readily in many regions.

A Dwindling Stream of Innovation

More broadly, it is difficult to see where the flow of other novel antimicrobials we need could realistically come from. The former official's statement nodded to the fact that surveying the living world for biological compounds – as with penicillin – has had diminishing returns. Use of AI has been mooted to accelerate the discovery process, although a much-celebrated initial discovery identified in 2020 hasn't yet advanced past animal trials. Fully lab-created compounds, that are largely or entirely lab-created, are continually in development, but often confront the fundamental rules of chemistry – the fact that we imagine a molecule does not guarantee we can synthesise it without great difficulty.

Running Fast to Stay in Place

The prevailing expert assessment is that when it comes to antibiotics, we must move with great speed indeed just to stay in the current position. Careful, globally managed use is the sole method to maintain our advantage. Sadly, the scale of forthcoming breakthroughs is going to seem miserly in contrast to the therapeutic revolution of the 20th century.