The global fight against antibiotic-resistant infections has received a rare piece of good news, yet the broader outlook remains critically bleak. This month, the US Food and Drug Administration (FDA) approved two new antibiotics specifically for gonorrhoea, a disease that has developed strains resistant to every known treatment. While this marks a significant victory, it underscores a much larger and losing battle: the desperate worldwide scramble to develop new antimicrobial drugs before our current arsenal becomes completely obsolete.
A New Model for a Stagnant Pipeline
The approval of one drug, Zoliflodacin, is notable not just for its medical potential but for how it was developed. It is the product of an innovative partnership between the non-profit Global Antibiotic Research and Development Partnership (GARDP) and the pharmaceutical firm Innoviva. This model, where a non-profit provides upfront funding and navigates costly clinical trials, is designed to steer the industry towards areas of urgent global health need that are typically unprofitable.
This approach mirrors the UK government's pioneering 'subscription model', launched in 2022, which guarantees revenue to companies that invest in developing certain high-priority antibiotics. Since 2017, only 16 new antibiotics have gained widespread regulatory approval, most being close relatives of existing drugs. The development of genuinely novel treatments is slow and financially unattractive compared to medicines for chronic conditions, making these new incentive models our best hope for a continued trickle of innovation.
The Inevitability of Resistance and the Rationing Dilemma
Zoliflodacin is cautiously described as a new class of antibiotic, meaning it attacks bacteria in a novel way, theoretically forcing pathogens to start from scratch in evolving resistance. However, scientists universally agree that future resistance to this drug is inevitable. This creates an immediate ethical and practical dilemma: should such a precious new tool be held in reserve, rationed only for the most resistant cases?
While this rational approach is ideal, it is difficult to implement globally, particularly in the global south where access to high-end laboratory testing needed to identify highly resistant strains can be limited. The sad reality is that every new antibiotic begins its useful life with an expiration date, and preserving its efficacy requires internationally coordinated, careful use that is often at odds with immediate healthcare needs.
A Drying Well of Discovery
The fundamental challenge, as former WHO Director-General Dr Margaret Chan observed, is that all the "easy" antibiotics have been found. The golden age of discovering drugs like penicillin from natural sources has yielded diminishing returns. The hope that artificial intelligence could rapidly accelerate discovery has yet to bear fruit; a celebrated AI-identified candidate from 2020, halicin, remains stuck in animal trials.
Fully synthetic, lab-created drugs are constantly in development but bump against the 'iron laws of chemistry' – designing a theoretical molecule is one thing, synthesising it effectively is another. The prevailing scientific view is stark: in the antibiotic arena, we must run very fast just to stand still. The scale of future breakthroughs is likely to seem miserly compared to the curative bonanza of the 20th century.
The approval of new drugs for gonorrhoea is a vital proof of concept for new research models, but it is a small victory in a war humanity is currently losing. Without sustained global effort in coordinated drug use, international funding, and innovative development pathways, the miracle of modern antibiotics risks becoming a relic of the past.
