The predictions read like something out of dystopian novel.  

A study based on current resistance figures from 204 countries estimates that by mid-century antimicrobial resistance (AMR) will directly cause 39 million deaths and be associated with a broader 169 million more. To put that figure into perspective, that is more than four times the number of deaths from HIV since the virus was identified. Deaths attributed to AMR are expected to increase by almost 75% from current levels, which would make untreatable infections the leading cause of death ahead of cancer and heart disease.  

Deaths from AMR occur when bacteria changes in ways that no longer respond to treatment. The more antibiotics used; the more bacteria become resistant. Infections that were once treatable such as pneumonia or staph infections are growing increasingly difficult to cure. Cases of ceftriaxone-resistant gonorrhoea – a last-resort treatment – have been rising, leading to concerns that the sexually transmitted disease could become completely untreatable.  

“Pharma companies will never make enough money developing a new class of antibiotics as they would make on something like Ozempic or a new cancer drug,” says McKinney, “Which is why you need to put money into push funding.”

Further complicating the picture is unregulated factory farming in the US and middle-income countries. As parts of Asia, Latin America and Africa become wealthier, the appetite for meat increases. When too many antibiotics are used on factory farms, the excess can contaminate the water supply with the potential to make humans more resistant to antibiotics. A water treatment facility in Hyderabad in India was found to have a concentration of ciprofloxacin, a broad-spectrum antibiotic, that was enough to treat 44,000 people. A report on the global burden of AMR published in The Lancet predicts that most deaths associated with incurable infections will be in Asia, Sub-Saharan Africa, and The Caribbean.  

Despite the grim forecast, relatively little investment is going into researching the development of new antibiotics. The last new class of antibiotics was discovered in the 1980s and came to market in 2004. While there have been new antibiotics approved since then, they have been variations of existing classes rather than truly new discoveries. 

David McKinney, director at The Alliance for Reducing Microbial Resistance, says the problem getting new antibiotics to market is that it can cost billions to develop a new drug only for doctors to resist prescribing it to avoid building resistance. Biotech startups developing in new antibiotics have gone bankrupt in recent years because they could not find ways to recuperate investment, and pharma giants including Novartis and Allergan have fled the sector.  

“Pharma companies will never make enough money developing a new class of antibiotics as they would make on something like Ozempic or a new cancer drug,” says McKinney, “Which is why you need to put money into push funding.”  

Push funding is another way of saying incentivising research so that drug companies are not worried about recuperating costs. One such method is known as the ‘Netflix’ model – a subscription-based approach where governments pay a fixed annual fee to a pharmaceutical company for access to new antibiotics, regardless of how much they end up using.  

The National Health Service in England is piloting a Netflix subscription model with two pharmaceutical companies, Pfizer and Shionogi, where it will pay a fixed amount each year for access to WHO-approved antibiotics. The National Institute for Health and Care Excellence will assess each medicine’s eligibility for the scheme, which will pay fees of between £5mn and £20mn per year. Each new pharma company that wishes to participate needs certification to prove they have responsibly disposed of waste and active pharmaceutical ingredients from the antibiotics. This is done to minimize the risk of antibiotics trickling into wastewater which can lead to resistance in humans further down the line.  

McKinney says his concern with the Netflix model is that it needs to be a collective effort on the part of all developed countries. So far, the UK is the only G7 country to contribute to the scheme. Past subscription schemes for expensive medications have proven successful. Australia piloted a model in 2016 for a subscription deal with a group of pharmaceutical companies for a novel and expensive drug for Hepatitis-C. The scheme led to improved health benefits and a savings of $5bn for the Australian government.  

There is some good news in the antibiotic pipeline. Earlier this year a researcher at McMaster University in Canada discovered a new antibiotic in the soil from his backyard. The lasso-shaped molecule called lariocidin has a distinct mode of action that makes it the first of an entirely new class of antibiotic compound. But discovering the molecule is only the first step to getting it to patients. Multiple clinical trials and millions in investment will be needed to confirm the compound’s efficiency. 

If each country paid its fair share of the research costs, they could get the new antibiotic much sooner.