Antimicrobial resistance (AMR) poses a significant global threat, with an estimated 92 million deaths projected between 2025 and 2050. Efforts to address this challenge have largely focused on economic incentives, such as the Pioneering Antimicrobial Subscriptions To End Upsurging Resistance (PASTEUR) Act in the United States. However, history has shown that antibiotic discovery follows a cyclical boom-and-bust pattern, with market saturation leading to reduced investment and eventual shortages. Rather than relying solely on financial subsidies, sustainable solutions should prioritise reducing selective pressure on antimicrobial use, fostering responsible prescribing practices and stabilising the antibiotic development pipeline.
While the intention behind economic incentives like the PASTEUR Act is to encourage pharmaceutical companies to develop new antibiotics, this model fails to address the underlying problem: the overuse and misuse of antibiotics, which accelerates the development of resistance. Simply increasing the number of available antibiotics does not guarantee their effective use or longevity. Without effective stewardship and market reforms, resistance will continue to outpace drug development, rendering newly discovered antibiotics ineffective in a relatively short timeframe. Instead, a more balanced approach must be considered—one that strengthens existing antibiotics while minimising unnecessary exposure to them.
Understanding the History of AMR
Microbial resistance to antimicrobial agents has existed for billions of years, making the complete eradication of resistance impossible. Despite numerous antibiotic discoveries over the past century, repeated boom-and-bust cycles have led to periods of antibiotic shortages. The rapid emergence of resistance to newly developed antibiotics further complicates the issue, rendering short-term solutions ineffective. Instead of flooding the market with similar antibiotics, strategies must focus on minimising the overuse of existing treatments, developing new classes of antimicrobials with minimal cross-resistance and ensuring a consistent pipeline for discovery.
Historically, each surge in antibiotic development has been followed by an inevitable downturn. The first major wave of antibiotic discovery occurred between the 1940s and 1960s, bringing numerous breakthrough treatments to market. However, the rapid emergence of resistance soon diminished their effectiveness. The pattern repeated in the 1970s through the 1990s, with another pipeline collapse occurring in the early 2000s. This cyclical instability highlights the need for a more sustainable approach that does not solely rely on the continuous introduction of new drugs but also ensures their judicious use.
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Challenges in Antibiotic Development and Accessibility
The claim that the antibiotic pipeline is collapsing is misleading. While antibiotic approvals declined sharply between 2008 and 2012, significant efforts in research and development have since revitalised the field. The number of antibiotics in clinical development has increased by over 600% since 2004. However, despite these advances, many new antibiotics remain prohibitively expensive or inaccessible in lower-income regions. High costs limit widespread use, meaning that increasing the number of antibiotics alone does not effectively address AMR-associated deaths. Instead, solutions should ensure equitable access to existing and new antibiotics while prioritising infection prevention strategies.
The disparity in antibiotic accessibility highlights a crucial problem: while innovation continues, affordability and distribution remain significant challenges. Many new antibiotics are priced at levels that healthcare systems in lower-income countries cannot afford, preventing those who need them most from receiving effective treatment. Furthermore, the availability of antibiotics alone does not resolve the issue of AMR-related mortality, as infections continue to pose severe health risks even when effective treatments exist. Instead, broader systemic reforms are needed to bridge the gap between innovation and accessibility, ensuring that life-saving antibiotics are both available and used appropriately.
Sustainable Strategies for AMR Mitigation
To combat AMR without relying on indefinite government funding, alternative approaches must be adopted. Implementing pay-for-performance mechanisms can discourage overprescription by linking financial incentives to responsible antibiotic use. Additionally, research funding should be directed toward preventive measures, such as vaccines, microbiome-based therapies and rapid diagnostics, to reduce reliance on antibiotics. Another key reform requires specialised training in antimicrobial stewardship for healthcare providers who prescribe new antibiotics. This would promote responsible prescribing practices and slow the emergence of resistance.
Reducing the selective pressure that drives AMR is critical. Overuse and misuse of antibiotics in both human healthcare and agriculture continue to accelerate resistance development. Regulatory measures can play a pivotal role in curbing inappropriate use. For example, enforcing restrictions on non-prescription antibiotic sales, as successfully implemented in some countries, has significantly reduced unnecessary antibiotic consumption. Similarly, implementing certification requirements for healthcare providers prescribing critical antibiotics ensures that only those with adequate training make these crucial decisions, preventing excessive and inappropriate prescriptions.
Addressing AMR requires a shift from reactive financial incentives to sustainable, systemic reforms. History has demonstrated that an overreliance on economic subsidies fosters temporary solutions rather than long-term stability. By prioritising stewardship, responsible prescribing and equitable access, global health systems can mitigate AMR while preserving the efficacy of existing and future antibiotics. A proactive approach will help balance the need for new antibiotics with strategies that reduce dependence on them, ensuring a more sustainable and effective response to AMR.
Ultimately, the fight against AMR is not about simply increasing the number of available antibiotics but about preserving the ones we already have through better regulation, research and global cooperation. Economic incentives alone cannot resolve this crisis—broader systemic changes must take precedence. Through responsible use, improved accessibility and sustained innovation, the global healthcare community can address AMR to ensure long-term stability without perpetuating the cycle of antibiotic dependency and resistance.
Source: Health Affairs Scholar
Image Credit: iStock
