The Solution to AMR Needs a Multi-Pronged Approach

Antimicrobial resistance (AMR) is too often described as a future threat. For physicians treating drug-resistant infections and for patients with limited options, it is already a present-day crisis. In 2019, bacterial antimicrobial resistance was associated with an estimated 4.95 million deaths worldwide, including 1.27 million deaths directly attributable to resistant bacterial infections.¹

For me, antimicrobial resistance is not an abstract policy issue; it is a real and urgent problem that affects whether clinicians have options when patients need them most. I know how difficult it is to develop a new antimicrobial therapy, and I also know how important it is that we keep pushing forward. Without an environment that can support that work, even the most promising science may never reach the patients who need it.

The problem is not only that bacteria evolve. It is that the traditional system built to discover, finance, and sustain new medicines—which only rewards investment through drug sales—is not compatible with the development of novel antibiotics and often undervalues them when they are doing the most public-health good. A new antibiotic may be most important when clinicians use it sparingly for severe infections, yet that is exactly why a sales-driven market offers its developer the least return.

Rebuilding the antibiotic pipeline is necessary, but it will not be sufficient. AMR will require more than another round of promising compounds: the antibiotics that are most needed do not provide the economic returns to encourage their development. Addressing AMR will need coordinated scientific, clinical, economic, and public-health action to deliver differentiated new therapies, effective diagnostics, stewardship, reliable access, and market structures that reward preparedness rather than volume.

The Pipeline Needs Differentiation, Not Just Volume

The antibiotic pipeline is often judged by the number of candidates in development. Counting programs, however, is an imperfect measure of preparedness. The more important question is whether those candidates provide genuinely new tools for infections that have become resistant to existing therapies.

The World Health Organization’s (WHO) 2023 review of antibacterial agents in clinical and preclinical development assessed whether these direct-acting small molecules met predefined innovation criteria, including absence of known cross-resistance and presence of a new target, mode of action, or drug class. Of the 97 antibiotics in clinical development, most did not address antibiotic-resistant antimicrobial organisms. Thus, the WHO concluded that the current pipeline remains insufficient to meet the growing burden of drug-resistant infections.

The problem is not merely a shortage of candidates. It is also a shortage of novelty. Drugs derived from familiar classes can still help patients, but they may remain vulnerable to resistance mechanisms that bacteria have already learned to deploy. A crowded pipeline can therefore create the appearance of progress while still leaving clinicians with too few distinct options when resistant infections emerge.

Differentiating antimicrobial science could expand treatment options in specific, high-need settings. One example is a newer class of nucleotide derivatives, called Bisphosphocin compounds. This newer class of small-molecule antimicrobials includes Nu-3, an investigational topical antibiotic being evaluated for infected diabetic foot ulcers. In a peer-reviewed preclinical study, Nu-3 demonstrated a broad-spectrum antibacterial profile in vitro and significant activity in mouse infection models.² While promising, these findings require confirmation in well-controlled clinical studies.

Yet, incremental advances to current antimicrobials remain valuable. Existing antibiotic classes are foundational to modern medicine, and improvements in spectrum, potency, safety, dosing, or resistance coverage can materially benefit patients. But given that the WHO identified multiple pathogens with antibiotic resistance as either critical- or high-priority pathogen, a more resilient antimicrobial ecosystem also requires therapies with differentiated mechanisms of action, novel molecular architectures, and the potential to retain activity against pathogens that have accumulated resistance to widely used drugs. These assessments can help direct scarce research resources toward areas of substantial public health need.

Even so, developers should not assume that any antimicrobial will remain insulated from resistance. Bacteria will continue to evolve. The goal is to give clinicians multiple scientifically distinct options and reduce dependence on a narrow set of vulnerable mechanisms. That requires a development environment that can support the difficult transition from promising preclinical findings to rigorous clinical evidence.

Stewardship Creates a Market Paradox

Scientific difficulty is only part of the challenge. Antibiotic economics remain fundamentally misaligned with public health need.

Stewardship practices are necessary to preserve new antibiotics, but they also constrain the revenues available to their developers. That tension is easy to miss until it is stated plainly: society wants the drug on the shelf, effective and ready, while a conventional pharmaceutical model rewards use. The result is a mismatch between public-health value and commercial return.³

The answer is not weaker stewardship. Responsible antibiotic use remains essential. The market must instead reward developers for producing and maintaining access to valuable therapies even when appropriate use is selective. Subscription or market-entry models—a one‑time, government‑funded payment (pull incentive) to the developer upon market entry of a new antibiotic—are designed to delink part of a product’s return from the number of units sold.³

For example, the Pioneering Antimicrobial Subscriptions To End Upsurging Resistance Act of 2023, or PASTEUR Act, proposed that the US Department of Health and Human Services enter subscription contracts for designated critical-need antimicrobial drugs. Such a model would reward access to qualifying products rather than relying only on prescription volume, while retaining requirements related to stewardship, appropriate use, product availability, and postmarketing obligations.

Industry groups, including the Biotechnology Innovation Organization, have supported subscription-style payments that would decouple antimicrobial returns from sales volume while encouraging access, stewardship, and continued development. But the policy debate should extend beyond whether a particular incentive is adopted. The larger question is whether health systems are prepared to pay for antimicrobial readiness before an outbreak or resistance pattern makes the need impossible to ignore.

To address this, pull incentives should be paired with sustained push incentives, including grants, public-private partnerships, nondilutive translational funding, and development support. Scientific progress is not enough if the organizations generating it cannot survive the journey from discovery through clinical development, review, and responsible commercialization.

The Market Must Recognize that Antibiotics are Healthcare Infrastructure

Antibiotics are not ordinary commercial products. They are a form of healthcare infrastructure. Their value lies partly in use, but also in readiness: the ability to treat a resistant infection when it appears, protect procedures that depend on effective infection control, and preserve clinical options before a crisis unfolds. Quarterly unit sales cannot capture that preparedness value.

A durable market for new antibiotics must therefore recognize the difference between a medicine’s sales volume and its societal value. It must support reliable manufacturing, appropriate distribution, and continued availability after approval. In this field, restraint is not market failure; it is often the public health goal, but it should not be the reason for reduced capital investment in new approaches.

Targeted capital has continued to support some programs with differentiated science and credible development plans. The AMR Action Fund was launched as an industry-led initiative expected to raise more than $1 billion, invest in smaller biotechnology companies, and support a goal of bringing two to four new antibiotics to patients by 2030. But selective investment cannot substitute for durable reimbursement, procurement, and access mechanisms. Without them, even scientifically successful antibiotics may struggle to remain available after approval.

Science Must Be Paired with Prevention

Even highly effective new antimicrobial therapies will not solve AMR on their own. The central challenge is building a framework that keeps antimicrobial therapies effective and deploys them responsibly. A successful strategy must connect new treatments with diagnostics, stewardship, prevention, and access.

Faster, more actionable diagnostics are critical to this. Clinicians often begin treatment before identifying the causative organism or its resistance profile. Rapid tests can support more targeted therapy, reduce inappropriate antibiotic exposure, and help preserve broad-spectrum options for patients who truly need them.

As new antibiotics and diagnostics become available, stewardship must evolve alongside this development. The goal is not simply to restrict use, but to ensure that patients receive the right therapy at the right time and for the right duration. Effective stewardship protects existing antibiotics and provides a framework for introducing new ones responsibly.

Innovation must also reach patients in real-world settings. A therapy that remains inaccessible because of cost, distribution barriers, limited diagnostic capacity, or fragmented reimbursement cannot deliver its full public health value. Because AMR is global, the response must account for both advanced health systems and resource-constrained settings.

Building a Durable Response

I am encouraged by researchers and companies exploring new antimicrobial classes that could complement existing antibiotics and broaden the treatment options available to clinicians. But I have also learned that discovery does not move on its own. To reach patients, promising innovation needs a policy environment that rewards access, preparedness, and meaningful therapeutic differentiation.

This is what keeps me focused on the work. When patients face drug-resistant infections, they deserve more than a dwindling set of therapeutic choices. I feel that urgency most clearly when I think about a clinician reaching the limits of existing antibiotics and still needing another answer for the patient in front of them.

That is why I do not believe responsibility can rest with researchers or companies alone. If we are serious about preserving treatment options, the full antimicrobial ecosystem must be part of the answer: scientists, clinicians, investors, pharmaceutical companies, regulators, governments, and patient advocates. The next generation of therapies will require tolerance for scientific risk and a long-term view of value that recognizes an antibiotic may be most important when it is used least often, for patients with nowhere else to turn.

The antibiotic pipeline remains essential, but counting development programs is not enough. Success should be measured by whether we can deliver scientifically differentiated therapies, preserve their effectiveness through stewardship, and sustain the organizations capable of bringing those therapies to patients.

AMR is both a biological challenge and an economic one, and it will take more than one kind of solution. New therapies, better diagnostics, responsible stewardship, dependable access, and revised incentives all matter. But the larger choice is straightforward: if we keep treating antibiotics as ordinary commercial products, we should expect the same fragile result. If we value them as essential protection for patients, we have a better chance of building the durable response this crisis demands.

Disclosure of Conflict of Interest: Kelvin Cooper is chief executive officer of Lakewood-Amedex Biotherapeutics, which develops the investigational antimicrobial candidate Nu-3 and other members of the Bisphosphocin class discussed in this article. He has a direct commercial interest in the development of these programs. Lakewood-Amedex Biotherapeutics is a member of the Biotechnology Innovation Organization.