The Antibiotic Crisis: Why Pharma Abandoned the Drugs We Need Most

A Slow-Motion Catastrophe

In 2019, a woman in Nevada died from an infection that resisted all 26 antibiotics available in the United States. Every drug doctors tried failed. The bacterium, Klebsiella pneumoniae, had evolved defenses against everything modern medicine could throw at it.

Her case made headlines, but it wasn't unique. An estimated 5 million people die each year from infections involving antibiotic-resistant bacteria. That's more than HIV/AIDS, malaria, and breast cancer combined. And the problem is getting worse.

We're not running out of antibiotics because we can't make them. We're running out because it doesn't pay to make them.

The Economics of Abandonment

Developing a new antibiotic costs roughly the same as developing any other drug: somewhere between $1 billion and $2.5 billion, depending on who's counting. The development timeline is similar too, around 10-15 years from discovery to approval.

But here's where antibiotics differ from, say, a cholesterol drug or a cancer treatment: doctors don't want to use them.

When a new antibiotic launches, infectious disease specialists immediately recommend using it sparingly. It becomes the drug of last resort, reserved for patients who've failed everything else. This is good medicine. It slows the development of resistance. But it's terrible business.

Consider the math. A new diabetes drug might be taken by millions of patients for decades, generating tens of billions in revenue. A new antibiotic might be prescribed to a few thousand patients per year, generating tens of millions if you're lucky. For pharmaceutical companies, the choice is obvious.

Of the 18 largest pharmaceutical companies, 15 have abandoned antibiotic research entirely. The companies that remain are mostly small biotechs, and they're struggling. Several have gone bankrupt even after successfully bringing new antibiotics to market.

The ESKAPE Pathogens

In 2017, the WHO published a list of the bacteria that pose the greatest threat to human health. At the top: the ESKAPE pathogens, a group of six bacteria that have become increasingly resistant to available antibiotics.

These bacteria share a terrifying trait: they can acquire resistance genes from other bacteria, even other species. A resistance gene that evolves in one bacterium can spread horizontally through bacterial populations, jumping from species to species like wildfire.

Laboratory studies show that ESKAPE pathogens can develop clinically relevant resistance to new antibiotics within 60 days of exposure. We're not just losing a race; we're falling further behind with every passing year.

How We Got Here

The golden age of antibiotic discovery ran from the 1940s through the 1960s. Scientists found new classes of antibiotics in soil samples, moldy bread, and microbial cultures. Each new class worked differently, attacking bacteria through distinct mechanisms. Resistance to one class didn't confer resistance to others.

Then the discoveries stopped. Not because scientists stopped looking, but because the easy finds had been found. The low-hanging fruit was gone. No new class of antibiotics has been discovered since 1987.

Meanwhile, antibiotic use exploded. Doctors prescribed them for viral infections (which antibiotics can't treat). Farmers fed them to livestock to promote growth and prevent disease in crowded feedlots. Patients stopped taking courses early, allowing partially-resistant bacteria to survive and spread.

Evolution did the rest. Bacteria reproduce quickly, sometimes dividing every 20 minutes. Each division is an opportunity for mutations that confer resistance. The antibiotics we overused created massive evolutionary pressure selecting for resistant strains.

The Innovation Desert

The pipeline of new antibiotics is dangerously thin. According to the Pew Charitable Trusts, only about 39 antibiotics were in clinical development as of 2024. Of these:

• Only 13 (33%) are likely to reach market
• Only 31% would be effective against ESKAPE pathogens
• Almost none represent new classes with novel mechanisms

Most antibiotics in development are variations on existing classes. They may work for a while against resistant bacteria, but the same resistance mechanisms will eventually defeat them. We need fundamentally new approaches, but those are the riskiest and most expensive to develop.

The companies trying to develop new antibiotics face brutal economics. Achaogen spent 15 years and nearly $1 billion developing plazomicin, a new antibiotic for serious urinary tract infections. The FDA approved it in 2018. A year later, the company declared bankruptcy. Sales totaled $800,000. Similar stories have played out across the industry.

"The capitalistic model that has overtaken most pharmaceutical companies and now drives science innovation based on return on investment does not work anymore for antibiotics."

Beyond Traditional Antibiotics

Recognizing that the traditional model has failed, researchers are exploring alternative approaches:

Bacteriophages: Viruses that infect and kill bacteria. Phage therapy was popular in the Soviet Union but largely abandoned in the West after antibiotics arrived. Now it's getting a second look. Unlike antibiotics, phages can evolve alongside bacteria, potentially staying effective longer. Several companies are developing phage therapies for resistant infections.

Antibody therapies: Monoclonal antibodies that target specific bacterial toxins or surface proteins. These are expensive but can be lifesaving for specific infections.

Microbiome approaches: Using beneficial bacteria to outcompete pathogens. Fecal microbiota transplants have proven remarkably effective against C. difficile infections, which kill 30,000 Americans yearly.

Antibiotic potentiators: Drugs that don't kill bacteria directly but disable their resistance mechanisms, making existing antibiotics effective again.

Antimicrobial peptides: Natural compounds produced by the immune system that bacteria have difficulty developing resistance against.

Policy Failures and Potential Solutions

The antibiotic crisis is fundamentally a market failure. The drugs we need most are the drugs least profitable to make. Several policy solutions have been proposed:

Push incentives: Government grants and tax credits to support antibiotic R&D. The US BARDA program and the UK's Antibiotic Research UK provide some funding, but amounts remain modest compared to the billions needed.

Pull incentives: Guaranteed payments to companies that successfully develop new antibiotics, regardless of sales. The UK has piloted a "subscription model" where the government pays a fixed annual fee for access to new antibiotics, decoupling revenue from volume. The US PASTEUR Act would create similar incentives but has stalled in Congress.

Market entry rewards: Large lump-sum payments (potentially $1 billion or more) when a new antibiotic receives approval, providing immediate return on investment.

Stewardship improvements: Better diagnostics to ensure antibiotics are prescribed only when needed. Restrictions on agricultural use. Global coordination to preserve the antibiotics we have.

The Countdown

Without intervention, projections are grim. The O'Neill Review, commissioned by the UK government, estimated that antimicrobial resistance could cause 10 million deaths per year by 2050, more than cancer kills today. The economic cost could reach $100 trillion in lost global output.

We've been warned about this crisis for decades. In 1945, Alexander Fleming, who discovered penicillin, cautioned in his Nobel Prize lecture that bacteria would evolve resistance if antibiotics were overused. We ignored him.

The good news: we know what to do. The science exists. The policy solutions exist. What's lacking is political will and creative financing. Antibiotics are a global public good, like clean air or a stable climate. They don't fit neatly into market-based healthcare systems.

The alternative to action is a return to the pre-antibiotic era, when a scratch could kill, surgery was a gamble, and pneumonia was called "the captain of the men of death." We have the knowledge to prevent that future. Whether we have the wisdom is another question.