Antibiotic Stewardship Is Undermining the Economics of Drug Development
Antibiotics are indispensable medicines, but their commercial model is breaking down, argues the Financial Times’ Aanu Adeoye: they take decades and more than $1bn to develop, yet responsible use requires that sales be kept low. As drug resistance drives more than 1mn deaths a year and large companies cut their pipelines, advocates are pushing subscription payments that reward access rather than volume, alongside greater public funding for development.
Antibiotics’ public value is colliding with their commercial logic
Aanu Adeoye describes antibiotics as medicines that have cured countless infections and extended average human lifespan by as much as 23 years. Yet the category faces a basic mismatch between medical need and the economics of developing products to meet it.
Bacteria are becoming resistant to existing medicines, while too few replacements are reaching the market. Large pharmaceutical companies have increasingly left the field altogether. According to the Access to Medicine Foundation, the number of antimicrobial pipeline projects at large research-based companies fell 35% over the five years to 2026.
The underlying problem, Adeoye says, is that antibiotics are not sold like many other drugs. Developing one can take decades and cost more than $1bn in research, development and clinical trials, with no guarantee that it will be profitable. Even a successful product faces deliberately constrained demand.
Antibiotics are generally used sparingly to slow the emergence of bacterial resistance. That limits sales precisely when companies are trying to recover a long and expensive investment. As use-by dates expire, potential income is lost while manufacturers must bear the cost of producing fresh replacements. Drug companies, Adeoye says, have struggled not merely to make money from antibiotics, but to recover their costs.
Generally, antibiotics are used sparingly to slow the inevitable process of bacterial resistance.
A shrinking pipeline faces a rising resistance burden
The decline in development is concrete: the Access to Medicine Foundation count shown by Adeoye falls from 92 antimicrobial pipeline projects in 2021 to 60 in 2026.
| Year | Antimicrobial pipeline projects |
|---|---|
| 2021 | 92 |
| 2026 | 60 |
Researchers estimate that drug-resistant infections directly cause more than 1mn deaths every year. The source presents a projection of roughly 2mn annual deaths by 2050 if the development of new antibiotics continues to lag behind bacterial resistance.
| Period | Estimated annual deaths directly caused by drug-resistant infections |
|---|---|
| Current | >1mn |
| 2050 projection | ~2mn |
Development has not stopped. Small and medium-sized companies are still developing treatments, including for antibiotic-resistant fungal infections. Among the three large pharmaceutical companies that continue to invest, GSK has 30 projects under way. Adeoye says the UK company won approval in 2025 for the first new class of drugs to combat urinary tract infections in almost 30 years.
Those projects and approvals sit against a larger gap: the pipeline at major research-based companies has shrunk while the projected burden from drug resistance rises sharply.
Advocates want payment untied from sales volume
Advocates want governments to expand subscription schemes, under which payment is for access to antibiotics rather than the volumes sold. The proposal addresses the commercial constraint Adeoye identifies: a company’s sales are limited in part because antibiotics are meant to be used sparingly.
The source does not set out the specific terms of such schemes. But advocates present them as part of a broader effort to reward investment in a category where conventional sales have not reliably covered development and manufacturing costs.
Public funding is also beginning to target the development gap. In April 2026, the European Commission announced a €30mn investment in public-private partnerships involved in developing new antibiotics. Aanu Adeoye describes that as a “shot in the arm,” while noting that advocates say more is needed to reward investment.