Antibiotic effectiveness is one of the invisible infrastructures on which modern society depends. It rarely attracts attention when it works, yet much of contemporary medicine would be difficult, dangerous, or impossible without it. Surgery, organ transplantation, cancer chemotherapy, intensive care, neonatal medicine, and the management of many common infections all depend on the availability of effective antibiotics. As antimicrobial resistance (AMR) advances, this infrastructure is progressively undermined, and the consequences extend far beyond infectious diseases.
AMR has often been portrayed primarily as a medical problem, presumably because its most immediate manifestations occur at the bedside. A patient develops an infection, available antibiotics fail, treatment options narrow, hospitalization becomes longer and more complex, and the risk of complications and death increases. These consequences are real and devastating. Yet viewing AMR only through this clinical lens is insufficient. Resistance is also a public-health, economic, developmental, environmental, and societal challenge. A narrow perspective risks reducing a systemic global threat to a succession of individual treatment failures and, in doing so, prevents AMR from receiving the political attention and collective response that it requires.
The consequences of declining antibiotic effectiveness extend throughout health systems. When first-line antibiotics no longer work, patients may require more expensive or toxic alternatives, longer hospital stays, additional diagnostic procedures, and more intensive care. Healthcare-associated infections become more difficult to prevent and treat. Procedures that depend on effective antimicrobial prophylaxis become increasingly risky. The consequences are particularly severe in health systems already facing shortages of trained professionals, microbiology laboratories, medicines, infection-prevention resources, and financial capacity.
AMR is therefore also a global health equity issue. Resistant organisms do not respect national borders, but societies do not have equal capacity to prevent, detect, and treat the infections they cause. In resource-constrained settings, inadequate access to diagnostics, clean water, sanitation, vaccination, infection prevention and control, and quality-assured antibiotics can magnify the consequences of resistance. At the same time, lack of access to antibiotics remains a major cause of preventable illness and death in many parts of the world. The global response must therefore confront two seemingly opposing challenges: excessive and inappropriate antibiotic use where antibiotics are readily available, and inadequate access where effective treatment remains unavailable. Stewardship without access is inequitable; access without stewardship is unsustainable.
AMR also threatens progress towards the United Nations Sustainable Development Goals. Its consequences extend beyond health to poverty, economic productivity, food security, inequality, and the resilience of communities and health systems. Resistant infections increase healthcare expenditure, prolong illness, reduce productivity, and place additional financial pressure on patients, families, and governments. These effects fall disproportionately on populations with the fewest resources to absorb them. Protecting antibiotic effectiveness therefore means protecting not only individual patients but also human capital, health-system resilience, economic development, and progress towards the 2030 Agenda.
This broader perspective leads to a fundamental question: how should antibiotic effectiveness itself be valued?
Antibiotics are pharmaceutical products, but their continued effectiveness is a shared and finite resource. Every use of an antibiotic has consequences that may extend beyond the individual patient. Antibiotic exposure creates selective pressure, and the emergence and spread of resistance can progressively reduce the future effectiveness of antimicrobial therapy. The benefits of preserving antibiotic effectiveness, conversely, extend across populations, countries, and generations. In this sense, antibiotic effectiveness should be regarded as a global public good—or, more precisely, as a shared global resource whose preservation requires collective action.
This concept exposes a profound contradiction within the traditional pharmaceutical business model. Developing a new antibiotic is scientifically difficult, costly, and financially risky. Yet once an effective antibiotic reaches the market, responsible stewardship requires precisely the opposite of what conventional commercial models tend to reward. A new antibiotic should not be prescribed as widely as possible. It should be used appropriately and only when clinically indicated, with the right drug, dose, route, and duration. In some circumstances, the most valuable new antibiotics should be preserved as options for infections caused by resistant organisms.
The paradox is clear. Society needs pharmaceutical companies to develop new antibiotics, but it simultaneously needs those antibiotics to be used cautiously.
A market model based predominantly on sales volume is poorly aligned with this objective. If commercial return depends on selling more units, stewardship can conflict with economic incentives. Conversely, if responsible use limits sales, antibiotic development may become commercially unattractive despite its enormous societal value. This helps explain why conventional market mechanisms alone are unlikely to provide a sustainable antibiotic pipeline.
New economic models are therefore required to better align innovation with public health. Incentives should reward the societal value of developing an effective antibiotic rather than simply the volume sold. So-called “push” incentives can support research and development through grants, public investment, tax incentives, and public-private partnerships, reducing the financial risks of early antibiotic development. “Pull” incentives can reward successful development through mechanisms that partially delink revenue from sales volume, including subscription models, market-entry rewards, or other value-based approaches. The underlying simple principle is that innovation should be rewarded without creating incentives for unnecessary consumption.
Yet developing new antibiotics cannot, by itself, solve AMR. New drugs introduced into systems that fail to protect them will eventually face the same evolutionary pressures as their predecessors. Innovation without stewardship merely postpones the problem.
Appropriate antibiotic use must therefore remain central. Antimicrobial stewardship seeks to ensure that patients who need antibiotics receive effective treatment while avoiding unnecessary exposure and optimizing drug selection, dose, route, and duration. Stewardship is not about withholding antibiotics. It is about protecting patients today while preserving therapeutic effectiveness for patients tomorrow. This requires access to reliable diagnostics, microbiology laboratories, surveillance, clinical expertise, prescribing guidance, education, and systems capable of measuring antimicrobial consumption and resistance.
Protecting antibiotic effectiveness, however, cannot rely on stewardship and drug development alone. Infection prevention and control is equally fundamental because the most sustainable way to reduce antibiotic consumption is to prevent infections from occurring in the first place.
Vaccination, hand hygiene, safe water and sanitation, environmental hygiene, appropriate use of medical devices, prevention of healthcare-associated infections, effective surveillance, and robust infection-prevention programmes all reduce the need for antimicrobial treatment and the opportunities for resistant organisms to emerge and spread. Infection prevention also produces benefits that extend well beyond AMR, reducing morbidity, mortality, healthcare costs, and pressure on health systems.
The relationship between prevention, access, stewardship, and innovation must therefore be understood as complementary rather than competitive. Investment in one cannot compensate for neglect of the others. A sustainable strategy requires preventing infections whenever possible; ensuring timely access to effective antibiotics when they are needed; using them responsibly; detecting and containing resistant organisms; and maintaining a viable pipeline of new antimicrobials, diagnostics, vaccines, and alternative approaches.
This responsibility also extends beyond human healthcare. Antibiotic use and resistance connect human health, animal health, agriculture, food systems, and the environment. Resistant organisms and resistance genes can circulate across these domains. Preserving antibiotic effectiveness consequently requires a One Health approach that recognizes these interconnections and translates them into coordinated policies rather than treating them as separate problems.
No country can protect antibiotic effectiveness alone. Resistant organisms cross borders through travel, migration, food, animals, trade, and the environment. Weak surveillance or uncontrolled transmission in one setting can have consequences elsewhere. At the same time, countries differ profoundly in their resources and ability to respond. Global solidarity is therefore not simply an ethical aspiration; it is a practical requirement for effective AMR control.
The central challenge is ultimately one of collective responsibility. Antibiotic effectiveness must be treated as a limited global resource at risk of becoming progressively scarce. Preserving it requires governments, healthcare systems, professionals, researchers, industry, international organizations, and communities to recognize that decisions made today will determine which infections remain treatable tomorrow.
Antibiotics transformed medicine because they turned once-fatal infections into treatable diseases and made increasingly complex medical interventions possible. Losing their effectiveness would not simply return infectious diseases to an earlier era. It would undermine many of the foundations upon which modern healthcare has been built.
Safeguarding antibiotics therefore means investing in the future. Their effectiveness is neither an inexhaustible resource nor an ordinary commercial commodity. It is a shared global asset on which everyone depends and that no generation has the right to exhaust.
Treating antibiotic effectiveness as a global public good is therefore not only a public-health imperative and an economic necessity. It is a responsibility to future generations.
References
Worldwide Antimicrobial Resistance National/International Network Group (WARNING) Collaborators. Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action. World J Emerg Surg. 2023 Oct 16;18(1):50.
A Global Declaration on Appropriate Use of Antimicrobial Agents across the Surgical Pathway. Surg Infect (Larchmt). 2017 Nov/Dec;18(8):846-853.
Author
Massimo Sartelli
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