“Are we too protective of new antibiotics?”

Antimicrobial Resistance, Antimicrobial Stewardship, Confessions of a Microbiologist, ,

By reserving new antibiotics for the sickest of the sick and for the most resistant of resistant organisms, are we essentially making them commercially non-viable?

To be honest I am not really surprised that pharmaceutical industries do not want to invest in development of new antibiotics. Such drugs will only be necessary for a small proportion of the population and unlike many other drugs (e.g. cardiac, arthritis drugs) will only be given for a short duration (i.e. 1-2 weeks).

And then, as antimicrobial stewards, we make matters even worse by insisting that these antibiotics need to be fiercely protected in order to prevent or at least delay the development of antimicrobial resistance.

The consequence of this is that any new antibiotic needs to be priced at ridiculous levels to even have a chance at being commercially viable. Hospitals and governments baulk at such prices and subsequently the new antibiotic becomes almost impossible to get hold of. Industry then has to charge even more to make a return, and thus, a vicious cycle is started.

Have a look at the list of new antibiotics from 2000-202 below:
  • 2000: Linezolid (Zyvox) — The first oxazolidinone, a new class effective against vancomycin-resistant enterococci (VRE) and MRSA.
  • 2003: Daptomycin (Cubicin) — The first lipopeptide approved for skin and skin structure infections.
  • 2005: Tigecycline (Tygacil) — First glycylcycline, a derivative of minocycline designed to overcome resistance.
  • 2010: Ceftaroline fosamil (Teflaro) — First cephalosporin with activity against MRSA.
  • 2011: Fidaxomicin (Dificid) — A macrocyclic antibiotic for Clostridioides difficile.
  • 2012: Bedaquiline (Sirturo) — First diarylquinoline for multi-drug resistant tuberculosis (MDR-TB).
  • 2014: Dalbavancin (Dalvance) & Oritavancin (Orbactiv) — Lipoglycopeptides for acute bacterial skin and skin structure infections (ABSSSI).
  • 2014: Tedizolid (Sivextro) — A second-generation oxazolidinone.
  • 2014: Ceftolozane/tazobactam (Zerbaxa) — Cephalosporin/β-lactamase inhibitor combination.
  • 2015: Ceftazidime/avibactam (Avycaz) — Novel β-lactamase inhibitor combination for serious Gram-negative infections.
  • 2017: Meropenem/vaborbactam (Vabomere) — Combination targeting carbapenem-resistant Enterobacteriaceae (CRE).
  • 2017: Delafloxacin (Baxdela) — An anionic fluoroquinolone with activity against MRSA.
  • 2017: Ozenoxacin (Ozanex) — Topical quinolone.
  • 2018: Plazomicin (Zemdri) — Next-generation aminoglycoside.
  • 2018: Eravacycline (Xerava) — Novel synthetic fluorocycline.
  • 2018: Omadacycline (Nuzyra) — Aminomethylcycline for pneumonia and skin infections.
  • 2018: Sarecycline (Seysara) — Tetracycline for acne.
  • 2019: Cefiderocol (Fetroja) — Siderophore cephalosporin for MDR Gram-negative infections.
  • 2019: Lefamulin (Xenleta) — First systemic pleuromutilin for community-acquired pneumonia (CABP).
  • 2019: Pretomanid — Nitroimidazole for extensively drug-resistant TB (XDR-TB)

Then work out how many antibiotics on this list are available for use at your local hospital? In my local hospital in New Zealand, I could comfortably count on one hand the number of antibiotics from the above list that are available for me as a clinical microbiologist to recommend without multiple barriers to prescribing. The majority are just not available in New Zealand at all…

I would argue that increasing the range of antibiotic classes that are available for use is much more important than restricting the use of new antibiotics.

I am not claiming that we shouldn’t have good antimicrobial stewardship, of course we should. Neither am I claiming that antimicrobial resistance to new antibiotics will not develop if we use them, of course it will. However, if we have more classes of antibiotics available, then one would expect classes that are used infrequently over a certain time period to recover a degree of susceptibility.

I think we need to be encouraging the use of new antibiotics so that they are sufficiently used to get an idea of their efficacy, and so that any developing resistance can be effectively monitored.

If we reserve new antibiotics only for when there are no other options available, then in a country like New Zealand, we might only be using them a few times each year.

We need to be somewhat less zealous in our antimicrobial stewardship efforts when it comes to new antibiotics. We need to work alongside industry, not against them in maximising the range of antibiotics that are available to us. However, the goal should be sustainable use, not reckless use…

I know solutions have been proposed to the above problem, essentially allowing industry to get a return on their investment regardless of how often the new antibiotic is actually used (i.e. de-linking). I remain unconvinced by such proposals as a long-term solution, as it relies on successive governments to both prioritise and fund such initiatives.

I also know that some (possibly most!) of my colleagues will not agree with me on this particular topic. But when we sit on antimicrobial stewardship committees, we need to consider the whole picture, and not try and protect the sanctity of the new antibiotic at all costs…

Michael

“ASA Antimicrobials 2026 Adelaide”

Confessions of a Microbiologist, , ,

I was privileged to go to the ASA Antimicrobials conference in Adelaide last week. Although I have not been to this particular conference for a few years, it is one of my favourites. It is not too big, it has a good mixture of clinical microbiologists, ID physicians and microbiology scientists attending, and the quality of the talks is generally very high. there were very few talks that I did not take anything away from.

Here are a few of the highlights below:

Angela Huttner gave an excellent talk on UTI, and reminded us that the definitions of uncomplicated v complicated UTI have changed, moving more towards extent of infection within the urinary system, and away from host factors. This makes a lot of sense to me, and simplifies things a lot for the lab in terms of testing and reporting.

Angela also reminded the audience that enterococci and Group B streptococci are uncommon causes of uncomplicated cystitis in young women. Voided midstream urine culture and acute cystitis in premenopausal women – PubMed. I will need to go back to my lab and sort out suitable comments to go on enterococcal and Group B strep urinary isolates on this cohort. We almost certainly overplay their significance…

Hemalatha Varadhan informed us that they were no longer culturing central line tips at their institution in NSW, on the grounds of poor sensitivity, specificity, and the fact that it is not required for the definition of a CLABSI. Good for her I thought. If they can do it, why can’t we at our own lab. I will do some reading and have a chat to our stakeholders…

Chris Blyth presented on “newish vaccines” with a focus on RSV, meningococcal and emerging Gp B strep vaccines. He also reminded us that it is one thing to develop new vaccines, it is quite another to persuade people to get them…

Steven Tong presented an update on the legendary SNAP trial for Staphylococcus aureus bacteraemia. A good refresher, and a reminder that further evidence-based answers on SAB management issues are not far away. 

Tony Korman gave us an irreverent but highly entertaining review of 2025: The Year in Clinical Microbiology” and highlighted the debates on Twitter/X such as “Oral is the new IV”, “Shorter is better” and the CRP/ESR “Zombie tests”. Angela Huttner commented on the lack of nuance that sometimes occurs in such debates when the argument is presented in a black and white fashion. 

John Turnidge and his team gave an excellent EUCAST/AUSCAST session. It was a good reminder of the amount of work that goes into antimicrobial breakpoint setting. Tony Korman made the excellent point that implementation of EUCAST guidelines on a practical level is becoming increasingly problematic for diagnostic laboratories and that this should be taken into consideration by the EUCAST team when issuing their annual updates.

I was fortunate enough to be able to present myself at the conference, kindly invited by BD to present on diagnostic stewardship at the BD sponsored lunchtime symposium. Being an inveterate introvert, I was quite nervous to begin with, but soon settled down and got my diagnostic stewardship messages across to an audience which seemed engaged in my presentation (I think!). 

It was my first visit to Adelaide. It is a very nice place, nice climate, friendly people and quite a lot to do. Unfortunately, I did not get a chance to visit the Barossa Valley vineyards, next time hopefully!

Michael

Creating Microbiology Presentations Using AI

Confessions of a Microbiologist, Future of Microbiology, , ,

I have been using AI to help create a couple of microbiology-related educational presentations over the past few weeks, for the first time in a couple of years.

I shouldn’t have left it so long…

Things have clearly improved. AI technology is now evolving at an incredible rate. Pause for breath and you will be left behind. It is not perfect by any means but starting to become functional in the professional setting in many different facets, including presentations.

Here are a couple of my personal comments on using AI to generate microbiology presentations for teaching purposes.

  • I used Co-Pilot to generate the presentations: Because I am old and stuck in my ways, I still use PowerPoint for all my presentations. As a result, it makes sense for me to use Co-Pilot, as this is also a Microsoft product and is thus designed to generate PowerPoint presentations. 
  • Prompting is everything: A good initial “prompt ” is key in producing a good AI-generated presentation. How many slides do you want it to produce? Who is the target audience? What areas do you want it to focus on? Do you want it to reference the evidence for its statements? Do you want it to be humorous? Do you want it to include pictures/graphs/tables. Do you want it to include hypothetical case studies. Do you want it to produce MCQs on the topic at the end. And that is just for starters… I think in future I am going to develop a template prompt for presentations which I can then amend for each topic I need to teach on.
  • It still has a tendency to produce generic presentations: My experience so far is that AI has a tendency to produce generic presentations. As I get better at prompting, hopefully I will get better at getting AI to include interesting details in the presentations and not “genericise” so much.
  • Editing is key: The presentation it produces for you will never be exactly the way you want it, even with optimal prompting. Therefore, you will need to dedicate a significant amount of time to editing and polishing it, and indeed giving it a personal touch.
  • Watch out for Hallucinations: In the AI age, hallucinations now have a very different meaning than back in my student days! Large Language Model (LLM) AI systems still have a tendency to make things up if they don’t know the answer. This flaw is becoming less common with more sophisticated software but watch out for it nevertheless. Bias can be another issue. My AI generated presentations did not have any evidence of hallucinations, but there were a couple of clear instances of bias which required editing.
  • It is more difficult to present an AI generated presentation: Because you have not actually written the presentation yourself, it is more difficult to actually present it to an audience. So rehearsal is key. Usually, I would spend 3-4 hours writing a presentation then 1/2 hour rehearsing it. With AI, I would recommend 1/2 hour on the prompt, an hour editing and an hour rehearsing your presentation. AI does save time, but not as much as you might think.

Despite my amateurish initial attempts, I am going to persist with using AI for presentations. The technology can only continue to improve, and very quickly at that. The presentations that it can produce now are light years ahead of what it could do a couple of years ago. I am keen to get tips from anyone else experimenting with giving microbiology presentations by AI. I would also encourage all my colleagues to give it a go.

Several of my children have already been “pinged” at school for using AI in their assignments. Being the bad parent that I am, I ignore the teachers’ frustrations and let the kids embrace the technology as much as they are able. This is the future whether the teachers like it or not…

Michael