Sustainable solutions to the continuous threat of antimicrobial resistance.

To combat antimicrobial resistance (AMR), advocates have called for passage of the Pioneering Antimicrobial Subscriptions To End Upsurging Resistance (PASTEUR) Act in the United States, which would appropriate $6 billion in new taxpayer-funded subsidies for antibiotic development. However, the number of antibiotics in clinical development, and US Food and Drug Administration approvals of new antibiotics, have already markedly increased in the last 15 years. Thus, instead of focusing on more economic subsidies, we recommend reducing selective pressure driving AMR by (1) establishing pay-for-performance mechanisms that disincentivize overprescribing of antibiotics, (2) focusing existing research and development funding on strategies that decrease reliance on antibiotics, and (3) changing regulation or law to require specialized training in antibiotic stewardship for a clinician to be able to prescribe new antibiotics that target unmet AMR need. To stabilize the antibiotic market, we recommend (1) establishment of an advisory board of clinical practitioners to more accurately target existing antibiotic incentives and (2) endowment of nonprofit companies that sustainably self-fund antibiotic discovery, creating a bench of molecules that can be partnered with industry at later stages of development.