Antibacterial R&D at a Crossroads: We’ve Pushed as Hard as We Can … Now We Need to Start Pulling!

((See the Major Article by Dheman et al on pages e4444–50.)) In this issue of Clinical Infectious Diseases, Dheman et al [1] present an analysis by experts at the US Food and Drug Administration (FDA) of trends in antibacterial clinical development over the past 4 decades. By turns instructive and disturbing, this 40-year perspective provides insight into the impact of efforts to restore the antibacterial pipeline. As a preview, the key messages from Dheman et al are all bad news for public health: (1) the number of new antibacterials in clinical development is (again) falling, (2) the risk of failure is rising, (3) the speed of clinical development is slowing, and (4) most large companies with the capability to market agents on a global scale have exited clinical development. Several factors have led to this state of play, as follows.