Antimicrobial Resistance: Is Health Technology Assessment Part of the Solution or Part of the Problem?

Antimicrobial Resistance (AMR) Development Map: A Conceptual Map and a Tool to Support Economic Evaluation of AMR Interventions

INTRODUCTION

Antimicrobial resistance (AMR) is a complex, inter-sectoral and international problem. Economic evaluation (EE) methods offer systematic, evidence-driven approaches to inform policy decisions about which AMR interventions to fund. EE of AMR interventions is complicated owing to diffuse effects, complex mechanics of the problem and high levels of uncertainty. Current AMR EE literature restricts the analytical scope, potentially resulting in omissions of effects that may limit the utility of EE to inform policy decisions. We aimed to systemise the key evolutionary and ecological processes of AMR to elucidate the paths through which AMR interventions impact population health and healthcare costs to support EE design and to support decision makers in understanding the limitations of EE evidence for decision-making.

METHODS

A conceptual map and a corresponding tool were developed on the basis of a literature review in consultation with experts across the relevant disciplines of molecular biology, infectious disease modelling, health economics and ecology.

RESULTS

The AMR development map: (1) distils the key AMR processes and process drivers behind AMR development and maps the available types of AMR interventions to AMR process drivers; (2) proposes a way to conceptualise the spatial scope of analysis through considering the connectivity of the wider ecosystem and (3) outlines the key dimensions that AMR burden and intervention effects could be measured across. An AMR development map tool was developed to support conceptual modelling, with the focus on the choice of scope in the EE of AMR interventions, and an illustrative case study was provided.

DISCUSSION

This work summarises the key underlying biological principles of AMR development to provide mechanistical grounding for considering the scope of effects of AMR interventions and the appropriate system of analysis to support conceptual modelling in EE of AMR interventions. In addition, this map can facilitate the identification of effects that cannot be considered or quantified, thus enabling transparency about these omissions within decision-making.

Antibacterial potential of silver-selenium nanocomposites in mitigating fire blight disease in Pyrus communis L

Pyrus communis L. is a vital fruit tree known for its nutritional and economic importance. Thus, for humans, it is an essential element for their balanced nutritional diet, as it contains the major dietary fibers, vitamins, and minerals. All of these nutritionally important aspects decrease with the impact of disease fire blight. Erwinia amylovora is a causative agent of fire blight. This infection causes a considerable loss in the production of Pyrus communis L. Annually, approximately 50% of pear fruit in Pakistan is misplaced because of these illnesses. Therefore, we propose nanotechnology remediation to treat pear plants and obtain the desired yield. In this regard, an experiment was designed to treat infected plants with different concentrations of silver-selenium nanocomposites, which was based on a literature review that indicated the antimicrobial activities of silver and selenium nanoparticles. Silver-selenium nanocomposites were prepared using a green synthesis method, and their synthesis was confirmed using characterization techniques. The experiment was performed at a farmhouse in Chakwal district, Punjab, Pakistan. The experimental results showed increased morphological, physiological, and biochemical parameters. In this regard, the best treatment remained at 50 ppm for the Ag-Se nanocomposite, which improved the plant in different aspects. At the same time, they have improved fruit metrics, such as vitamin C, pH, and juice content. Thus, these results show a possible improvement in enhancing the resistance against fire blight by using green-synthesized Ag-Se NCs. Further studies are needed to understand fully the molecular mechanisms and actions of Pyrus communis L. in treating fire blight disease and to establish the optimal treatment plan.

Antimicrobial drug pricing

Despite the constant development of antimicrobial resistance (AMR), few new antimicrobials are currently becoming available clinically. Alternative approaches, such as different mechanisms to fund their use, are being explored to encourage development of new antimicrobials.

Overcoming challenges in the economic evaluation of interventions to optimise antibiotic use

Bacteria are becoming increasingly resistant to antibiotics, reducing our ability to treat infections and threatening to undermine modern health care. Optimising antibiotic use is a key element in tackling the problem. Traditional economic evaluation methods do not capture many of the benefits from improved antibiotic use and the potential impact on resistance. Not capturing these benefits is a major obstacle to optimising antibiotic use, as it fails to incentivise the development and use of interventions to optimise the use of antibiotics and preserve their effectiveness (stewardship interventions). Estimates of the benefits of improving antibiotic use involve considerable uncertainty as they depend on the evolution of resistance and associated health outcomes and costs. Here we discuss how economic evaluation methods might be adapted, in the face of such uncertainties. We propose a threshold-based approach that estimates the minimum resistance-related costs that would need to be averted by an intervention to make it cost-effective. If it is probable that without the intervention costs will exceed the threshold then the intervention should be deemed cost-effective.

Microbial lipopeptides: their pharmaceutical and biotechnological potential, applications, and way forward

As lead molecules, cyclic lipopeptides with antibacterial, antifungal, and antiviral properties have garnered a lot of attention in recent years. Because of their potential, cyclic lipopeptides have earned recognition as a significant class of antimicrobial compounds with applications in pharmacology and biotechnology. These lipopeptides, often with biosurfactant properties, are amphiphilic, consisting of a hydrophilic moiety, like a carboxyl group, peptide backbone, or carbohydrates, and a hydrophobic moiety, mostly a fatty acid. Besides, several lipopeptides also have cationic groups that play an important role in biological activities. Antimicrobial lipopeptides can be considered as possible substitutes for antibiotics that are conventional to address the current drug-resistant issues as pharmaceutical industries modify the parent antibiotic molecules to render them more effective against antibiotic-resistant bacteria and fungi, leading to the development of more resistant microbial strains. Bacillus species produce lipopeptides, which are secondary metabolites that are amphiphilic and are typically synthesized by non-ribosomal peptide synthetases (NRPSs). They have been identified as potential biocontrol agents as they exhibit a broad spectrum of antimicrobial activity. A further benefit of lipopeptides is that they can be produced and purified biotechnologically or biochemically in a sustainable manner using readily available, affordable, renewable sources without harming the environment. In this review, we discuss the biochemical and functional characterization of antifungal lipopeptides, as well as their various modes of action, method of production and purification (in brief), and potential applications as novel antibiotic agents.

Unveiling biological activities of biosynthesized starch/silver-selenium nanocomposite using Cladosporium cladosporioides CBS 174.62

BACKGROUND AND OBJECTIVES

Microbial cells capability to tolerate the effect of various antimicrobial classes represent a major worldwide health concern. The flexible and multi-components nanocomposites have enhanced physicochemical characters with several improved properties. Thus, different biological activities of biosynthesized starch/silver-selenium nanocomposite (St/Ag-Se NC) were assessed.

METHODOLOGY

The St/Ag-Se NC was biosynthesized using Cladosporium cladosporioides CBS 174.62 (C. cladosporioides) strain. The shape and average particle size were investigated using scanning electron microscope (SEM) and high-resolution transmission electron microscope (HR-TEM), respectively. On the other hand, the St/Ag-Se NC effect on two cancer cell lines and red blood cells (RBCs) was evaluated and its hydrogen peroxide (H2O2) scavenging effect was assessed. Moreover, its effects on various microbial species in both planktonic and biofilm growth forms were examined.

RESULTS

The St/Ag-Se NC was successfully biosynthesized with oval and spherical shape and a mean particle diameter of 67.87 nm as confirmed by the HR-TEM analysis. St/Ag-Se NC showed promising anticancer activity toward human colorectal carcinoma (HCT-116) and human breast cancer (MCF-7) cell lines where IC50 were 21.37 and 19.98 µg/ml, respectively. Similarly, little effect on RBCs was observed with low nanocomposite concentration. As well, the highest nanocomposite H2O2 scavenging activity (42.84%) was recorded at a concentration of 2 mg/ml. Additionally, Staphylococcus epidermidis (S. epidermidis) ATCC 12,228 and Candida albicans (C. albicans) ATCC 10,231 were the highly affected bacterial and fungal strains with minimum inhibitory concentrations (MICs) of 18.75 and 50 µg/ml, respectively. Moreover, the noticeable effect of St/Ag-Se NC on microbial biofilm was concentration dependent. A high biofilm suppression percentage, 87.5% and 68.05%, were recorded with S. epidermidis and Staphylococcus aureus (S. aureus) when exposed to 1 mg/ml and 0.5 mg/ml, respectively.

CONCLUSION

The biosynthesized St/Ag-Se NC showed excellent antioxidant activity, haemocompatibility, and anti-proliferative effect at low concentrations. Also, it exhibited promising antimicrobial and antibiofilm activities.

Examining how well economic evaluations capture the value of mental health

Health economics evidence informs health-care decision making, but the field has historically paid insufficient attention to mental health. Economic evaluations in health should define an appropriate scope for benefits and costs and how to value them. This Health Policy provides an overview of these processes and considers to what extent they capture the value of mental health. We suggest that although current practices are both transparent and justifiable, they have distinct limitations from the perspective of mental health. Most social value judgements, such as the exclusion of interindividual outcomes and intersectoral costs, diminish the value of improving mental health, and this reduction in value might be disproportionate compared with other types of health. Economic analyses might have disadvantaged interventions that improve mental health compared with physical health, but research is required to test the size of such differential effects and any subsequent effect on decision-making systems such as health technology assessment systems. Collaboration between health economics and the mental health sciences is crucial for achieving mental-physical health parity in evaluative frameworks and, ultimately, improving population mental health.

Estimating the Treatment and Prophylactic Economic Value of New Antimicrobials in Managing Antibiotic Resistance and Serious Infections for Common Pathogens in the USA: A Population Modelling Study

BACKGROUND

Antimicrobial resistance is a growing public health concern. There is a global need to estimate the population-level value of developing new antimicrobials and to ensure the effective use of existing antimicrobials as strategies to counteract antimicrobial resistance. To this aim, population-level value criteria need to be considered alongside conventional value measures.

OBJECTIVE

The objective of this study was to develop a novel modelling approach to estimate the value of new antimicrobials, considering the transmission, diversity and enablement elements of STEDI value.

METHODS

We developed a population-based mathematical model for the assessment of antimicrobial value considering both prophylactic use of antimicrobials and the treatment of selected serious hospital-acquired infections in hospitals in the USA at a population level. Large-scale clinical and population healthcare data were used to inform a modelling-based analysis assessing the impact of introducing a new antimicrobial compared with continuing with no new antimicrobial, accounting for the transmission, diversity and enablement value of antimicrobial agents.

RESULTS

Over a 10-year period, the addition of a new antimicrobial as part of an antimicrobial stewardship strategy in the USA was estimated to result in a proportional reduction of 9.03% in projected antimicrobial resistance levels. This yielded an estimated reduction of $64.3 million in hospitalization costs and a gain of over 153,000 quality-adjusted life-years at an economic value of over $15.4 billion over 10 years. Considering input uncertainty, the estimate of monetary benefit ranged from $11.1 to $21.4 billion.

CONCLUSIONS

The use of a new antimicrobial for treatment and prophylactic indications yields considerable clinical and economic benefits including transmission diversity and enablement value. These findings may provide decision makers with important evidence to support investment in new antimicrobials and antimicrobial stewardship policy that address the patient, population and system burden associated with antimicrobial resistance.

Green biosynthesis of bimetallic selenium-gold nanoparticles using Pluchea indica leaves and their biological applications

Increasing bacterial resistance and the negative impact of currently used antibacterial agents have produced the need for novel antibacterial agents and anticancer drugs. In this regard, nanotechnology could provide safer and more efficient therapeutic agents. The main methods for nanoparticle production are chemical and physical approaches that are often costly and environmentally unsafe. In the current study, Pluchea indica leaf extract was used for the biosynthesis of bimetallic selenium-gold nanoparticles (Se-Au BNPs) for the first time. Phytochemical examinations revealed that P. indica leaf extract includes 90.25 mg/g dry weight (DW) phenolics, 275.53 mg/g DW flavonoids, and 26.45 mg/g DW tannins. X-ray diffraction (XRD), transmission electron microscopy (TEM), Fourier-transform infrared (FTIR) spectroscopy, dynamic light scattering (DLS), scanning electron microscopy (SEM), and energy-dispersive X-ray spectroscopy (EDX) techniques were employed to characterize Se-Au BNPs. Based on UV-vis spectra, the absorbance of Se-Au BNPs peaked at 238 and 374 nm. In SEM imaging, Se-Au BNPs emerged as bright particles, and both Au and Se were uniformly distributed throughout the P. indica leaf extract. XRD analysis revealed that the average size of Se-Au BNPs was 45.97 nm. The Se-Au BNPs showed antibacterial properties against Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, and Bacillus subtilis, with minimum inhibitory concentrations (MICs) of 31.25, 15.62, 31.25, and 3.9 μg/mL, respectively. Surprisingly, a cytotoxicity assay revealed that the IC50 value toward the Wi 38 normal cell line was 116.8 μg/mL, implying that all of the MICs described above could be used safely. More importantly, Se-Au BNPs have shown higher anticancer efficacy against human breast cancer cells (MCF7), with an IC50 value of 13.77 μg/mL. In conclusion, this paper is the first to provide data on the effective utilization of P. indica leaf extract in the biosynthesis of biologically active Se-Au BNPs.

Capturing Value Attributes in the Economic Evaluation of Ceftazidime with Avibactam for Treating Severe Aerobic Gram-Negative Bacterial Infections in the United Kingdom

INTRODUCTION

Antimicrobial resistance remains a serious and growing threat to public health, both globally and in the UK, leading to diminishing effectiveness of antimicrobials. Despite a clear need for new antimicrobials, the clinical pipeline is insufficient, driven by high research and development costs and limited expected returns on investment. To counteract this, National Institute for Health and Care Excellence (NICE) and National Health Service (NHS) England have launched a reimbursement mechanism, de-linked from volume of sales, that aims to reduce economic risk by recognising the broader population-level value of antimicrobials. The objective of this study was to quantify the value of ceftazidime-avibactam for treating gram-negative infections in the UK considering some of these broader value elements unique to antimicrobials.

METHODS

A previously developed dynamic disease transmission and cost-effectiveness model was applied to assess the value of introducing ceftazidime-avibactam to UK treatment practice in the management of gram-negative hospital-acquired infections in line with the licenced indications for ceftazidime-avibactam. Model inputs were parameterised using sources aligned to the UK perspective.

RESULTS

The introduction of ceftazidime-avibactam into a two-line treatment sequence saved over 2300 lives, leading to a gain of 27,600 life years and 22,000 quality-adjusted life years (QALY) at an additional cost of £17 million, over a ten-year transmission period. Ceftazidime-avibactam was associated with a net monetary benefit of £642 million at willingness to pay threshold of £30,000 per QALY; even at a lower threshold of £20,000 per QALY, the net monetary benefit is £422 million.

DISCUSSION

Increasing the diversity of antimicrobial treatments through the introduction of an additional antimicrobial, in this instance ceftazidime-avibactam, was associated with substantial clinical and economic benefits, when considering broader population-level value. Despite revealing considerable benefits, the value of ceftazidime-avibactam is only partially reflected in this analysis. Further efforts are required to fully operationalise the spectrum, transmission, enablement, diversity and insurance (STEDI) value framework and accurately reflect the population-level value of antimicrobials.

Origin of Antibiotics and Antibiotic Resistance, and Their Impacts on Drug Development: A Narrative Review

Antibiotics have revolutionized medicine, saving countless lives since their discovery in the early 20th century. However, the origin of antibiotics is now overshadowed by the alarming rise in antibiotic resistance. This global crisis stems from the relentless adaptability of microorganisms, driven by misuse and overuse of antibiotics. This article explores the origin of antibiotics and the subsequent emergence of antibiotic resistance. It delves into the mechanisms employed by bacteria to develop resistance, highlighting the dire consequences of drug resistance, including compromised patient care, increased mortality rates, and escalating healthcare costs. The article elucidates the latest strategies against drug-resistant microorganisms, encompassing innovative approaches such as phage therapy, CRISPR-Cas9 technology, and the exploration of natural compounds. Moreover, it examines the profound impact of antibiotic resistance on drug development, rendering the pursuit of new antibiotics economically challenging. The limitations and challenges in developing novel antibiotics are discussed, along with hurdles in the regulatory process that hinder progress in this critical field. Proposals for modifying the regulatory process to facilitate antibiotic development are presented. The withdrawal of major pharmaceutical firms from antibiotic research is examined, along with potential strategies to re-engage their interest. The article also outlines initiatives to overcome economic challenges and incentivize antibiotic development, emphasizing international collaborations and partnerships. Finally, the article sheds light on government-led initiatives against antibiotic resistance, with a specific focus on the Middle East. It discusses the proactive measures taken by governments in the region, such as Saudi Arabia and the United Arab Emirates, to combat this global threat. In the face of antibiotic resistance, a multifaceted approach is imperative. This article provides valuable insights into the complex landscape of antibiotic development, regulatory challenges, and collaborative efforts required to ensure a future where antibiotics remain effective tools in safeguarding public health.

Isolation, Identification, and Antibacterial Properties of Prodigiosin, a Bioactive Product Produced by a New Serratia marcescens JSSCPM1 Strain: Exploring the Biosynthetic Gene Clusters of Serratia Species for Biological Applications

Prodigiosin pigment has high medicinal value, so exploring this compound is a top priority. This report presents a prodigiosin bioactive compound isolated from Serratia marcescens JSSCPM1, a new strain. The purification process of this compound involves the application of different chromatographic methods, including UV-visible spectroscopy, high-performance liquid chromatography (HPLC), and liquid chromatography-mass spectrometry (LC/MS). Subsequent analysis was performed using nuclear magnetic resonance (NMR) to achieve a deeper understanding of the compound's structure. Finally, through a comprehensive review of the existing literature, the structural composition of the isolated bioactive compound was found to correspond to that of the well-known compound prodigiosin. The isolated prodigiosin compound was screened for antibacterial activity against both Gram-positive and Gram-negative bacteria. The compound inhibited the growth of Gram-negative bacterial strains compared with Gram-positive bacterial strains. It showed a maximum minimum inhibitory concentration against Escherichia coli NCIM 2065 at a 15.9 ± 0.31 μg/mL concentration. The potential binding capabilities between prodigiosin and the OmpF porin proteins (4GCS, 4GCP, and 4GCQ) were determined using in silico studies, which are generally the primary targets of different antibiotics. Comparative molecular docking analysis indicated that prodigiosin exhibits a good binding affinity toward these selected drug targets.

Watermelon Rind Mediated Biosynthesis of Bimetallic Selenium-Silver Nanoparticles: Characterization, Antimicrobial and Anticancer Activities

One of the most hazardous diseases that influences human health globally is microbial infection. Therefore, bimetallic nanoparticles have received much attention for controlling microbial infections in the current decade. In the present study, bimetallic selenium-silver nanoparticles (Se-Ag NPs) were effectively biosynthesized using watermelon rind WR extract through the green technique for the first time. UV-visible spectroscopy, transmission electron microscopy (TEM), and energy dispersive X-ray spectroscopy (EDX) methods were used to characterize the produced NPs. The results indicated that the bimetallic Se-Ag NPs had synergistic antimicrobial activity at low concentrations, which helped to reduce the toxicity of Ag NPs after the bimetallic Se-Ag NPs preparation and increase their great potential. Se-Ag NPs with sizes ranging from 18.3 nm to 49.6 nm were detected by TEM. Se-Ag NP surfaces were uniformly visible in the SEM picture. The cytotoxicity of bimetallic Se-Ag NPs was assessed against the Wi38 normal cell line to check their safety, where the IC50 was 168.42 µg/mL. The results showed that bimetallic Se-Ag NPs had antibacterial action against Candida albicans, Escherichia coli, Pseudomonas aeruginosa, Klebsiella oxytoca, Bacillus subtilis, and Staphylococcus aureus with a minimum inhibitory concentration (MIC) of 12.5 to 50 µg/mL. Additionally, bimetallic Se-Ag NPs had promising anticancer activity toward the MCF7 cancerous cell line, where the IC50 was 21.6 µg/mL. In conclusion, bimetallic Se-Ag NPs were biosynthesized for the first time using WR extract, which had strong antibacterial, antifungal and anticancer properties.

Abundance and prevalence of ESBL coding genes in patients undergoing first line eradication therapy for Helicobacter pylori

The spread of extended-spectrum beta-lactamases (ESBLs) in nosocomial and community-acquired enterobacteria is an important challenge for clinicians due to the limited therapeutic options for infections that are caused by these organisms. Here, we developed a panel of ESBL coding genes, evaluated the abundance and prevalence of ESBL encoding genes in patients undergoing H. pylori eradication therapy, and summarized the effects of eradication therapy on functional profiles of the gut microbiome. To assess the repertoire of known beta lactamase (BL) genes, they were divided into clusters according to their evolutionary relation. Primers were designed for amplification of cluster marker regions, and the efficiency of this amplification panel was assessed in 120 fecal samples acquired from 60 patients undergoing H. pylori eradication therapy. In addition, fecal samples from an additional 30 patients were used to validate the detection efficiency of the developed ESBL panel. The presence for majority of targeted clusters was confirmed by NGS of amplification products. Metagenomic sequencing revealed that the abundance of ESBL genes within the pool of microorganisms was very low. The global relative abundances of the ESBL-coding gene clusters did not differ significantly among treatment states. However, at the level of each cluster, classical ESBL producers such as Klebsiella sp. for blaOXY (p = 0.0076), Acinetobacter sp. for blaADC (p = 0.02297) and others, differed significantly with a tendency to decrease compared to the pre- and post-eradication states. Only 13 clusters were common across all three datasets, suggesting a patient-specific distribution profile of ESBL-coding genes. The number of AMR genes detected in the post-eradication state was higher than that in the pre-eradication state, which could be attributed, at least in part, to the therapy. This study demonstrated that the ESBL screening panel was effective in targeting ESBL-coding gene clusters from bacterial DNA and that minor differences exist in the abundance and prevalence of ESBL-coding gene levels before and after eradication therapy.

Rapid Diagnostic Test Value and Implementation in Antimicrobial Stewardship Across Low-to-Middle and High-Income Countries: A Mixed-Methods Review

Despite technological advancements in infectious disease rapid diagnostic tests (RDTs) and use to direct therapy at the per-patient level, RDT utilisation in antimicrobial stewardship programmes (ASPs) is variable across low-to-middle income and high-income countries. Key insights from a panel of seven infectious disease experts from Colombia, Japan, Nigeria, Thailand, the UK, and the USA, combined with evidence from a literature review, were used to assess the value of RDTs in ASPs. From this, a value framework is proposed which aims to define the benefits of RDT use in ASPs, separate from per-patient benefits. Expert insights highlight that, to realise the value of RDTs within ASPs, effective implementation is key; actionable advice for choosing an RDT is proposed. Experts advocate the inclusion of RDTs in the World Health Organization Model List of essential in vitro diagnostics and in iterative development of national action plans.

The role of drug regulatory authorities and health technology assessment agencies in shaping incentives for antibiotic R&D: a qualitative study

BACKGROUND

Few antibiotics have entered the market in recent years despite the need for new treatment options. Some of the challenges of bringing new antibiotics to market are linked to the marketing authorization and health technology assessment (HTA) processes. Research shows great variation in geographic availability of new antibiotics, suggesting that market introduction of new antibiotics is unpredictable. We aimed to investigate regulatory authorities' and HTA agencies' role in developing non-financial incentives to stimulate antibiotic research and development (R&D).

METHODS

We conducted individual, semi-structured, stakeholder interviews. Participants were recruited from regulatory authorities (EMA and FDA) and HTA agencies in Europe. Participants had to be experienced with assessment of antibiotics. The data were analyzed using a deductive and inductive approach to develop codes and identify key themes. Data were analyzed using thematic analysis including the constant comparison method to define concepts, and rival thinking to identify alternative explanations.

RESULTS

We found that (1) interpretation of key concepts guiding the understanding of what type of antibiotics are needed vary (2) lack of a shared approach on how to deal with limited clinical data in the marketing authorization and HTA processes is causing barriers to getting new antibiotics to market (3) necessary adaptations to the marketing authorization process causes uncertainties that transmit to other key stakeholders involved in delivering antibiotics to patients.

CONCLUSIONS

A shared understanding of limited clinical data and how to deal with this issue is needed amongst stakeholders involved in antibiotic R&D, marketing authorization, and market introduction to ensure antibiotics reach the market before resistance levels are out of control. Regulatory authorities and HTA agencies could play an active role in aligning the view of what constitutes an unmet medical need, and direct new economic models towards stimulating greater diversity in the antibiotic armamentarium.

Recent advances in addressing the market failure of new antimicrobials: Learnings from NICE's subscription-style payment model

Background

Antimicrobial resistance (AMR) is a growing threat to global health. With pathogenic bacteria inevitably becoming more resistant to existing antimicrobials, mortality and costs due to AMR will significantly increase over the next few decades if adequate action is not taken. A major challenge in addressing AMR is the lack of financial incentives for manufacturers to invest in developing new antimicrobials. This is partly because current approaches in health technology assessment (HTA) and standard modeling methods fail to capture the full value of antimicrobials.

Aim

We explore recent reimbursement and payment frameworks, particularly pull incentives, aimed to address the market failures in antimicrobials. We focus on the "subscription-style" payment model recently used in the UK and discuss the learnings for other European countries.

Methods

A pragmatic literature review was conducted to identify recent initiatives and frameworks between 2012 and 2021, across seven European markets. The National Institute for Health and Care Excellence (NICE) technology appraisals for cefiderocol and for ceftazidime with avibactam were reviewed to evaluate how the new UK model has been applied in practice and identify the key challenges.

Conclusion

The UK and Sweden are the first European countries to pilot the feasibility of implementing pull incentives through fully and partially delinked payment models, respectively. The NICE appraisals highlighted the complexity and large areas of uncertainty of modeling antimicrobials. If HTA and value-based pricing are part of the future in tackling the market failure in AMR, European-level efforts may be needed to overcome some of the key challenges.

The past, present, and future of antibiotics

Antibiotics have transformed modern medicine. They are essential for treating infectious diseases and enable vital therapies and procedures. However, despite this success, their continued use in the 21st century is imperiled by two orthogonal challenges. The first is that the microbes targeted by these drugs evolve resistance to them over time. The second is that antibiotic discovery and development are no longer cost-effective using traditional reimbursement models. Consequently, there are a dwindling number of companies and laboratories dedicated to delivering new antibiotics, resulting in an anemic pipeline that threatens our control of infections. The future of antibiotics requires innovation in a field that has relied on highly traditional methods of discovery and development. This will require substantial changes in policy, quantitative understanding of the societal value of these drugs, and investment in alternatives to traditional antibiotics. These include narrow-spectrum drugs, bacteriophage, monoclonal antibodies, and vaccines, coupled with highly effective diagnostics. Addressing the antibiotic crisis to meet our future needs requires considerable investment in both research and development, along with ensuring a viable marketplace that encourages innovation. This review explores the past, present, and future of antimicrobial therapy.

The economic challenges of new drug development

The COVID-19 pandemic has witnessed highly successful efforts to produce effective vaccines and treatments at an unprecedented pace. This perspective discusses factors that made this possible, from long-term investments in research infrastructure to major government interventions that absorbed much of the risk from research and development. We discuss key economic obstacles in the discovery of new drugs for infectious diseases, from novel antibiotics to diseases that primarily affect the poor. The world's collective experience of the pandemic may present an opportunity to reform traditional economic models of drug discovery to better address unmet needs. A tax-funded global institution could provide incentives for drug discovery based on their global health impact. International co-operation would be needed to agree and commit to adequate funding mechanisms, and the necessary political will would require strong public support. With the current heightened appreciation of the need for global health system resilience, there may be no better opportunity than now.

Current Treatment Strategies Against Multidrug-Resistant Bacteria: A Review

There are several bacteria called superbugs that are resistant to multiple antibiotics which can be life threatening specially for critically ill and hospitalized patients. This article provides up-to-date treatment strategies employed against some major superbugs, like methicillin-resistant Staphylococcus aureus, carbapenem-resistant Enterobacteriaceae, vancomycin-resistant Enterococcus, multidrug-resistant Pseudomonas aeruginosa, and multidrug-resistant Escherichia coli. The pathogen-directed therapeutics decrease the toxicity of bacteria by altering their virulence factors by specific processes. On the other hand, the host-directed therapeutics limits these superbugs by modulating immune cells, enhancing host cell functions, and modifying disease pathology. Several new antibiotics against the global priority superbugs are coming to the market or are in the clinical development phase. Medicinal plants possessing potent secondary metabolites can play a key role in the treatment against these superbugs. Nanotechnology has also emerged as a promising option for combatting them. There is urgent need to continuously figure out the best possible treatment strategy against these superbugs as resistance can also be developed against the new and upcoming antibiotics in future. Rational use of antibiotics and maintenance of proper hygiene must be practiced among patients.