Where are we in the battle against antibiotic-resistant infections

For infectious disease (ID) specialist Helen Boucher, MD, dean of the Tufts University School of Medicine and chief academic officer of Tufts Medicine, the threat of drug-resistant superbugs is up close and personal.

"I have had the sad duty to have to tell a patient that we couldn't [offer] chemotherapy for their cancer, or [give them] a joint replacement or a heart transplant, because they had an infection that was resistant to antibiotics," says Boucher.

This scenario has become frustratingly common. According to an alarming October 2025 report from the World Health Organization (WHO), many frontline antibiotics are losing their effectiveness, with potentially stark consequences for public health around the world.

One in 6 laboratory-confirmed bacterial infections were resistant to all known antibiotics in 2023, the data show. From 2018 through 2023, antibiotic resistance rose in more than 40% of the antibiotic-pathogen combinations that WHO monitors, increasing the risk posed by common blood, urinary tract, gut, and sexually transmitted infections.

"We're at a place now where antibiotic resistance is a global crisis," says Boucher. "It's killing large numbers of people around the world every day."

Antimicrobial resistance is already responsible for the deaths of 1.2 million people a year worldwide and contributes to nearly 5 million additional deaths, other WHO data show. In the United States, some 2.8 million antimicrobial-resistant infections occur each year, killing more than 35,000 people, according to Centers for Disease Control and Prevention (CDC) data.

The stakes of the crisis are too high to ignore. Antibiotics are critical to support treatments ranging from biologics and chemotherapy to implantable medical devices.

"Common procedures like C-sections, hip replacements, and prostate biopsies - all of these rely on functional antibiotics to either prevent or treat the infections associated with those procedures," says Lance Price, PhD, director of the Antibiotic Resistance Action Center (ARAC), at the George Washington (GW) University Milken Institute School of Public Health.

Developing countries at higher risk

The WHO report was assembled with data on 23 million infections from 104 countries. Researchers found that antibacterial resistance hits the world's less advanced countries with particular force.

"There's frequently an inverse relationship between antimicrobial resistance and GDP [gross domestic product]," says Vance G. Fowler, MD, an ID specialist, professor of medicine at Duke University School of Medicine, and codirector of the National Institutes of Health-supported Antibacterial Resistance Leadership Group (ARLG), a collaboration of experts working to combat the problem through research and thought leadership. "The most vulnerable populations of the world tend to bear the greatest burden of drug-resistant bacteria."

Some low- and middle-income countries have weaker health systems and are less likely to have robust infection prevention and control measures in place. Many such nations are less able to afford newer, more effective antibiotics, leaving some infections inadequately treated. These nations may also allow patients to access antibiotics without a prescription. In addition, adequate diagnostics are in short supply. Collectively these factors fan the flames of drug resistance.

Antimicrobial resistance also varies by geographic region, the WHO report found.

"It means different things in different parts of the world," says Fowler. "For instance, for most of Asia, the leading problem is resistant gram-negative bacteria. In much of the Americas, the leading drug-resistant pathogen is MRSA [methicillin-resistant Staphylococcus aureus]."

Here's how the United States is working to protect the antibiotic arsenal and what needs to happen to stem drug resistance.

Infection control and antibiotic stewardship

Prior to the COVID-19 pandemic, prevention and infection control efforts in the United States had reduced deaths from antimicrobial-resistant infections by 18% overall and by nearly 30% in hospitals, data show.

However, antibiotic prescribing shot up when COVID struck - as doctors sought to treat or preempt secondary bacterial infections - and with it, rates of antibiotic resistance. CDC data show that six antimicrobial-resistant hospital-acquired infections increased by a combined 20% during the pandemic, compared with the pre-pandemic period. At the same time, a common yeast, Candida auris, that spreads in health care facilities and is often resistant to antifungal medications increased more than fourfold.

Nevertheless, Boucher says, "we are making some progress in decreasing the prevalence of certain antibiotic-resistant bacteria in hospitals by really upping our game in infection prevention. That's everything from washing our hands, to making sure we perform procedures as well as we can, to practicing good antibiotic stewardship."

Antibiotic stewardship is defined as using the right antibiotic at the right time at the right dose in each patient to treat infections. As hospital-associated infections are reported to the Centers for Medicare & Medicaid Services and reimbursement rates are tied to infection control, antibiotic stewardship programs in hospitals have grown more robust. In 2023, approximately 96% of U.S. hospitals had implemented the seven core elements of an antibiotic stewardship program, as laid out by the CDC. They include factors from having a strong commitment from hospital leadership, strict accountability measures, and pharmacy expertise, to tracking antibiotic use and outcomes.

Runaway outpatient prescribing

But while many hospitals have improved antibiotic use, it's a different story in the community.

"We're seeing increases in [antibiotic-resistant] infections in patients who never came near a hospital," says Boucher.

One in 10 visits to a doctor's office result in a prescription for an antibiotic, and as many as 30% of those prescriptions may not be needed, according to Cindy M. Liu, MD, PhD, MPH, associate professor of environmental and occupational health at the GW Milken Institute School of Public Health, and chief medical officer of ARAC. The challenge is magnified in urgent care facilities, where nearly half of the visits are for minor infections.

"Antibiotics are not always warranted," Liu says. "A lot of respiratory symptoms, like cough and sore throat, are due to viruses."

But consumers often pressure providers for antibiotics, and may get them, due to perverse incentives. "The salaries and bonuses of urgent care providers are often tied to patient satisfaction," Liu explains.

Such prescribing practices may help explain why rates of a certain type of bacteria that cause resistant urinary tract infections (UTIs) - ESBL-producing Enterobacteriaceae - rose by more than 50% from 2013 to 2019, according to Boucher. To fight the infection, increasing numbers of patients with UTIs who were once easily treated with oral antibiotics now require intravenous forms of the drugs administered in a hospital, she says.

The CDC has established the core elements of antibiotic stewardship programs for outpatient settings and provides informative resources for clinicians and patients. For example, the agency has a handout for patient education on the types of infections that warrant antibiotics.

Academic health centers have also instituted interventions aimed at reducing antibiotic prescribing. When Intermountain Health, based in Salt Lake City, implemented an antibiotic stewardship initiative in its large urgent care network, antibiotic prescribing for respiratory conditions decreased from 47% to 33%. A patient fact sheet describes the concept of "watchful waiting," to see if symptoms improve before filling a prescription for antibiotics.

Denver Health Medical Center promotes a similar tactic - "delayed antibiotic prescribing." Research shows that the practice, initiated by pediatricians seeing patients for earaches, increased the rate of delayed antibiotic prescribing from 2% at baseline to 21%.

Antimicrobial use in livestock and agriculture

More than 70% of the antibiotics in the nation's stockpile are used in animals, including cows, pigs, and chickens. Historically, food producers have added them to feed to prevent and control infection, as well as to promote growth, which can fuel outbreaks of drug-resistant organisms such as salmonella, E.coli, and campylobacter, which spread through the environment.

However, "we've had good progress in high-income countries in terms of curbing unnecessary use of the most important antibiotics in animals," says Price. "If you look at all the classes of antibiotics being used, it's mostly tetracycline and other drugs that were once really important to human health but aren't as important today."

The situation is very different in many low- and middle-income countries, where there's a significant overlap in the types of antibiotics used in treating human infections and those used in food production, he says.

Price sees trouble on another front - the use of antifungal medications in agriculture.

"This could be an important driver of drug-resistant fungal infections," says Price, who is involved in research exploring the connection between antifungal usage and drug-resistant aspergillus infections - fungal infections of the lungs. Aspergillus is found in the soil, and while most people inhale its spores without problems, this can be risky for those who are immunocompromised or who have underlying lung conditions.

"We've had all this progress on stewardship in animal production, but the EPA [Environmental Protection Agency] regulates use in plants, and they currently look at whether a drug might be toxic but not whether it could drive resistance," Price says.

The antimicrobial pipeline

Conserving the existing arsenal of antimicrobials is only part of the equation. As bacteria inevitably become resistant to antibiotics, new agents are needed to replace less effective ones.

"You're dealing with living organisms that are trying to stay alive," says Fowler. "They stay alive by developing resistance to the tools we have to treat them."

Concerningly, says Fowler, "there's been a vast exodus from antibiotic development by most major pharmaceutical companies. From the perspective of a company that is obligated to shareholders, it is very difficult to make an argument that an antibiotic can provide an acceptable return [on the investment]. These are not statins, antidepressants, or erectile dysfunction drugs." Such drugs are taken on a long-term basis or even for the rest of a person's life, while antibiotics are typically used for seven to 14 days.

There is hope that the bipartisan Pioneering Antimicrobial Subscriptions To End Upsurging Resistance Act of 2021, or PASTEUR Act, will reinvigorate the pipeline by providing "subscription-based" government contracts for access to new, high-priority antibiotics. "It would allow producers of these compounds to have some possibility of a return," says Fowler.

Pharmaceutical profits are typically tied to how much of a drug is sold. The PASTEUR contracts would instead pay for new antibiotics based on their value to public health. The bill is still under consideration in Congress.

Other strategies for outsmarting resistant bacteria besides using antibiotics are in the works. One involves the use of bacteriophages, or phages - viruses that kill microbes. Researchers from the David Geffen School of Medicine at UCLA recently announced the findings of a multisite, double-blind, randomized control phase 2 trial testing a phage "cocktail" in combination with standard of care antibiotics for patients with complicated Staphylococcus aureus bacteremia.

"It demonstrated very favorable results in terms of efficacy, and there was no real toxicity," says Fowler, who chaired a blinded independent adjudication committee evaluating the study results.

More work is needed in the diagnostic arena, particularly the need for more rapid diagnosis of some bacterial infections, which usually take one to five days to diagnose, depending on the organism. That would allow clinicians to use available antibiotics more judiciously, thus safeguarding their potency.

"There's been a lot of progress on the scientific side for diagnostic tests," says Boucher. "The challenge has been ascertaining the best way to use these new tools and figure out a way to make them cost-effective. That said, we still, in many cases, don't have a fast, easy, and inexpensive means to determine if something is a viral infection or a bacterial infection."

ID workforce shortages

ID doctors and other professionals are needed to care for patients with resistant infections, manage hospital infection prevention and control programs, and conduct surveillance and research, Boucher says.

"We know that having an ID physician participate in the care of patients with life-threatening infections improves outcomes," she says.

Yet in 2025, only half of ID physician training programs filled their available fellowship positions. And about 80% of U.S. counties lack an ID physician, according to the Infectious Diseases Society of America (IDSA).

"Year after year, we're seeing the numbers of recruits into ID stagnate or even decline," says Boghuma K. Titanji, MD, PhD, an assistant professor of medicine in the Division of Infectious Diseases at the Emory University School of Medicine. "We had a slight bump during the pandemic, and then things went back to where they were before."

One of the problems is compensation, which lags behind that of other fields, despite the additional years of training required. "There is a remuneration problem, where infectious disease physicians are among the lowest paid of our medical [specialists]," says Boucher.

"Someone coming out of residency with an internal medicine board certification and going on to work in hospital medicine could make about $300,000 working as a hospitalist," says Titanji. "If you were to go train as an ID physician and stayed in academics, for example, you could be making half of that, with an additional two years of training to pay for."

Even so, the field is rich with possibilities for a rewarding career, Titanji believes. "You can do so many things with it," she says. "There's crossover with health policy, social determinants of health, and the ability to do research. ID doctors also have tremendous clinical variety."

The IDSA has put forth several proposals to address the workforce challenge, including increasing Medicare reimbursement for ID physicians through such strategies as increasing the value of the codes they bill most frequently. Other potential incentives include eligibility for favorable loan-repayment plans, to offset the financial burden of training, Titanji says.

While there are signs of hope in the struggle to reduce the impacts of antimicrobial resistance, experts say the battle is far from over, particularly in the developing world.

"I was in India recently, and it was great to see the level of innovation that is happening there," says Boucher. "But it was also sobering to realize the scope of the problem."

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