The global antibiotics market has changed substantially in the past two decades. We examined data on this market tracked by the IQVIA Institute for Human Data Science to understand some of the environment surrounding the well-documented departure of large companies from research and development (R&D) on innovative antibacterial drugs and the financial crises faced by smaller companies in this period.

Since 2001, the branded (on-patent) antibiotic market declined as the generics market grew. In 2001, global revenues for on-patent antibiotics peaked at $21 billion, with steady declines thereafter, falling to $8 billion by 2021 (Fig. 1a; all US$ figures are in constant Q1 2022 US$). This reduction is particularly steep in the USA, perhaps due to increased availability of generics, and successful introduction of stewardship programmes to combat antimicrobial resistance, which result in lower antibiotic use (Fig. 1b). A similar, though less pronounced, trend is seen in major markets in Europe.

Fig.1 | Trends in the usage, spending on and cost of antibiotics from 1999–2021. a, Generic antibiotics account for the majority of the global usage (measured in standard units (SUs)) and spending on antibiotics overall, and both have increased over the past two decades, while usage of and spending on branded antibiotics have declined. b, Antibiotic usage in the USA and five major markets in Europe (UK, France, Germany, Italy and Spain) has declined, whereas it has increased in the rest of the world (ROW). c, The global average cost per antibiotic SU has declined slightly, while global usage and overall spending have increased. The SU cost of branded and generic antibiotics has been converging. All US$ figures are in constant Q1 2022 US$. Source: IQVIA MIDAS, August 2022.

One thing that has not changed is how inexpensive antibiotics are: the price per standard unit (defined by IQVIA as one tablet, capsule, or 5 mL ampoule/vial/oral suspension) has declined slightly since 1999 (Fig. 1c). Antibiotics are cheap and keep getting cheaper. In conjunction, overall use has increased, measured by unit sales (Fig. 1c). Low prices facilitate access, but concerns remain about inappropriate use.

Another remarkable aspect of the competition between branded and generic antibiotics over the past two decades has been converging standard unit costs (Fig. 1c). In 1999, the cost per standard unit for a branded antibiotic was $1.25 and $0.19 for a generic antibiotic, implying a patent premium of $1.06 per standard unit. In 2021, the cost per standard unit had fallen to $0.88 for branded antibiotics and risen to $0.41 for generics, an implied patent premium of $0.47. Branded antibiotics have shown declines in both standard unit usage and unit prices, resulting in 2021 revenues that are only 43% of those in 1999, adjusting for inflation (Supplementary Figure 1).

In conclusion, the global antibiotics market continues to shift toward lower-cost generics, representing a boon for access but raising concerns about inappropriate use and supply chain issues such as shortages due to unsustainably low prices. Furthermore, sales of branded antibiotics in high-income countries are key inputs into financing R&D for the next generation of antibiotics (Cardozo Law Rev. 31, 613–678; 2010). Unlike most drug classes, antibiotics decline in effectiveness over time due to the evolution of bacterial resistance. New innovative antibacterial drugs are vital to avoid slipping behind, but at present, market sales are not enough to ensure that sufficient R&D is incentivized (Health Aff. 40, 1758–1765; 2021). Recognizing this problem, the G7 recently discussed the need for global push and pull incentives for antibiotic R&D. If the objective is to reverse the long-term decline of revenues of industry in the field, a return to 2001 levels of branded revenues would require an additional $13 billion each year, globally.

Acknowledgements

Data were provided by the IQVIA Institute for Human Data Science.

The authors declare no competing interests.