Your questions answered: Are there alternatives to antibiotics?

Garlic has antibacterial properties but hasn't been tested as an antibiotic in clinical trials. Keystone / Gaetan Bally

Readers asked us a host of questions about antibiotics amid rising rates of antimicrobial resistance and a lack of investment in new drugs to fight bacterial infections. We have some answers.

Antibiotics transformed modern medicine and helped double the average human lifespan in the last century. But bacteria evolve to outsmart drugs designed to kill them.

Dangerous infections that no longer respond to antibiotics are spreading quickly around the world, by as much as 15% a year, according to a report by the World Health Organization (WHO) published in October. In 2023, one in six bacterial infections was already resistant to antibiotic treatments.

What can we do about it? We received many questions from you about antibiotics in response to an article we wrote about the urgent need for new drugs to fight bacterial infections. A key theme emerged around whether there are potential alternatives to antibiotics. We investigated three reader questions. 

Q1: How effective are natural products such as garlic or oregano oil in fighting bacterial infections?

Before modern antibiotics emerged in the mid-20^th century, people relied on natural remedies like garlic, honey, leeches, and even moldy bread to prevent and treat bacterial infections.

In fact, many of the compounds in today’s antibiotics were extracted from natural products, such as plants, fungi, microorganisms, and marine sponges. Investigating naturally occurring molecules is a key area of research in organic and pharmaceutical chemistry.

However, for a substance to be approved as a medicine, it is necessary to identify its active ingredients, clarify its mechanisms of action and toxicity, and conduct well-designed clinical trials. And this hasn’t been done for garlic, says Silvio Brugger, a doctor and researcher in the department of infectious diseases at the University Hospital Zurich.

“A lot of plants – including garlic – contain compounds, and polyphenols show antimicrobial activity in the laboratory,” he says. “However, the truth is this knowledge, although it’s interesting, has never made it into adequately designed clinical trials.”

Brugger adds that eating one clove of garlic would not be enough to fight an infection to the degree antibiotics could. “You would need kilograms to produce those compounds in a way that they show activity,” he said. But doing so could, at the same time, damage good bacteria in the body.

Q2: Why don’t drug companies look into traditional medicine like ancient Ayurveda for answers to antibiotic resistance?

There are several reasons why pharmaceutical companies haven’t invested heavily in Chinese medicine or Ayurveda, an ancient Indian medical system that incorporates herbal medicine alongside yoga and meditation.  

One is the sheer complexity. Much of today’s modern medicine is focused on identifying a single active ingredient. Traditional herbal medicine often uses a mix of herbs and minerals, making it difficult to define the precise compound. 

Another key factor is intellectual property. Many traditional formulas are centuries old and in the public domain, which makes them difficult to patent and therefore earn a high return on investment.

Western drug approval systems like the US Food and Drug Administration also demand rigorous clinical trials to prove safety and efficacy, which are expensive. Some academics and government institutes, especially in Asia, carry out trials into roots like Ashwagandha or curcumin (turmeric).

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Some medicines regulators approve traditional remedies as pharmaceuticals such as Kampo in Japan. In Switzerland, there is a simplified authorization procedureExternal link for herbal medicine products. Many alternative therapies are also covered by basic insurance.

But Brugger says companies are reluctant to invest in plants or herbs with antibacterial properties because it takes a lot of money to “bring an interesting lab finding to patients”. Antibiotics are supposed to be used sparingly to prevent resistance. so companies struggle to sell enough volume to get a return on investment.

Q3: What research is being done into alternatives to antibiotics?

There’s a lot of research underway into technologies and methods to fight bacterial infections beyond antibiotics. Many of these target the human gut.

One promising area of research is in phages, naturally occurring viruses that infect and kill bacteria. They are found wherever you find bacteria and are abundant in the gut microbiome. They were discovered in the early 20th century and gained popularity in Eastern Europe. But many Western countries abandoned them in favour of antibiotics, which were easier to produce in large quantities.

As we see increasing “problems with resistance to antibiotics, “there is renewed interest in phages”, says Brugger. Phages are highly specific, targeting only certain types of bacteria, which means they take time to produce. However, advances in genetic sequencing and manufacturing have speeded up the process, making them more interesting to researchers.

Balgrist University Hospital in Zurich has several projectsExternal link looking at phage therapy for urinary tract infections. Some companies are also using gene-editing tools like CRISPR to engineer phages to target specific bacteria.

What are phages?

Phages have been called Mother Nature’s remedy for bacterial infections. Phages are viruses that attach to specific bacterial receptors, inject their genetic material, and hijack the host cell’s machinery to create new phages. Once assembled, the new phages release enzymes that cause the bacterial cell to burst, allowing the new phages to spread and infect other bacteria and eradicate the infection. 

Researchers are also studying how to manipulate the microbiome – an ecosystem of bacteria, fungi, viruses in an area like your gut or skin – to prevent and treat infections. When the microbiome is healthy, it acts as a protective barrier for the immune system.

“The idea is to alter microbiomes in a way that resistant bacteria can’t reside in them,” Brugger says.

The Lausanne University Hospital (CHUV) is leading a nationwide projectExternal link to test fecal microbiota transfer (FMT), including in the form of a capsule taking orally. FMT is a medical procedure that transfers fecal matter containing healthy bacteria from a donor into a patient’s gastrointestinal tract to restore a healthy gut microbiomeExternal link.

In February the Swiss medicines regulator, Swissmedic, granted CHUV authorisation to carry out FMT to treat chronic intestinal infections. FMT is provided in a capsule form produced at CHUV.

Brugger is interested to see if a similar approach could work in the airways. He is currently leading a researchExternal link project on how microbiota-targeted therapies could be used for respiratory infections. Clinical trials are expected to start next year.

But if any of these treatments are successful, they won’t be available to patients for years. What’s more, Brugger says many are likely to be used in combination with antibiotics rather than as alternatives. 

“There is an urgent need to invest in developing new antibiotics.” says Brugger. “Because antibiotics will still be used for quite a long time to come.”

Edited by Virginie Mangin and Hiroko Satoh/ts