Nice post, glad somebody wrote this, it has been on my list of things to cover for a while. I think you're right that the risk of a highly-transmissible, antimicrobial resistant pandemic is low but that there is a lot of risk related to secondary bacterial infections within a viral pandemic and that this was an underappreciated driver of Covid-19 mortality. 

Great question and something we're hoping to dive into in some more detail in a future post. Modelling on this generally isn't considered to be very reliable but as a start, the commonly sited number of 10M+ deaths by 2050 is modelled on a "worst case" scenario where there is very high levels of resistance to the most widespread infections. Therefore, this is probably fairly close to the upper end estimate that we can expect year on year. Details of the modelling here. 

Drugs which aren't novel are likely to have quite short periods before they are widely resisted, due to their similarities to existing drugs. The average time to first resistance for drugs commercialised from the 1970s - 2000s was just 2 - 3 years vs. 11 years for drugs pre-1960 (although overuse will certainty have played a part in this rapid resistance as well).

Without new drugs (and accurate and cheap diagnostics to go with them) we could also enter a bad feedback loop where more resistant infections lead to doctors proscribing more 2nd, 3rd and last line antimicrobials in infections where they are only partially effective. Therefore, giving further opportunities for microbes to develop resistance than they would have had if we had more specific drugs available in the first place. 

Thanks for the comment, ensuring better stewardship, especially in countries such as India, is definitely a really important part of combating AMR but it's not something we're planning to work on directly in the near term. The main reason for this is that as a small organisation we want to keep a narrow focus on what we think will be the most tractable option for us to have a big impact. Development of new antimicrobials seems to be a good option for this as they will always be needed, regardless of improvements to stewardship and given the lag from a policy passing to us actually seeing high-value antimicrobials on the market is likely to be at least 10 years, this felt extremely pressing to us. 

We also think that new antimicrobials will play an important role in supporting stewardship and we're particularly interested in policies that can enable this. The policies we support would reduce the incentives for pharmaceutical companies to make money through sales as you've mentioned, although, they don't fully tackle the overprescribing or misprescribing issue. Additionally, more specific antimicrobials combined with better diagnostics should also help in reducing this issue. 

Thanks for the comment Pat. Widespread use of antibiotics in animal agriculture is certainty a concern, however, the role that it plays in driving resistance overall is quite poorly understood. We think it's unlikely that because most antibiotics are used in animals therefore most resistance relevant to humans arises from their use in animals. This forum post gives a good explanation of why this is likely the case. 

Given how poorly understood the drivers of resistance are (see this paper for more), and the fact that it seems unlikely that we'll be able to reduce the growth of resistance in the short term though stewardship efforts, development of new antimicrobials seems to us to be a robust option to reducing the burden of AMR.