An oral carbapenem, but only now intravenous penicillin: the paradox of Japanese antimicrobials.

At present there is a profound paradox in antimicrobial use and development in Japan. A tightly held domestic pharmaceutical market with significant barriers to the importation and registration of foreign agents, has spurred domestic pharmaceutical companies to develop a vast range of antimicrobials. Many Japanese developed antimicrobials are now used globally. A negative consequence of this environment, however, is the lack of availability of several 'workhorse' narrow-spectrum agents to treat patients in Japan. Absent agents include anti-staphylococcal penicillins and until recently, intravenous benzylpenicillin. In substitution for these unavailable agents, patients are frequently administered broader spectrum antimicrobials. This change offers no additional benefit to the patient and is potentially contributing to treatment failure and high rates of antimicrobial resistance amongst key bacterial pathogens in Japan. The situation in Japan illustrates the broader global challenges faced in integrating the development of new antimicrobial agents with maintaining the supply and use of older and less profitable agents.