Book Review

The Antibiotic Paradox: How Miracle Drugs Are Destroying the Miracle

N Engl J Med 1993; 328:1792June 17, 1993

Article

The Antibiotic Paradox: How Miracle Drugs Are Destroying the Miracle
By Stuart B. Levy. 279 pp., illustrated. New York, Plenum, 1992. $24.95. ISBN: 0-306-44331-7

There is ample reason to be alarmed about the emergence of antibiotic-resistant microorganisms. Stuart Levy provides an informed account of how the antibiotic miracle, which began only 50 years ago, is now threatened by the extraordinarily casual manner in which these drugs are used. After a brief exposition of the development of antibiotics and their role in the control of infectious diseases, Levy moves on to describe how the heavy selective pressure of excessive use, combined with the remarkable genetic plasticity of microbes, has led to this problem. After an overview of plasmid-mediated multiple-drug resistance, he addresses the irrational demand of consumers for antibiotic treatment of trivial infections and the problems of antibiotic resistance, which are fostered by sales without prescription in developing countries.

Levy is particularly concerned about the large amounts of tetracyclines added as “growth promoters” to animal feed and the potential ecologic effects of antibiotic use in agriculture, aquaculture, and the care of pets and other animals. He fears the development of multidrug-resistant strains that might infect humans. He cites an epidemic of multidrug-resistant Salmonella newport infection that was traced to contaminated hamburger, but he is on much weaker ground when he claims that farm workers may acquire resistant organisms from their livestock. It is extremely difficult to differentiate the effects of drug use in humans and animals in the spread of antibiotic resistance in farm families. It is also unlikely that many of the organisms that commonly infect farm animals produce disease in humans.

The book concludes with a series of reasonable recommendations to help deal with the problem. These include warnings to consumers to use antibiotics only when needed and suggestions that we improve medical education on antimicrobial therapy, conduct more research on mechanisms of resistance, provide incentives to pharmaceutical companies to discover new antibiotics, increase the use of vaccines, improve sanitation, and maintain surveillance.

This book is intended primarily to inform a lay audience about the problem of antibiotic resistance. Levy provides some problematic advice, however. For example, he implies that eating yogurt may prevent recurrent urinary tract infections and says that he advised one woman not to eat in a local cafeteria in order to eliminate the organisms that were causing her recurrent infections. Although some experimental evidence suggests that lactobacilli may interfere with the colonization of the vagina by Escherichia coli, it is unclear whether this can be accomplished by eating pasteurized yogurt.

Those of us who work in hospitals and must deal with the enormous problems of selection and transmission of microorganisms that are resistant to highly sophisticated drugs will wonder about the relevance of this book to our experience. I wish that Levy had been a bit harder on the pharmaceutical companies for heavily promoting the use of new oral third-generation cephalosporins, quinolones, and macrolides in office practice. A more appropriate subtitle for this book might have been “how heavy promotion and irrational use by humans are destroying the miracle.”

Calvin M. Kunin, M.D.
Ohio State University, Columbus, OH 43210