Book Review

Antimicrobial Resistance: Problem Pathogens and Clinical Countermeasures

N Engl J Med 2009; 360:550-551January 29, 2009

Article

Antimicrobial Resistance: Problem Pathogens and Clinical Countermeasures
(Infectious Disease and Therapy. 48.) Edited by Robert C. Owens, Jr., and Ebbing Lautenbach. 492 pp., illustrated. New York, Informa Healthcare, 2008. $299.95. ISBN: 978-0-8247-2941-7

The antimicrobial era began about 75 years ago. Although it is far from over, it is being increasingly challenged by the emergence of resistant microorganisms. Antimicrobial resistance is the inevitable result of Darwinian evolution — natural selection and survival of the fittest. The emergence of resistance has been accelerated by the excessive use of antibiotics in conjunction with the remarkable genetic plasticity of microorganisms.

There is a close association between nosocomial infections and antibiotic use. Antimicrobial drugs can be helpful in the management of infectious complications of invasive procedures, immunosuppression, and aging, but they can have adverse side effects and can lead to the spread of superinfections caused by resistant microorganisms. Current goals of those working in antimicrobial programs are to block transmission of nosocomial infections, to devise better tactics to contain resistance, and to develop new drugs and vaccines.

These issues are superbly addressed in Antimicrobial Resistance. The editors have assembled an outstanding group of experts to define the broad clinical and economic issues in part 1, the characteristics of problem pathogens in part 2, and the interventional strategies needed to combat resistance in part 3. Each chapter contains a well-referenced, comprehensive review and thoughtful analysis of the assigned topic. Overlap is of little concern because the chapters are not interdependent. Although this book is aimed at clinicians and hospital epidemiologists, coverage of the underlying molecular mechanisms should be sufficient to interest basic scientists. I could not detect any major weaknesses. The book is packed with so much valuable information that it is nearly impossible to summarize it in a brief review.

Part 1, “Resistance Concerns for the Practicing Clinician: General Considerations,” is more informative than its title suggests. The opening chapter is a sophisticated economic analysis of the attributable costs of resistant infections in hospital settings. The authors analyze the different perspectives of physicians, patients, health care businesses, and the drug industry, and the economic implications for each group. The next chapter is a description of how the pooling of clinical and laboratory data from multiple institutions can lead to the identification of “benchmarks” against which individual institutions can measure the effectiveness of their own programs for antimicrobial management. Large surveillance systems of antimicrobial resistance provide information that can help clinicians to select the most appropriate antibiotics and to determine the need for new products. Chapter 3, “Antibiotic Resistance: Opportunity or Obstacle for the Pharmaceutical Industry?,” examines the constraints that large pharmaceutical companies face as they attempt to develop new antibiotics and the initiatives of the Infectious Diseases Society of America to augment new discoveries. The final chapter in this section focuses on the sound epidemiologic methods that are needed to conduct studies of resistant microorganisms.

Color-Enhanced Scanning Electron Micrograph Showing Clumps of Methicillin-Resistant Staphylococcus aureus (MRSA).

Part 2, “Contemporary Antimicrobial Resistance Issues: Gram-Positive, Gram-Negative, and Miscellaneous Pathogens,” contains definitive chapters whose authors dig into the details of epidemiology, mechanisms of resistance, clinical implications, control, and treatment of infections caused by specific microorganisms. These include resistant Staphylococcus aureus, enterococci, Streptococcus pneumoniae, acinetobacter species, Pseudomonas aeruginosa, Clostridium difficile, problematic beta-lactamases, and candidemia.

The chapters in part 3, “Interventional Strategies to Combat Resistance,” provide useful information about what does and does not work. There are discussions of empiric and de-escalation therapy, cycling programs (which rarely work), antimicrobial stewardship, short-course and combination antimicrobial therapy, and several other approaches. Surveillance programs need to do more than document failure; they must be closely linked to proven control measures. Chapter 20, “The Impact of Hospital Epidemiology on the Management and Control of Antimicrobial Resistance: Issues and Controversies,” is a comprehensive discussion that should be required reading for hospital administrators and legislators. As author August Valenti states near the end of the chapter, “Resources and commitment must back programs to combat antimicrobial resistance; unfunded mandates only serve to discourage those attempting to translate science into practice.” I agree.

Calvin M. Kunin, M.D.
Ohio State University, Columbus, OH 43221
ckunin@columbus.rr.com