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The Killers Within: The Deadly Rise of Drug Resistant Bacteria

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This book is scary. According to ethnobotanist Mark J. Plotkin and longtime Vanity Fair contributing editor Michael Shnayerson, the golden age of antibiotics that began with penicillin, a time when it was generally thought that infectious diseases were under control and largely a menace of the past, is over. Our naivete and our arrogance in imagining that we had just about defeated the bugs and could move on to other more pressing public health concerns came to an end in the nineties as one after another of the major human borne bacteria became resistant to our drugs. Through the exchange of DNA, that immunity has been transferred to other bacteria so that, as this book went to press just a few months ago, infectious diseases caused by bacteria are once again a major threat to humans everywhere in the world.

What happened? As the authors explain there are three main problems, (1) the overuse of antibiotics by the medical profession, (2) the misuse of antibiotics as growth enhancers in the meat and poultry industry, and (3) the failure of hospital personnel to follow CDC guidelines on hygiene, especially simply washing their hands.

(1) Too many doctors, either through ignorance or a desire to please their demanding patients, have over-prescribed antibiotics for routine infections, and in some cases actually prescribed antibiotics for viral infections (for which they are useless) "just in case" the patient also gets a bacterial infection. The result of this massive overuse of antibiotics is to give the bugs countless trillions of generational opportunities to evolve defenses against the antibiotic, leading to the antibiotic becoming useless.

(2) Tons of antibiotics--"24.6 million pounds a year," see p. 123--are routinely added to animal feed by the meat and poultry industry to promote growth so that their products will get fatter faster. What has happened is that the bugs have grown resistant to the antibiotics while transferring that immunity to bacteria living in, on and around humans. Even the use of an "analogue" antibiotic such as growth promoter virginiamycin can promote changes in bacteria that make them resistant to the antibiotic Synercid (e.g., see pages 115, 119 and 285). As the authors chronicle, this is a serious problem fraught with angry political battles as the meat and poultry people fight to maintain their profit margins while the disease control people fight to restrict the use of growth promoters.

(3) Surprisingly enough the authors report (see page 282 and elsewhere) that there is cynicism among some hospital personnel about the effectiveness of washing their hands and a belief that hygiene won't stop the proliferation of the bugs. The result is that hospitals have become very dangerous places. Most of the drug-resistant bacteria developed their resistance in hospitals. Most (or all) of them are endemic to the hospital environment. If you have to go to a hospital for any reason you are taking a chance of contacting a drug-resistant bug. Heaven help you if you have a compromised immune system, or if you are an infant or an elderly person.

How bad is the situation? According to the authors on pages 278-279 the high cost of developing new drugs (average "$802 million") and the fact that "return on investment from producing an antibiotic that might be used by a patient for less than a week versus return from a drug for a chronic condition that a patient might take daily for fifty years" is persuading big pharma to downsize the antibiotic end of the business. (See also page 94.) The authors ask the question, where are new drugs coming from? and answer that the "great glittering prospect was genomics." But "reality" has "sunk in." (p. 280) Drugs to fight bacteria developed from DNA manipulation "might take even longer to reach the market" than those previously developed. (p. 281)

The authors also touch on the possible use of drug-resistant bacteria as a bioterrorist weapon.

What does all this mean for you and me? It means that should we or our loved ones get a life-threatening bacterial infection, it's possible there won't be an antibiotic around that works. In effect, we might find ourselves back in the days before penicillin (the first really effective antibiotic, and one of the greatest of all medical miracles) when millions of people routinely died from staph, strep, TB and other bacterial infections. As Shnayerson and Plotkin report, right now there are strains of bacteria, including Staphylococcus aureus (the golden-globed bacteria pictured on the cover), Streptococcus pneumoniae, and the Mycobacterium that causes tuberculosis, that are immune to almost every antibiotic in use. There is even a strain of Enterococcus that is resistant to every antibiotic in use.

The authors do offer some hope. They report on the promising use of bacteriophages (viruses that invade and destroy bacteria)--see the very interesting Chapter 14, "Bacteria Busters." They present the idea of a more vigorously controlled use of antibiotics. If we prohibit their use as growth promoters and use them sparingly in an ordered sequence, perhaps bacteria would not have time to gain immunity and/or would lose it after the antibiotic is no longer in use. As pointed out on e.g., page 183, resistant bacteria are "encumbered" by an "extra chunk of DNA" that gives their non-resistant brethren an "ecological advantage" in an environment that doesn't contain the antibiotic. Additionally, the authors report the theory of population biologist Richard Levins who believes that if antibiotics are "saved for the most severe cases...then natural selection would favor the pathogens that produced the milder symptoms." (Explained on page 287).

Bottom line: this is a fascinating, scary and state of the art report on the pathogen wars written in a readable manner sure to interest not only the general public at which it is aimed but professionals as well.

Excellent, excellent job done in research and writing by Shnayerson & Plotkin. If the reader is involved in science or public health, the 'news' in this book does not come as a surprise to anyone. It's been known for years among those in these communities that bacteria has been developing resistance to our antibiotics from day one. We get taught this if you work in a lab, because it becomes vitally important to keep everything absolutely sterile and clean. I know it is taught in medical school, but they don't emphasize this enough to medical students and doctors and nurses, because many doctors continue to dispense antibiotics like candy even though they have been warned and warned again by the Center for Disease Control and others.

For those who enjoy reading stuff like this to scare themselves...well, good luck. This is the stuff of nightmares, and if you spend a lot of your time worrying, I certainly wouldn't recommend you read this book. There is always hope, as the authors point out, that researchers will continue to find antibiotics that will temporarily restrain bacterial onslaught. However, be assured this hope has been relied upon in the past, and the bacteria always seem to find a way to mutate around medication, regardless of whether the antibiotics had an organic chemical basis or was a synthetic/man-made one, not seen in nature.

Most of the time, the people who pick up this type of book are already involved and concerned about this public health disaster-in-the-making. Yet these authors are trying to get this information out to the public, and write in such a way as to make this science knowledge understandable. The book starts out slowly, but picks up pace quickly. I had difficulty putting it down after the first couple of chapters. It is absolutely vital that the public be aware that responsibility for correct antibiotic use lies not just with the physicians, but with the patients and parents of patients who beg their doctors for antibiotics, when those antibiotics are not called for. As the authors bring up, most antibiotics given out by pediatricians are for ear infections (>60%). Yet often times those ear infections will go away on their own, with the antibiotics only minimalizing the length of time of the course of infection. Yet, all of us are guilty of expecting physicians to give us 'something' to make a cold or the flu 'go away'. Unfortunately, too often those illnesses are not caused by bacteria, but by viruses, and giving antibiotics in this manner just give bacteria an opportunity to switch genes around to build resistance. Same thing with not taking all of a prescription after the patient starts feeling better, or sharing medication not prescribed for others.

I hope this book is widely read. Maybe if enough consumers become concerned, we can put a stop to certain practices such as the use of antibiotics in animal feed as growth factors, regardless if they are known to be used for human consumption. The public needs to get more involved in their own medical care, and that means participating in governmental processes to fight against massive lobbying by pharmaceutical companies and livestock/meat companies and their lackeys, who often don't know and don't care about the possible consequences of their indiscriminate use of antibiotics.

Karen Sadler,
Science Education,
University of Pittsburgh

If you think that modern medicine has all the answers, don't read this book! If you believe that science will save you, don't read this book! If you have faith in the wholesomeness of our food system, don't read this book! If you trust that industry has your best interests in mind, don't read this book! If you want sweet dreams at night, please, please, don't read this book!
The Killers Within weaves two very different emotional strands into a compelling narrative. One story is that of courage and curiosity, of those scientists who devote their lives to the pursuit of knowledge. These men and women toil for decades to understand the miniature worlds of bacterial organisms, enduring what (to me) seems like almost unbearable tedium in unravelling just one tiny aspect of these mysterious life forms. The book shines a lovely light on these Galahad figures, who seek their Holy Grails in dreary laboratories to keep the rest of us from harm. One wonders what these scientists feel about industry, which exploits the discoveries of science when it leads to profit, but ignores bedrock principles - such as evolution - if they threaten to inhibit corporate income in any way.
The other story woven into the book is that of evolving bacteria, and it's like looking into hell. Where only a few years ago doctors were crowing that we'd completely conquered infectious diseases, now it's the bacteria who are gaining the upper hand, and fast. There is a lot of medical and biological detail here; it takes some attention to follow but it's well-written and well-larded with colorful and helpful similies for the civilian. What makes the story especially disturbing is that much of the evolution of drug-resistant bacteria has been engineered by stupid or indifferent (worse!) humans. While the authors don't cast blame on any particular individuals, you don't have to be Perry Mason to figure out who the bad guys are here.

The main reason why you shouldn't read this book is that it presents a view that will forever demolish your belief that humans are the center of the universe. It's not exactly "Nature Red in Tooth and Claw", but it's ruthless. These bacteria will kill us if they can (we are just food sources for them, after all) and the next person dead in a heartbeat might be our child, our husband, our mother. After you have been sucked into the flourescent glare of this nightmarish book, read The Doomsday Book by Carol Willis, a novel that takes place during The Black Plague. I guarantee that you will never again forget to be grateful for your short and lucky life.

This is a reasonably good review of the problem, but there is just too much about the heroic docs and their saddest cases, and too little basic science. The book gets a little tedious and confusing because of this. It would profit from an introductory chapter devoted to the background science, and an appendix you can refer to with a table showing different kinds of antibiotics, possibly a figure explaining how antibiotic-resistance is evaluated (the MIC pops up everywhere, but is not explained well), a list of problem bugs and their acronyms, and another list of the principle mechanisms of resistance. There are web resources (listed) to go to for help-www.cdc.gov is a good place to start. The current research on nonantibiotic approaches to treating infections(principally antibacterial peptides from amphibians, and phage therapy) was very interesting to me: I have a good background in microbiology, and am probably being a little critical, but the science here was not explained very well.

This is a serious book about a very serious subject--the escalating arms race between humans and disease-causing microbes. The bad news is that we're losing, making the emergence of resistant disease causing bacteria "one of the greatest threats to the survival of the human species."

Co-written by Mark Plotkin, a leading ethnobotanist and Michael Schnayerson, a talented writer and editor, The Killers Within is a highly readable, often gripping narrative, full of stories, personalities and drama. At the same time, it presents a lot of the history, science and politics that surround the struggle of medical science to stay a step ahead of the deadly bugs that are proving remarkably adept at evolving ways to defeat our antibiotics.

The authors have no trouble identifying the culprits in this losing battle--an agricultural industry pouring millions of pounds of antibiotics into poultry and livestock as "growth promoters," doctors and patients who overuse antibiotics, and the interaction of profits and politics that determine what kinds of drugs reach the market and when. But behind these lies our naive blindness to the bacterial world's incredible capacity to defeat our most powerful weapons. Bacteria have multiple ways to evolve and swap handy genetic information, such as how to cleave penicillin molecules or pump antibiotics out of their cells. All it takes is one bacteria that survives an antibiotic by evolving a new resistance mechanism; within a few years even unrelated bacteria thousands of miles away will know the trick. It's as easy for the bacteria, the authors write, "as collecting charms on a charm bracelet."

The authors chillingly describe the costs of this war being fought out in our labs, hospitals and bodies--millions of illnesses, hundreds of thousands of deaths worldwide, and the risk to all of us of returning to a world where we are no longer protected by antibiotics. Most of the major pathogens have already evolved multiple drug resistance. The very young and the very old are already dying from untreatable infections, but any one of us is now at risk that a cut, an accident, a minor surgery or a bout of flu can lead on to a raging infection by bacteria resistant to most if not all antibiotics.

The authors do hold out some hope. Perhaps phages, vaccines, or new generations of genetically engineered antimicrobial agents will once again tip the balance in our favor. But for now, expect to see more headlines about outbreaks of resistant strains of bacteria and to hear more horror stories from friends whose scratch or surgery turned into a life-threatening nightmare. This book will help you make sense of those events. Let's hope that the dedicated and farsighted researchers it depicts will eventually win the day.

Robert Adler, author of Science Firsts: From the Creation of Science to the Science of Creation (Wiley, 2002).

The Killers Within is not only a thoroughly researched, spell-binding read, but also manages to make a complex, formidable topic of vital public concern both understandable and compelling.
For years, we've heard the warnings from respected scientists and journalists about the inevitable rise of drug-resistant bacteria (Dr. Stuart Levy and Laurie Garrett, among others). Prior to The Killers Within, I had somehow managed to intellectualize this problem and innocently assumed that science and government would magically resolve it. No more. We're facing a crisis of unspeakable proportions, and remarkably, as Plotkin and Shnayerson point out, every single one of us can actually do something about it.

I don't usually read mysteries. I seldom read thrillers. And I'm no science nerd. But I picked up this book at the bookstore and found I could not put it down. Literally: when I realized the store was closing I read it on my way to the cash register, and then found myself behind the wheel of the car reading the book in the parking lot. This is riveting stuff. A page-turner if there ever was one. And it's all TRUE! You'll find yourself calling your friends and reading them passages. Buy this one--and don't plan anything for the rest of the day.

This book deals with the extremely important issue of drug-resistant bacteria in a very straightforward fashion- something that was sorely missed until now. It clearly states the dire situation that we are confronting nowadays, the rampant over-prescription of antibiotics, and the attitude of a lot of the professional staff at hospitals (a friend of mine almost died because of a severe infection contracted at a hospital, disease that was shared by most of the patients at that ICU: I personally saw how the medical personnel failed to wash their hands between patients!)
All of this is done in a highly readable fashion- a medical page-turner for scientists and non-scientists alike!
The good thing about this book is that, while really scaring you about the situation that all of us are confronted with- not only in the US but around the world-, it suggests actions that everybody can take to prevent the spread of these very aggressive bacteria, and the incurable diseases that they cause.
I highly recommend this book, and will give copies to a bunch of my friends: we have to do something about this NOW, and the only way to do something is to know about it ASAP!!!

This book describes the problem of the bacteria developing resistance to the many antibiotics that humans are using to fight them and, the most important, that we are losing this battle. The book talks about the reasons behind this : overuse and abuse of antibiotics by us, use of antobiotics as "growth enhancers" and so on. I am already aware of this resistance problem but after reading this book I was thrilled and frightened. If we do not change our ways of using antibiotics soon then we will soon be unable to fight those drug resistant bacteria when they cause infections and a huge health problem will unfold. I for one strongly agree with the authors that antibiotics use as "growth enhancers" should be totally banned as soon as possible.

Buy this book at the airport bookstore. Get on an airplane and travel across the continent; say, from Portland, Oregon to Albany, New York. Turn on the overhead light, ignore your jabbering seatmate, and dive in. You're going to love this book about hidden killers, and it might even save your life.

Your seatmate is coughing occasionally, catching most of the goo and sputum in a handkerchief but nonetheless vaporizing your personal space with unknown and unseen critters. Now, that hacking could be the result of too many cigarettes, or the first warning sign that you are sitting next to a human cesspool of contagious diseases, from TB to something really exotic and hemorrhagic. Stuck for the next six hours beside a raging smallpox blanket of a fellow traveler who wants to chat and breathe on you. You reach in your pocket for the Airborne, and spray it into your pie-hole with the same prayer that they said back in London when they put on a necklace of garlic and went out to mingle with the victims of bubonic plague. You open this book by Messrs. Shnayerson and Plotkin and tune out.

Reading this book will persuade you to wear a 3-M mask in public someday soon, as the Japanese have been doing for decades. And you'll finally figure out what your crazy aunt was talking about, when she told you to wash up your hands for supper. Human beings have the power to fight this undeclared war on bacteria, but not the will; maybe we need to see War of the Worlds a few more times to understand a point: bacteria OWN this planet. We seem to forget that. Without them, we couldn't even digest our food. Without them, no yogurt. Without them and their microscopic cousins, we'd eventually overpopulate ourselves into oblivion.

Fortunately, there is flesh-eating bacteria. This information alone was worth the price of the book: If you get really sick, going to a hospital is a questionable option. Read this book in the ambulance, and you'll tell the EMT's to let you off near a bus stop.

Definitely worth reading. I would also recommend this book to anyone who uses public transportation; it will enhance the ride immensely. If you are also reading Lives of a Cell, you may even get laid that night. Tell your friends about this book, because they really need to know that all worry is wasted. Either your number is up, or it isn't. Bacteria are everywhere, and whether or not they kill you is purely up to karma.

And while reading this book, in a fit of humanity, you might offer your leprous sky-comrade a shot of your Airborne, without sweating what microbes you might be picking up.