The antibiotic era, barely 60 years old, is increasingly challenged by the continued emergence of drug-resistant organisms. The variables that currently predict the level of resistance in a community (or a hospital) are the misuse of antibiotics and the resultant selection of mutants, the spread of resistant strains as a result of poor infection control, and intrusion from the outside of strains already resistant to the drug. Without the pressure of antibiotics, however, the selection of strains in the community harboring the genes that code for resistance would not be so effective. No one has been more outspoken on this point than Stuart Levy, author of this encyclopedic account of the misuse of antibiotics. Ten years after the book's initial publication, the new edition is an accessible, fact-filled warning of the risks posed by the unwise use of the prize drugs -- antibiotics. Nowhere else are the history of antibiotic discovery and the mechanisms of microbial resistance so clearly presented for general readers. For those in medicine and related disciplines who are interested in the topic, this book is easy to read, a comfortable and logical presentation of the problem with sufficient notes and references for the serious student to pursue the topic by reading original publications beyond the book. Levy's writing is lucid, and his analogies are helpful in explaining complex biologic systems. For example, in describing the exciting discovery of transferable resistance, the genes coding for antibiotic resistance that are located on plasmids, Levy writes about a strain of Escherichia coli that was suddenly found to be resistant to four antibiotics: "Even if each mutation occurred once in 10 million, mutations to four drugs would have needed 10 million x 10 million x 10 million x 10 million or 10(sup 28) doublings! This realization led the astute Japanese workers to look for a different genetic basis for multiple drug resistance. They guessed that the resistance traits might be associated with genes not on the chromosome." Later, in explaining the genetic determinants of multidrug resistance on the plasmid, Levy writes: "It's like a snowball rolling downhill, picking up snow and any debris during its transit, becoming bigger in the process, and not losing what it had acquired before. So do plasmids as they `roll' through the environment." In discussing antibiotic use in animals and in agriculture, Levy has no peer. Some of the facts he offers are both fascinating and entertaining: there are five times as many domestic food animals as people in the United States, and "daily animal fecal excretion can be 5-400 times greater than that of humans. For example, the amount of feces excreted by a cow per day is 100 times that by a human. . . . Hence . . . animals are contributing a large amount of resistant bacteria to the natural environment." He also refers to studies showing that flies caught on flypaper carried antibiotic-resistant organisms with specific genetic markers of identical strains from nearby animals. Furthermore, with the local ground environment continually burdened with antibiotic-resistant bacteria, streams nearby could become contaminated. Later in the book, Levy also cites the volume of antibiotics continually used to treat fruit trees, hives of honeybees, and commercial catfish and salmon farms. Thus, he provides an unusually graphic portrait of a vibrant ecosystem contributing constantly to the spread of antibiotic-resistant strains of bacteria. The title of Levy's book is appropriate, because the reality is that our society still believes in the infallibility of antibiotics, their ability to cure whatever ailments we have, and the absence of important side effects. The paradox, of course, is that the more we use, the less we have. If we take this paradox to its logical conclusion, we may eventually be faced with what Levy calls the "impending disaster." At the time of printing there had been no identified cases of Staphylococcus aureus strains that were fully resistant to vancomycin. Thus, Levy could not address this latest threat. However, the fact that, in the summer of 2002, the United States witnessed the first case of vancomycin-resistant S. aureus with the vanA gene for resistance on a plasmid acquired from an enterococcus supports his thesis. Richard P. Wenzel, M.D.
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