The Antibiotic Paradox: How the Misuse of Antibiotics Destroys Their Curative Powers (review)

Inflated expectations and flawed understanding of the scope of antibiotic efficacy and applications have led to the rampant misuse and overuse of these so-called "miracle drugs." As Stuart Levy brilliantly captures in his timely second edition, widespread and inappropriate use of antibiotics have led to the selection of resistant strains of bacteria that threaten our ability to cure common bacterial infections and respond effectively to the threat of a bioterrorist attack. Therein lies the Levy's central statement about the antibiotic paradox: drugs that have revolutionized our ability to treat infectious disease since the mid-20th century have also increased our susceptibility to many of these bacterial infections.

Before delving into the complexities of the resistance problem, Levy presents readers with a historical framework for understanding how antibiotics came into existence. The text flows seamlessly between microbiology, anecdotes, and the history of scientific discovery. In Chapter 1, blaring headlines from the 1942 Cocoanut Grove nightclub fire, which took the lives of over 400 people in Boston, immediately draw readers into the story of how penicillin was knighted the "miracle drug." As Levy recounts, media coverage and public response to successful use of penicillin to treat victims of the incident marked the beginning of the Antibiotic Age.

This tale is laid in the context of the quest for the "magic bullet" by 19th-century chemist Paul Ehrlich, and Alexander Fleming's ominous warning of the potential for bacterial resistance accompanying his discovery of penicillin. The later obsession over antibiotics and exaggerated expectations of their curative capacity were fueled by advances in medical knowledge following the acceptance of Pasteur's germ theory of disease and the brilliant work of Koch and his pupils in identifying the causes of tuberculosis, cholera, diphtheria, typhoid, pneumonia, syphilis, gonorrhea, and a number of other diseases. The application of this knowledge in public health and clinical medicine gave rise to the antibiotic myth. Yet Levy does not let us forget that this is only half of the story. Bacterial ecology changed as more and varied antibiotics were applied in an expanding scope of diseases. While resistance genes have always existed, once antibiotics were introduced, bacteria expanded their arsenals for surviving and reproducing in ways that outsmarted the antibiotics.

With compelling data, Levy elaborates how our hygiene craze, propensity to self-medicate, demand for "a pill for every ill," and finally the widespread use of antibiotics in agriculture (e.g., animal feed to stimulate growth) have all contributed to the growing problem of antibiotic resistance. Examining the evidence for the multi-drug resistance that has emerged from antibiotic misuse, it becomes clear that we have reached a state in which there soon may be no assurance that we can treat common infections such as gonorrhea, strep throat, and pneumonia effectively with antibiotics.

Levy takes us into third world countries, where practices of dispensing and using antibiotics shock even those that pop antibiotics for the common cold in the United States. In Santiago, Chile, antibiotics are available over the counter, and a pharmacy window advertises discounted chloramphenicol. In Bangladesh, antibiotics for which resistance rates are too high to be effective are purchased and distributed simply because of their low cost. Some years ago, Milton Silverman, Mia Lydecker, and I (PRL) reviewed the problems of drug promotion and misuse in Prescriptions for Death:The Drugging of the Third World (1982) and Bad Medicine (1992). Levy brings us up to date and focuses on antibiotics.

The resounding message of this book is clear. Prudent use of antibiotics is imperative. Levy issues a compelling call to action that will leave health professionals, and policy makers, and parents with a lasting impression. Levy delineates the roles and responsibilities of different parties, including government health officials, physicians, patients, and pharmaceutical...