THE ANTIBIOTIC PARADOX How Miracle Drugs Are Destroying the Miracle THE ANTIBIOTIC PARADOX How Miracle Drugs Are Destroying the Miracle Stuart B. Levy, M.D. Springer Science+Business Media, LLC Llbrary of Congress Cataloglng-ln-Publlcatlon Oata Levy. Stuart B. The antlblotlc paradox : how mlracle drugs are destroylng the mlraele / Stuart B. Levy. p. cm. Includes blbllographleal references and Index. 1. Drug reslstance In mlcroorganlsMs. 2. Antlblotlcs. 1. T1tle. QR177.L48 1992 815'.329--dc20 92-19938 CIP ISBN 978-0-306-44331-2 ISBN 978-1-4899-6042-9 (eBook) DOI 10.1007/978-1-4899-6042-9 © 1992 Stuart B. Levy Origina11y published by Plenum US in 1992. Softcover reprint of the hardcover 1 ste dition 1992 All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher To Suzanne and Arthur and all future generations PREFACE Antibioties have been ealled the single most important therapeutie diseovery in the history of medicine. While other medications eould eompete for this distinetion, antibioties as a dass have clearly revolutionized Ollr ability to curb death and disease from infeetious microorganisms. An interesting feature of their historie diseoveries is that they oeeurred within the lifetime of many of the population living today. The ability of antibioties, such as penicillin, to effect rapid eures for previously fatal infeetions led to their being touted as umiracle drugs." This claim remains today, having been passed down through several reeent generations. While, to some extent, antibioties have merited this appellation, it paradoxieally has eaused some dent in their armor. The seemingly endless miracles attributed to these drugs have led to their misuse and overuse. Baeteria responded to the widespread applieations of antibioties by fmding ways to beeome resistant, in other words, insensitive to the killing effeets of these powerful drugs. Thus, antibioties sow the seeds of their own potential down fall by seleeting for rare strains of bacteria that have the ability to resist their aetivity. To eomplieate matters further, many of these resistanee traits ean be transferred or spread from one kind of resistant bacteria to other baeteria, even of different types. vii viii Preface This adverse result of antibiotic use, a phenomenon that I call the "antibiotic paradox," does not mean that antibiotics have failed or that antibiotics cannot still be used. It simply reflects the dual nature of the powerful effects they have and why they should be used prudently. Fortunately, antibiotics remain very effective in the treatment of a vast majority of bacterial infectious diseases. This situation, however, is not secure and is changing continually. In many parts of the world, cost-effective, inexpensive, and safe antibiotics are no longer successful because of the bacterial resis tance to them that has developed. Effective treatment is absent in many parts of the world where newer drugs developed to treat resistant bacteria are too expensive to be made available on the limited national budgets of these developing countries. Therefore, the older antibiotics continue to be used despite growing resis tance patterns and, in turn, continue to propagate new and often more resistant types of bacteria. Also, the distribution of these drugs is often uneven. In some areas, antibiotics are being over used, while in other areas, often those needing them the most, they are drastically underused because of a lack of availability. Hence, the general "use" of antibiotics needs improvement in all parts of the world. The aim of this book is to explain where and when antibiotics are useful and why they are so valuable. On the other side, there are various uses of antibiotics that should be changed and even curtailed. Our goal is not to suggest the removal of antibiotics from the physician's armamentarium but, in fact, to encourage making them even more effective by curbing the emergence and spread of resistant forms of infectious bacteria. This goal of improving antibiotic use must concern all mem bers of society using these drugs, namely: consumers, whether they be humans, animals, or the agriculture industry; prescribers, whether they be physicians, veterinarians, or plant pathologists; and the producers and companies that are making and marketing these drugs. By recognizing the different areas in which antibiotic use can be improved, we can hope to stimulate better distribution Preface ix and application, increase awareness of the benefits to be reaped, and curb the threat posed by resistance. The worldwide aim is to protect the effectiveness of these precious natural resources. Stuart B. Levy, M.D. Boston, Massachusetts ACKNOWLEDGMENTS I thank Linda Regan, Victoria Cherney, and Naomi Brier of Plenum Publishing Corporation for their important insights, suggestions, and probing questions, which helped me put these thoughts together and kept me on the path, aware of my audience. Much appredated were their continued interest and encouragement. I am particularly grateful to my long-term assodate Bonnie Marshall for her immense help during the fmal stages of this project, inc1uding repeated editing of the text and the superb rendition of the concepts into pictures and graphics. I thank Herbert Hächler, another one of those rare sdentists with an artist's flair, for his "made-to-order" cartoons that are on target and certainly liven up the text. I greatly appredate the help and information received from Anne Vidaver, Thomas Sullivan, Margaret Erwin, Hachiro Shima nuchi, Howard Myers, Charles Bramble, and Neil PeIletier in the preparation of the sections dealing with non-human uses of antibiotics. I thank Cameron Macauley for his help in researching the material for Chapter 1 and Peter Steere for assistance in the pharmaceutical details. I also thank those who contributed photographs, in particu lar Angelo dePaola, who also shared the catfish operation with me as weIl as so many of the interesting details about raising catfish. xi xii Acknowledgment8 I appreciate the hospitality of Mr. Richard Wolfe of the rare books seetion of the Countway Medical Library, where I was able to gather so much first-hand material dealing with the history of medicine. Special thanks go to Claire Sherman, Anne Ryan, Kenneth Ratzan, Jay Levy, Stephen Beal, and Patricia Suzman for their helpful comments on the text. I particularly thank my wife, Cecile, for her loving support throughout this venture, and my laboratory for providing me with the interesting experimental results relating to this subject.