Of the many books written on the topic of “superbugs” many focus on listing the greatest threats faced by infectious disease physicians, difficult patient anecdotes, warnings, and proposed solutions. The other type of infectious disease books involve exotic locales and explosive outbreaks. The latest book I read is different from these and, in my estimation, is a worthy addition to the shelves or ipads of those who like this topic. Superbugs: The Race to Stop an Epidemic by Cornell infectious disease physician Matt McCarthy is a book ostensibly about a clinical trial but has a lot more of value in it.
McCarthy begins the book’s prologue with a patient anecdote but quickly moves to what I see as the essential focus of the book: the ins and outs of an antibiotic trial. Along with this trial McCarthy peppers in a lot of interesting aspects regarding infectious diseases and the day-to-day of an academic infectious disease physician. Besides himself, the chief protagonist is his mentor, the renowned mycologist Thomas Walsh, and their interactions provide a really enjoyable perk of the narration.
The book does cover the initial development of antibiotics — the stories of Domagk and Fleming — but adds an often neglected aspect: the crucial and undervalued role of pharmaceutical companies. He quotes Tony Fauci to make this point:
You don’t want the federal government to be a pharmaceutical company because you’d have to build an entire industry...If the federal government tried to re-create Merck it would cost billions of dollars. The expertise of production, filling, packaging, and lot consistency. People take that for granted, but that’s an art form that has been perfected by these companies, not the government
He also notes that, contrary to what those who villainize antibiotic manufacturers may say, the net present value (NPV) of an antibiotic is just $42 million compared to the $1 billion for other pharmaceutical products. He later points to another analysis showing the NPV may be negative $50 million.
The focus of McCarthy’s clinical trial is on dalbavancin, an interesting long acting gram positive injectable antibiotic. The drug had a little bit of a tortured history being passed from Pfizer to Durata to Actavis to Allergan (Durata was acquired by Actavis which bought Allergan and kept the name). At that time, Allergan was one of a few remaining major pharmaceutical companies involved in antibiotic development (it has since tried to sell its infectious disease unit). While dalbavancin isn’t a breakthrough antibiotic on par with some others, it has an important niche in treating MRSA infections, avoiding hospitalization, and avoiding the use of long term intravenous lines. The book uses this trial as backdrop to discuss topics such as institutional review boards (IRBs), informed consent, FDA oversight, and patient recruitment. All of this makes for worthwhile reading.
He also discusses fungal infections, which often get short shrift to our detriment, one of the passions of his mentor. He tells of the discovery the first antifungal, nystatin, by two female researchers, which I had never heard before and recounts that it was named for the New York State (NYS) Department of Health. He also covers the emergence of Candida auris and the quest for new treatment options.
I found the book very enjoyable to read and think it is an important contribution because it demonstrates what it is to be an infectious disease physician in the modern era, concretizing the daily battles, the insoluble and endless puzzles, and the exhilarating rush one gets from figuring things out.