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Antibiotics for Surgical Infections. P. J. Sanderson. (Pp. 262; £24.50) Research Studies Press, Chichester, x983.

This is a useful book writ ten by a medical microbiologist with a good knowledge of clinical problems. Following the introductory chapter, Chapter 2 summarises the properties of the antibiotics and other antibacterial agents recommended in the book, and includes some information on the newer cephalosporins. T h e n comes a chapter giving clear guidance on the antibiotic management of surgical sepsis. Other chapters deal with a wide range of infections in general surgery, obstetrics and gynaecology, orthopaedics, burns, trauma, ophthalmology, E .N.T . surgery and other topics. T h e contents extend well beyond infections usually considered to be 'surgical ' , and include t reatment of sore throats, lower respiratory tract infections, gastrointestinal infections and sexually t ransmit ted diseases. Therapy of fungal, viral and mycobacterial infections is discussed, as well as that concerned with worms and protozoa. Many conditions relating to these may appear in surgical wards and therefore may need to be treated by the surgeon. Special problems such as septicaemia, post-operative infection, infect ions in intensive care units and those arising in immunosuppressed patients are dealt with in separate chapters. The general advice on choice of antibiotics and discussion of future develop- ments at the end of the book are well worth reading.

The book contains many useful tables including one on costs of antibiotics. This should be carefully examined by all involved in chemotherapy, particularly when prescribing the newer agents; in particular, the high cost of intravenous metronidazole in contrast to oral and rectal preparations should be noted. Most chapters have a useful selection of references. Criticisms are few. Inevitably there is some repetition but this is not unreasonable as most readers will expect each chapter to be self-sufficient.

For a small book it is remarkably comprehensive and contains many useful diagnostic hints. I t can be recommended to microbiologists and to physicians as well as surgeons. G . A . J . Ayliffe

Antibiotics in the Management of Infections : Outlook for the I98os. Alexander G. Bearn, Ed. (Pp. 258. $34.Io) Raven Press, Liverpool, I982.

This book is a record of a meeting of a score of experts brought together by a pharmaceutical company to present papers which were then discussed by members of the group. The result is a mixed collection of laboratory and clinical contributions. In a short review it is impossible to comment on all of them.

An introductory chapter on the ' Challenge of the Microbial Wor ld ' sets the scene with special reference to the changing features of sexually t ransmit ted diseases. This is followed by a paper on penicillin binding proteins, beta-lactam resistant South African strains ofpneumococci , and the expression of resistance in methicillin-resistant Staphylococcus aureus. In vitro tolerance of Streptococcus

182 Book reviews

sanguis to penicillin is also discussed with reference to the clinical finding that the organism responds well to penicillin therapy. New techniques in the study of microbial pathogenicity, especially the use of recombinant DNA, are clearly explained by Koomey, Welch and Falkow, with Escherichia coli haemolysin and gonococcal IgA i protease as examples.

Norrby ends his concise review ofpharmacokinetics and antibiotic treatment with the realistic but unhelpful conclusion that it 'is impossible to present a simple formula correlating antibacterial activity, pharmacokinetics and dosage'. I f it is difficult to choose a single therapy on rational grounds it is much more difficult to assess the value of combinations. The review of new antibiotic combinations briefly mentions t r imethopr im/sulphamethoxazole and amoxycillin/clavulanic acid. The major part of the chapter is on the combination of fludalanine and pentizidone. Fludalanine is a potent antimicro- bial substance with the unusual property of self-reversal at high concentration. This may be blocked by the inhibition of a second enzyme with cycloserine. On pharmacological grounds it was found that a cycloserine derivative, pentizidone, gave better results. The other combination discussed is N- formimidoyl- thienamycin with a compound to block its metabolism by renal dehydropeptidase-I . The N-formimidoyl thienamycin is active on its own but is excreted too quickly to be useful. Dur ing the panel discussion which followed this contribution, the difficulties of clinical evaluation of drug combinations were stressed. The difference between the progress made with combination regimes in cancer therapy and that made in infectious diseases was noted.

The discussion of Jackson's contribution on urinary tract infections em- phasised international differences in prescribing practice. In continental Europe, urinary antiseptics are particularly popular, in the U.S.A., beta- lactams, and in the U.K. the antimetabolites such as cotrimoxazole.

Bacterial meningitis is discussed by Norrby. What was a relatively simple subject is now complicated by the presence of chloramphenicol resistant and beta-lactamase producing Haemophilus influenzae as well as mult iply resistant strains of pneumococci. The results of experimental studies in animals can not always be extrapolated to man. Very few chemical studies on meningitis have been published, because they raise special ethical considerations. Fu thermore the numbers of patients are so small that mult icentre studies are needed.

Feinstein draws attention to quantitative considerations in evaluating anti- biotics. He states that any evaluation in clinical science should not be concerned exclusively with numerical quantities, but should also consider the phenomena and intellectual decisions that lie behind the numbers . The dangers of small samples are well known but excessively large samples may also be misleading by indicating significance in trivially small distinctions.

Veronesi 's discussion of antibiotic prescribing in less developed countries was a fascinating contribution about problems of which we, in Europe, are usually unaware. The amount of money available for health care, the degree of dependence on imported material and the lack of money for research in less developed countries are described. Quality control of products depends on the ethical standards of the private pharmaceutical companies. Recently two companies in Brazil were p roduc ing ' ampicillin ' a n d ' tetracycline' with wheat flour and corn meal respectively. Self-medication is common and this~

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combined with the over-use of aggressively promoted drugs, had led to the emergence of highly resistant strains of bacteria.

Cost was also important in the rapid methods used for diagnosing infectious diseases and described by Washington. In particular, enzyme immunoassays may be expensive, the cost of laboratory diagnostic proceedures exceeding the cost of the drugs given for treatment. This was especially so for the newer and more expensive drugs discussed by Neu. At face value this is a surprising contr ibution from someone whose name is usually linked with the latest antibiotic to appear on the market. He believes that in many infections host factors are probably more important for survival than minor differences among antibiotics. Many new antibiotics are introduced for treating neutropenic patients, each with a cure rate of 75-85 per cent. I t seems unlikely that new antibiotics will improve on these figures. With the exception of peritonitis in the presence of renal failure and Pseudomonas aeruginosa meningitis, there is no great need for new agents. It is much more important to make sure that clinicians make better use of the agents available. What would be of greater value would be to find some method of enhancing host resistance and preventing pathogenic bacteria from colonising patients in the first place. Not surprisingly this contr ibution provoked a robust defence among participants from the pharmaceutical industry. In general, the clinicians agreed with Professor Neu.

In summary, I found this to be a useful, informative book containing up to date summaries of topics of concern to clinical microbiologists. The discussion sections add greatly to the value of the book al though making for a rather unt idy layout. T h e inclusion of the discussions prevents the one-sided presentation often found in drug company sponsored publications. Despite the good features I feel that many of the articles will soon be superseded and I am uncertain who would want to buy the book. I t might be very useful for microbiologists studying for higher quaifications. No doubt many microbiol- ogists and infectious disease physicians would be pleased to receive a free copy of the book from the sponsoring pharmaceutical company but I doubt if many will buy personal copies. I t would make a useful addition to any departmental library but, al though broadly based, it contains many contributions to be found elsewhere. .7. Gray

Antibiotics : Assessment of Antimicrobial Activity and Resistance. A. D. Russell and L. B. Quesnel, Eds. (Pp. 386; £29.oo) Academic Press, London, 1983.

This book is in the Technical Series of the Society of Applied Microbiology. The contents are based upon a demonstrat ion meeting concerned with antibiotics held in Cardiff in I98X. The publication is timely as it appears when major technical advances have been made in evaluating antibiotic action and when there is an unprecedented glut of antibiotics to investigate. Precise descriptions of technical methods are of value in any field of microbiology. Thanks are due, therefore, to those authors in this volume who give exact details of quantities, buffers, apparatus, times, etc. of their procedures. Some