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Re: Ceftizoxime in the Treatment of Urinary Tract Infections, by H. W. Plimpton and E. D. Crawford, J. Urol., 128: 1231-1232, 1982
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LETTERS TO THE EDITOR prostate to radiation damage. Anterior rectal wall injury is one such example. Seed strength, spacing and distribution in relation to the rectal mucosa are of critical importance in determining liability for injury. As emphasized by Grossman in his Editorial Comment these parameters can be difficult to ascertain by any objective measurement during implantation. The designation of prostatorectal fistula as being unique to 125iodine (1 25 I) implantation is unfounded if not accompanied by information stating seed strength, total millicuries delivered and isodose curve characteristics for each patient having the complications. Furthermore, it would be meaningful to know the number of patients having 125I implantation from which this group of 4 with fistulas appeared. Did this complication occur in 10 or 1 per cent of the patients treated by 125 I implantation? Rectal injury and fecal fistulas have been reported in approximately 1 per cent of the patients undergoing radical prostatectomy.1-3 In our review of complications with interstitial implantation in 90 patients followed for >2 years 2 suffered a prostatorectal fistula between 12 and 24 months after treatment. One fistula was closed successfully by gracilis flap interposition and biopsies at that time revealed no evidence of residual tumor. It is now 4 years after treatment and the patient has no evidence of bowel, bladder or sexual dysfunction, or disease. The second patient had a fistula with actively growing tumor in the prostate and with widespread metastases. Therefore, diversion was performed without an attempt at repair. The first patient had BII moderately differentiated adenocarcinoma, and was implanted with 26 µc. and a minimal delivered dose of 16,000 rad to a volume of 29 cm. 3• The second patient had B-II moderately differentiated adenocarcinoma, and was implanted with 25 µc. and a minimal delivered dose of 16,000 rad to 36 cm. 3• No deviation in technique or difference in isodose curves could be identified in these patients compared to those free of injury. A host tolerance factor may be operative. In our series the prostatorectal fistula rate was 2.3 per cent but 1 patient was able to be repaired completely without residual dysfunction. 4 Complications as noted in this article need to be reported. However, they also need to be put in perspective by reporting a denominator, and by identifying any relationship between the complication and variants in technique. By so doing refinements for lessening complications can be developed or a particular procedure can be abandoned should the complications be unavoidable and excessively frequent. Lastly, I do not believe that it is possible to make the diagnosis of active tumor with the magnification of histology provided by the photograph in the article. Respectfully, Paul F. Schellhammer Department of Urology Eastern Virginia Medical School Norfolk, Virginia 23510
Reply by Authors. We appreciate and agree with these comments. The 4 patients were referred to us since we do not do 125I implantation. We, therefore, do not know the denominator (or total number of patients treated) to determine precisely the incidence of this complication. While prostatorectal fistula is not unique to 125I implantation we stand by our opinion that it is more common after this procedure than after radical prostatectomy. 125 I implantation was popularized by the Memorial Group and is now being applied by less skilled urologists and radiotherapists. In capable hands 125 I implantation has a low complication rate. It is our impression that all too often it is performed by inexperienced practitioners and, therefore, the complication of prostatorectal fistula occurs more frequently than the 2 per cent noted by Schellhammer. Transurethral resection after 125I implantation or 125I implantation after transurethral resection should be undertaken with great caution. Our point is that those who advocate 125I implantation to avoid the morbidity of radical prostatectomy should acknowledge that the former procedure is not without significant problems of its own. 1. Boxer, R. J., Kaufman, J. J. and Goodwin, W. E.: Radical prostatectomy for carcinoma of the prostate: 1951-1976. A review of 329 patients. J. Urol., 117: 208, 1977. 2. Jewett, H.J.: The present status of radical prostatectomy for stages A and B prostatic cancer. Urol. Clin. N. Amer., 2: 105, 1975. 3. Veenema, R. J., Gursel, E. 0. and Lattimer, J. K.: Radical retropubic prostatectomy for cancer: a 20-year experience. J. Urol., 117: 330, 1977. 4. Schellhammer, P. F. and El-Mahdi, A. M.: Pelvic complications after definitive therapy of prostate cancer by interstitial or external beam radiation. Urology, 21: 451, 1983.
RE: CEFTIZOXIME IN THE TREATMENT OF URINARY TRACT INFECTIONS H. W. Plimpton and E. D. Crawford
J. Urol., 128: 1231-1232, 1982
To the Editor. Several conclusions reached in this article and the accompanying Editorial Comment deserve additional comment. Less expensive therapy for any condition certainly is a praiseworthy goal but should not be achieved at the expense of therapeutic efficacy. A third of the patients treated by these investigators were infected with organisms that were resistant to cefamandole (5 Pseudomonas aeruginosa, 1 Proteus morgani and 1 Citrobacter). Similar spectra of organisms have been reported by other authors in patients with complicated urinary tract infection. Accordingly, for presumptive antibiotic therapy in this population I do not believe that this article supports the use of narrower spectrum, albeit less expensive, agents. Clearly, for urinary tract infection in patients with more sensitive organisms or once the antibiotic sensitivity pattern of the organism is known the use of narrower spectrum, less costly agents would be indicated. The authors also made the observation that" ... the cost of parenteral administration in our hospital for the week of treatment was 3 times more with ceftizoxime compared to cefamandole". The ceftizoxime used in this study was supplied to the hospital at no charge. In addition, I am not aware of any pricing information that has yet been released for this drug. Therefore, I do not understand on what basis this comparison was made. However, on the basis of the doses used (2 gm. daily for ceftizoxime and 4 gm. daily for cefamandole) I doubt that 14 gm. ceftizoxime (a 7 -day course) will cost 3 times as much as 28 gm. cefamandole. Cost comparisons between therapeutic regimens are rightfully assuming an increasingly prominent role in our selection of appropriate therapy. However, it is important that we not opt for cheaper therapy at the expense of therapeutic effect. In the study presented such a choice would have resulted in inadequate therapy for a third of the patients involved. Respectfully, Arnold L. Lentnek Medical Affairs Department Smith Kline & French Laboratory 1500 Spring Garden Street P. 0. Box 7929 Philadelphia, Pennsylvania 19101 1. Warren, J. W., Tenney, J. H., Hoopes, J.M., Muncie, H. L. and Anthony, W. C.: A prospective microbiologic study of bacteriuria in patients with chronic indwelling catheters. J. Infect. Dis., 146: 719, 1982. 2. Sherman, F. T., Tucci, V., Libow, L. S. and Isenberg, H. D.: Nosocomial urinary-tract infections in a skilled nursing facility. J. Amer. Geriatric Soc., 28: 456, 1980. 3. McLeod, J. W., Mason, J. M. and Neill, R. W. K.: Survey of the different urinary infections which develop in the paraplegic and their relative significance. Paraplegia, 3: 124, 1965. RE: KETOCONAZOLE THERAPY FOR FUNGAL URINARY TRACT INFECTIONS
J. R. Graybill, J. N. Galgiani, J. H. Jorgensen and D. A. Strandberg J. Urol., 129: 68-70, 1983
To the Editor. The authors of this article treated 11 patients for candidal infection of the urinary tract on the basis of candiduria, pyuria and fever. Three cases involving Torulopsis glabrata are included, since this organism now is in the process of being reclassified as Candida glabrata. The question arises of whether the 3 criteria are sufficient to establish a clear-cut diagnosis of this infection. We studied 64 patients suspected of having renal candidiasis with histological investigations, urinary colony counts, blood cultures and serum antibody tests.' Urinary colony counts were done in addition on 149 clean-catch samples from 83 persons proved free of the infection.2 The findings confirmed previous reports by Schiinebeck and associates 3• 4 and by Guze and Haley,5 and established the following diagnostic criteria for 20 patients histologically proved to have renal candidiasis. Candiduria occurred in all 20 cases of histologically proved candidiasis of the urinary tract. Colony counts of 10,000 to 15,000/ml. in a catheterized specimen, not necessarily 100,000, correlate with histologically proved cases. Schone beck and associates reported extensive renal
LETTERS TO THE EDITOR prostate to radiation damage. Anterior rectal wall injury is one such example. Seed strength, spacing and distribution in relation to the rectal mucosa are of critical importance in determining liability for injury. As emphasized by Grossman in his Editorial Comment these parameters can be difficult to ascertain by any objective measurement during implantation. The designation of prostatorectal fistula as being unique to 125iodine (1 25 I) implantation is unfounded if not accompanied by information stating seed strength, total millicuries delivered and isodose curve characteristics for each patient having the complications. Furthermore, it would be meaningful to know the number of patients having 125I implantation from which this group of 4 with fistulas appeared. Did this complication occur in 10 or 1 per cent of the patients treated by 125 I implantation? Rectal injury and fecal fistulas have been reported in approximately 1 per cent of the patients undergoing radical prostatectomy.1-3 In our review of complications with interstitial implantation in 90 patients followed for >2 years 2 suffered a prostatorectal fistula between 12 and 24 months after treatment. One fistula was closed successfully by gracilis flap interposition and biopsies at that time revealed no evidence of residual tumor. It is now 4 years after treatment and the patient has no evidence of bowel, bladder or sexual dysfunction, or disease. The second patient had a fistula with actively growing tumor in the prostate and with widespread metastases. Therefore, diversion was performed without an attempt at repair. The first patient had BII moderately differentiated adenocarcinoma, and was implanted with 26 µc. and a minimal delivered dose of 16,000 rad to a volume of 29 cm. 3• The second patient had B-II moderately differentiated adenocarcinoma, and was implanted with 25 µc. and a minimal delivered dose of 16,000 rad to 36 cm. 3• No deviation in technique or difference in isodose curves could be identified in these patients compared to those free of injury. A host tolerance factor may be operative. In our series the prostatorectal fistula rate was 2.3 per cent but 1 patient was able to be repaired completely without residual dysfunction. 4 Complications as noted in this article need to be reported. However, they also need to be put in perspective by reporting a denominator, and by identifying any relationship between the complication and variants in technique. By so doing refinements for lessening complications can be developed or a particular procedure can be abandoned should the complications be unavoidable and excessively frequent. Lastly, I do not believe that it is possible to make the diagnosis of active tumor with the magnification of histology provided by the photograph in the article. Respectfully, Paul F. Schellhammer Department of Urology Eastern Virginia Medical School Norfolk, Virginia 23510
Reply by Authors. We appreciate and agree with these comments. The 4 patients were referred to us since we do not do 125I implantation. We, therefore, do not know the denominator (or total number of patients treated) to determine precisely the incidence of this complication. While prostatorectal fistula is not unique to 125I implantation we stand by our opinion that it is more common after this procedure than after radical prostatectomy. 125 I implantation was popularized by the Memorial Group and is now being applied by less skilled urologists and radiotherapists. In capable hands 125 I implantation has a low complication rate. It is our impression that all too often it is performed by inexperienced practitioners and, therefore, the complication of prostatorectal fistula occurs more frequently than the 2 per cent noted by Schellhammer. Transurethral resection after 125I implantation or 125I implantation after transurethral resection should be undertaken with great caution. Our point is that those who advocate 125I implantation to avoid the morbidity of radical prostatectomy should acknowledge that the former procedure is not without significant problems of its own. 1. Boxer, R. J., Kaufman, J. J. and Goodwin, W. E.: Radical prostatectomy for carcinoma of the prostate: 1951-1976. A review of 329 patients. J. Urol., 117: 208, 1977. 2. Jewett, H.J.: The present status of radical prostatectomy for stages A and B prostatic cancer. Urol. Clin. N. Amer., 2: 105, 1975. 3. Veenema, R. J., Gursel, E. 0. and Lattimer, J. K.: Radical retropubic prostatectomy for cancer: a 20-year experience. J. Urol., 117: 330, 1977. 4. Schellhammer, P. F. and El-Mahdi, A. M.: Pelvic complications after definitive therapy of prostate cancer by interstitial or external beam radiation. Urology, 21: 451, 1983.
RE: CEFTIZOXIME IN THE TREATMENT OF URINARY TRACT INFECTIONS H. W. Plimpton and E. D. Crawford
J. Urol., 128: 1231-1232, 1982
To the Editor. Several conclusions reached in this article and the accompanying Editorial Comment deserve additional comment. Less expensive therapy for any condition certainly is a praiseworthy goal but should not be achieved at the expense of therapeutic efficacy. A third of the patients treated by these investigators were infected with organisms that were resistant to cefamandole (5 Pseudomonas aeruginosa, 1 Proteus morgani and 1 Citrobacter). Similar spectra of organisms have been reported by other authors in patients with complicated urinary tract infection. Accordingly, for presumptive antibiotic therapy in this population I do not believe that this article supports the use of narrower spectrum, albeit less expensive, agents. Clearly, for urinary tract infection in patients with more sensitive organisms or once the antibiotic sensitivity pattern of the organism is known the use of narrower spectrum, less costly agents would be indicated. The authors also made the observation that" ... the cost of parenteral administration in our hospital for the week of treatment was 3 times more with ceftizoxime compared to cefamandole". The ceftizoxime used in this study was supplied to the hospital at no charge. In addition, I am not aware of any pricing information that has yet been released for this drug. Therefore, I do not understand on what basis this comparison was made. However, on the basis of the doses used (2 gm. daily for ceftizoxime and 4 gm. daily for cefamandole) I doubt that 14 gm. ceftizoxime (a 7 -day course) will cost 3 times as much as 28 gm. cefamandole. Cost comparisons between therapeutic regimens are rightfully assuming an increasingly prominent role in our selection of appropriate therapy. However, it is important that we not opt for cheaper therapy at the expense of therapeutic effect. In the study presented such a choice would have resulted in inadequate therapy for a third of the patients involved. Respectfully, Arnold L. Lentnek Medical Affairs Department Smith Kline & French Laboratory 1500 Spring Garden Street P. 0. Box 7929 Philadelphia, Pennsylvania 19101 1. Warren, J. W., Tenney, J. H., Hoopes, J.M., Muncie, H. L. and Anthony, W. C.: A prospective microbiologic study of bacteriuria in patients with chronic indwelling catheters. J. Infect. Dis., 146: 719, 1982. 2. Sherman, F. T., Tucci, V., Libow, L. S. and Isenberg, H. D.: Nosocomial urinary-tract infections in a skilled nursing facility. J. Amer. Geriatric Soc., 28: 456, 1980. 3. McLeod, J. W., Mason, J. M. and Neill, R. W. K.: Survey of the different urinary infections which develop in the paraplegic and their relative significance. Paraplegia, 3: 124, 1965. RE: KETOCONAZOLE THERAPY FOR FUNGAL URINARY TRACT INFECTIONS
J. R. Graybill, J. N. Galgiani, J. H. Jorgensen and D. A. Strandberg J. Urol., 129: 68-70, 1983
To the Editor. The authors of this article treated 11 patients for candidal infection of the urinary tract on the basis of candiduria, pyuria and fever. Three cases involving Torulopsis glabrata are included, since this organism now is in the process of being reclassified as Candida glabrata. The question arises of whether the 3 criteria are sufficient to establish a clear-cut diagnosis of this infection. We studied 64 patients suspected of having renal candidiasis with histological investigations, urinary colony counts, blood cultures and serum antibody tests.' Urinary colony counts were done in addition on 149 clean-catch samples from 83 persons proved free of the infection.2 The findings confirmed previous reports by Schiinebeck and associates 3• 4 and by Guze and Haley,5 and established the following diagnostic criteria for 20 patients histologically proved to have renal candidiasis. Candiduria occurred in all 20 cases of histologically proved candidiasis of the urinary tract. Colony counts of 10,000 to 15,000/ml. in a catheterized specimen, not necessarily 100,000, correlate with histologically proved cases. Schone beck and associates reported extensive renal