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Caution when reconsidering empiric antimicrobial therapy for methicillin-resistant Staphylococcus aureus skin and soft-tissue infections
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The American Journal of Surgery, Vol 196, No 4, October 2008
3. Kanellos I, Demetriades H, Zintzaras E, et al. Incidence and prognostic value of positive peritoneal cytology in colorectal cancer. Dis Colon Rectum 2003;46:535–9. 4. Yamamoto S, Akasu T, Fujita S, et al. Long-term prognostic value of conventional peritoneal cytology after curative resection for colorectal carcinoma. Jpn J Clin Oncol 2003;33:33–7.
5. Wind P, Norklinger B, Roger V, et al. Long-term prognostic value of positive peritoneal washing in colon cancer. Scand J Gastroenterol 1999;34:606 –10. 6. Hase K, Ueno H, Kuranaga N, et al. Intraperitoneal exfoliated cancer cells in patients with colorectal cancer. Dis Colon Rectum 1998;41: 1134 – 40.
Re: does Barrett’s esophagus impact outcome after laparoscopic Nissen fundoplication? To the Editor: I read with great interest the article by Cowgill et al [1] concerning Barrett’s esophagus and laparoscopic fundoplication, and I have several comments and questions: 1. What was the length of the Barrett’s mucosa in the 80 patients with Barrett’s esophagus (BE)? My hunch is that the majority had short-segment BE. It is completely different to report results in patients with BE 20 mm in length versus those with BE 80 to 100 mm in length. 2. I am surprised that only 24% of the BE patients had esophagitis. In my experience, even in patients with short-segment BE, the incidence of esophagitis is much higher. 3. How is possible that non-BE patients had a higher incidence of esophageal stricture? Which type of mucosa was lining the esophagus distal to the stricture in these patients? 4. What were the manometric findings before and after surgery in both groups? I imagine that the investigators always perform manometric studies before pH studies, to correctly place the pH electrodes, as we always do according to the recommendations of scientific societies. 5. I did not see the length of follow-up in the operated patients. I hope that it was a long period because with a short follow-up of only 1 or 2 years, one cannot make
any scientific conclusions if one is dealing mainly with BE patients. 6. It is evident that results of manometric and pH studies after surgery are missing. How is it possible to conclude excellent or good outcomes when no objective scientific data are presented? I humbly insist again that in patients with BE, the results of surgery should be evaluated not only according to symptoms but also the results of endoscopic evaluation, histologic analysis, and 24-hour pH monitoring tests performed during long-term follow-up of at least 5 years. Attila Csendes, F.A.C.S. Clinical Hospital University of Chile Santos Dumont 999 Santiago, Chile doi:10.1016/j.amjsurg.2007.11.004
Reference 1. Cowgill S, Al-Saadi S, Villadolid D, et al. Does Barrett’s esophagus impact outcome after laparoscopic Nissen fundoplication? Am J Surg 2006;192:622– 6.
Caution when reconsidering empiric antimicrobial therapy for methicillin-resistant Staphylococcus aureus skin and soft-tissue infections To the Editor: 1
The proposal of the study by Awad et al of a reconsideration of empiric antimicrobial therapy for skin and softtissue infections called our attention because there has been an increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections in patients in our community. However, there were many drawbacks in this study to be considered. The first consideration is that we do not know the number of isolates evaluated in the study because most of the data were provided as percentages. We know that there were 288 patients who underwent surgical debridement, but we be-
lieve that it is unlikely that all patients had a positive culture to be analyzed. If so, it would be extremely unlikely that all recovered isolates were S aureus. The lack of absolute numbers considerably impairs the analysis of their data. A second point is that although the recently emerging community-associated MRSA isolates, including their genetic differences and classifications, have been mentioned several times, the authors did not differentiate these MRSA isolates even on an epidemiologic basis (ie, if infections were considered community or hospital-acquired). Once they propose alternative regimens for community-acquired infections, it seems clear that these data should be analyzed.
Letters to the Editor Finally, the increase in vancomycin minimal inhibitory concentrations of MRSA shown in the study were not submitted to a statistical test, so any inference of a possible increasing incidence may be merely speculative. Furthermore, there are no data that conclusively show that a minimal inhibitory concentration of 2 g/mL is a predictor of poor clinical outcomes in patients with MRSA skin and soft-tissue infections. Incipient data suggest that it might influence outcomes of patients with MRSA pneumonia, but it still requires further investigations.2 In summary, we believe that the authors final recommendations for empiric therapy are neither supported by their study findings nor by any data published elsewhere to date. Although new promising drugs for treatment of MRSA infections have been increasingly available, any recommendations for their use should be based on solid evidencebased data.
619 Leticia Vale Scribel da Silva Alexandre Prehn Zavascki, M.D., Ph.D. Monica Vinhas de Souza, M.D., M.Sc. Aline Marcadenti Medical Sciences Post-Graduate Program Hospital de Clínicas Porto Alegre, Brazil doi:10.1016/j.amjsurg.2007.12.046
References 1. Awad SS, Elhabash SI, Lee L, et al. Increasing incidence of methicillinresistant Staphylococcus aureus skin and soft-tissue infections: reconsideration of empiric antimicrobial therapy. Am J Surg 2007;194:606 –10. 2. Deresinski S. Vancomycin: does it still have a role as an antistaphylococcal agent? Expert Rev Anti Infect Ther 2007;5:393– 401.
The American Journal of Surgery, Vol 196, No 4, October 2008
3. Kanellos I, Demetriades H, Zintzaras E, et al. Incidence and prognostic value of positive peritoneal cytology in colorectal cancer. Dis Colon Rectum 2003;46:535–9. 4. Yamamoto S, Akasu T, Fujita S, et al. Long-term prognostic value of conventional peritoneal cytology after curative resection for colorectal carcinoma. Jpn J Clin Oncol 2003;33:33–7.
5. Wind P, Norklinger B, Roger V, et al. Long-term prognostic value of positive peritoneal washing in colon cancer. Scand J Gastroenterol 1999;34:606 –10. 6. Hase K, Ueno H, Kuranaga N, et al. Intraperitoneal exfoliated cancer cells in patients with colorectal cancer. Dis Colon Rectum 1998;41: 1134 – 40.
Re: does Barrett’s esophagus impact outcome after laparoscopic Nissen fundoplication? To the Editor: I read with great interest the article by Cowgill et al [1] concerning Barrett’s esophagus and laparoscopic fundoplication, and I have several comments and questions: 1. What was the length of the Barrett’s mucosa in the 80 patients with Barrett’s esophagus (BE)? My hunch is that the majority had short-segment BE. It is completely different to report results in patients with BE 20 mm in length versus those with BE 80 to 100 mm in length. 2. I am surprised that only 24% of the BE patients had esophagitis. In my experience, even in patients with short-segment BE, the incidence of esophagitis is much higher. 3. How is possible that non-BE patients had a higher incidence of esophageal stricture? Which type of mucosa was lining the esophagus distal to the stricture in these patients? 4. What were the manometric findings before and after surgery in both groups? I imagine that the investigators always perform manometric studies before pH studies, to correctly place the pH electrodes, as we always do according to the recommendations of scientific societies. 5. I did not see the length of follow-up in the operated patients. I hope that it was a long period because with a short follow-up of only 1 or 2 years, one cannot make
any scientific conclusions if one is dealing mainly with BE patients. 6. It is evident that results of manometric and pH studies after surgery are missing. How is it possible to conclude excellent or good outcomes when no objective scientific data are presented? I humbly insist again that in patients with BE, the results of surgery should be evaluated not only according to symptoms but also the results of endoscopic evaluation, histologic analysis, and 24-hour pH monitoring tests performed during long-term follow-up of at least 5 years. Attila Csendes, F.A.C.S. Clinical Hospital University of Chile Santos Dumont 999 Santiago, Chile doi:10.1016/j.amjsurg.2007.11.004
Reference 1. Cowgill S, Al-Saadi S, Villadolid D, et al. Does Barrett’s esophagus impact outcome after laparoscopic Nissen fundoplication? Am J Surg 2006;192:622– 6.
Caution when reconsidering empiric antimicrobial therapy for methicillin-resistant Staphylococcus aureus skin and soft-tissue infections To the Editor: 1
The proposal of the study by Awad et al of a reconsideration of empiric antimicrobial therapy for skin and softtissue infections called our attention because there has been an increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections in patients in our community. However, there were many drawbacks in this study to be considered. The first consideration is that we do not know the number of isolates evaluated in the study because most of the data were provided as percentages. We know that there were 288 patients who underwent surgical debridement, but we be-
lieve that it is unlikely that all patients had a positive culture to be analyzed. If so, it would be extremely unlikely that all recovered isolates were S aureus. The lack of absolute numbers considerably impairs the analysis of their data. A second point is that although the recently emerging community-associated MRSA isolates, including their genetic differences and classifications, have been mentioned several times, the authors did not differentiate these MRSA isolates even on an epidemiologic basis (ie, if infections were considered community or hospital-acquired). Once they propose alternative regimens for community-acquired infections, it seems clear that these data should be analyzed.
Letters to the Editor Finally, the increase in vancomycin minimal inhibitory concentrations of MRSA shown in the study were not submitted to a statistical test, so any inference of a possible increasing incidence may be merely speculative. Furthermore, there are no data that conclusively show that a minimal inhibitory concentration of 2 g/mL is a predictor of poor clinical outcomes in patients with MRSA skin and soft-tissue infections. Incipient data suggest that it might influence outcomes of patients with MRSA pneumonia, but it still requires further investigations.2 In summary, we believe that the authors final recommendations for empiric therapy are neither supported by their study findings nor by any data published elsewhere to date. Although new promising drugs for treatment of MRSA infections have been increasingly available, any recommendations for their use should be based on solid evidencebased data.
619 Leticia Vale Scribel da Silva Alexandre Prehn Zavascki, M.D., Ph.D. Monica Vinhas de Souza, M.D., M.Sc. Aline Marcadenti Medical Sciences Post-Graduate Program Hospital de Clínicas Porto Alegre, Brazil doi:10.1016/j.amjsurg.2007.12.046
References 1. Awad SS, Elhabash SI, Lee L, et al. Increasing incidence of methicillinresistant Staphylococcus aureus skin and soft-tissue infections: reconsideration of empiric antimicrobial therapy. Am J Surg 2007;194:606 –10. 2. Deresinski S. Vancomycin: does it still have a role as an antistaphylococcal agent? Expert Rev Anti Infect Ther 2007;5:393– 401.