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Consultant of Intensive Care Sahloul University Hospital Professor Faculty of Medicine 4054 Sousse, Tunisia houssem_hmouda{at}yahoo.com
Consultant of Internal Medicine and Infectious Diseases Clinique les Oliviers Professor Faculty of Medicine Sousse
Published Online, October 5, 2004. www.theannals.com, DOI 10.1345/aph.1D156a
We fully agree with the conclusion of Adra and Lawrence that, in select infections, TMP/SMX may be a useful alternative to vancomycin for treatment of severe S. aureus infections. Our previously reported experience in this field is encouraging.2 Furthermore, despite the availability of vancomycin in our country, we still use TMP/SMX to treat serious S. aureus infections based on antibiotic sensitivity. VISA and VRSA have not yet been isolated. It would be a disaster if they emerge since newer agents are expensive and are not available in our country. However, we strongly believe that any new recommendation for the medical community on the use of TMP/SMX should be based on strong evidence rather than sporadic case reports or series.
We also believe that a strategy of antibiotic rotation including TMP/SMX might prove useful in preventing the emergence of VISA and VRSA. Local infection control committees should play a major role regarding this matter by implementing policies and procedures for rotating antibiotics and evaluating the impact of such strategies on the incidence of MRSA infections.
As emphasized by the authors, TMP/SMX is a desirable option for the treatment of infections due to susceptible strains of MRSA and for transitioning patients to oral therapy. The low cost of TMP/SMX, its adequate oral bioavailability, and the potential vancomycin-sparing effect are enough reasons to proceed in this direction. Randomized studies comparing the efficacy, safety, and cost-effectiveness of TMP/SMX with that of linezolid and vancomycin are mandatory. The modalities of treatment (dose, duration), adverse effects, cure rates, and failure should be clarified.
Although promising, new therapies for the treatment of glycopeptide-resistant S. aureus, such as daptomycin, fail to alleviate concerns that pharmaceutical development cannot outpace the rise in antimicrobial resistance. Therefore, it is pertinent to reexamine the clinical efficacy of older active therapies, such as TMP/SMX, for treating severe infections due to MRSA.
Many thanks to the authors for their clear-sightedness and pragmatism.
Footnotes
Comments on articles previously published are submitted to the authors of those articles. When no reply is published, either the author chose not to respond or did not do so in a timely fashion. Comments and replies are not peer reviewed.–ED.
References
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