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Correspondence |

End-of-Life Treatment and Antibiotic Resistance Data Raise Questions FREE TO VIEW

Elisabeth Meyer, MD
Author and Funding Information

From the Institute of Hygiene and Environmental Medicine, Charité University Medicine Berlin.

Correspondence to: Elisabeth Meyer, MD, Institute of Hygiene and Environmental Medicine, Charité University Medicine Berlin, Hindenburgdamm 27, 12203 Berlin, Germany; e-mail: elisabeth.meyer@charite.de


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;138(5):1285-1286. doi:10.1378/chest.10-1433
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Published online

To the Editor:

I read with interest the recent article in CHEST by Levin and colleagues (September 2010),1 which reported that only a limitation-of-therapy order in ICU patients was independently associated with acquisition of resistant organisms, whereas other factors such as antibiotic days, ICU length of stay prior to isolation of a resistant organism, antibiotic therapy prior to ICU admission, and so forth were not. However, the data reported and the study design raise some questions.

First, the authors included two ICUs in their study: an Israeli 12-bed ICU from July 2005 to January 2006 and a Canadian 20-bed ICU from January 2003 to December 2003. In 2007, Levin and colleagues2 published data about the same Canadian ICU (Sunnybrook Health Sciences Centre, Toronto, ON) during the same period of time and on almost the same number of patients (338 and 337, respectively). Differences in the data published (quinolone-resistant bacteria) are summarized in Table 1.

Table Graphic Jump Location
Table 1 —Differences in Data Published on Canadian ICU

Second, also in 2007, Levin et al3 published data on the same Israeli medical-surgical ICU, describing transmission of Acinetobacter baumannii due to the contamination of portable radiographs. One might speculate whether the high amount of A baumannii isolates present (94 within 6 months in the Israeli ICU vs only eight within 12 months in the Canadian ICU) was also because of a prolonged outbreak.

Third, in 450 patients, 649 unique pathogens were isolated, with a maximum of 331 being resistant.1 Twenty-seven patients were excluded because they were infected or colonized at admission, and 82 were grouped as having a resistant pathogen, meaning that on average, a patient harbored four resistant pathogens, which seems fairly high.

Fourth, it remains unclear why data from incomparable ICUs (with respect to their attitude toward limitation of therapy, general resistance situation, amount of antibiotics used, etc) are combined to perform a logistic regression analysis (which requires homogeneity) to find predictors for the isolation of resistant pathogens. Why was this not done separately for each ICU?

Finally, the authors concluded that nonwithdrawal of therapy leads to increased use of antibiotics and consecutively to a higher prevalence of resistant pathogens. However, another explanation might be that no more or less microbiologic sampling was done in patients after withdrawal of therapy, and thus, no more pathogens could be found.

Levin PD, Simor AE, Moses AE, Sprung CL. End-of-life treatment and bacterial antibiotic resistance: a potential association. Chest. 2010;1383:588-594. [CrossRef] [PubMed]
 
Levin PD, Fowler RA, Guest C, Sibbald WJ, Kiss A, Simor AE. Risk factors associated with resistance to ciprofloxacin in clinical bacterial isolates from intensive care unit patients. Infect Control Hosp Epidemiol. 2007;283:331-336. [CrossRef] [PubMed]
 
Levin PD, Shatz O, Sviri S, et al. Contamination of portable radiograph equipment with resistant bacteria in the ICU. Chest. 2009;1362:426-432. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1 —Differences in Data Published on Canadian ICU

References

Levin PD, Simor AE, Moses AE, Sprung CL. End-of-life treatment and bacterial antibiotic resistance: a potential association. Chest. 2010;1383:588-594. [CrossRef] [PubMed]
 
Levin PD, Fowler RA, Guest C, Sibbald WJ, Kiss A, Simor AE. Risk factors associated with resistance to ciprofloxacin in clinical bacterial isolates from intensive care unit patients. Infect Control Hosp Epidemiol. 2007;283:331-336. [CrossRef] [PubMed]
 
Levin PD, Shatz O, Sviri S, et al. Contamination of portable radiograph equipment with resistant bacteria in the ICU. Chest. 2009;1362:426-432. [CrossRef] [PubMed]
 
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