NDT Advance Access published online on April 18, 2008
Nephrology Dialysis Transplantation, doi:10.1093/ndt/gfn197
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Reply
Correspondence and offprint requests to: E-mail: claudio.ponticelli{at}fastwebnet.itSir,
In response to the kind letter of Dr Labriola et al., I would like to specify the following points:
- The aim of my editorial was to illustrate the new recommendations for Gram-positive bacteraemia. This is why I did not review the wide literature devoted to the empiric antibiotic administration. On the other hand, it should be pointed out that such therapy remains empiric by definition and the choice of broad spectrum antibiotics widely ranges among different countries.
- Dr Labriola et al. attribute the low incidence of MRSA bacteraemia observed in their dialysis unit to the use of cefazolin. Actually, cefalosporins proved to be effective in preventing Gram-positive infection. The problem is that in the last 20 years many strains of Enterococci and Staphylococci acquired resistance to these antimicrobial agents [1]. Thus, the good results obtained in Louvain cannot necessarily be repeated in other dialysis units.
- As pointed out in my editorial, I fully agree with the importance of hygienic preventive measures. However, whether antibiotic lock therapy may be helpful for preventing catheter infection is still disputed. Even the meta-analysis of Dr Labriola et al., unfortunately available at present only in the form of abstract [2], does not seem to allow firm conclusions. In their analysis, the authors could not find differences in catheter infection between patients assigned to antibiotic lock therapy and untreated controls. However, they reported that gentamycin-containing lock solutions significantly reduced the risk of catheter-related bacteraemia. Thus, the choice of the antibiotic can influence the efficacy of antibiotic lock therapy. At any rate, I recommended a word of caution with antibiotic lock therapy as this preventive treatment may theoretically favour resistance.
- I have not reported an uncommon side effect of vancomycin, namely thrombocytopenia. Cases of thrombocytopenia have been described and it has been shown that they may be related to anti-platelets antibodies by Von Drygalski et al. [3]. It should be noted, however, that during a period of 5 years only 34 serum samples from patients in several parts of the United States in whom vancomycin-induced thrombocytopenia was suspected were referred to the Platelet and Neutrophil Immunology Laboratory at the Blood Center of Wisconsin (Milwaukee) to be tested for vancomycin-dependent antibodies. It was out of the scope of the editorial to describe the many side effects that may occur with vancomycin (other adverse events were also not mentioned, i.e. rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue; bloody stools; chest pain; decrease in the frequency of urination or in the amount of urine; fever, chills, or sore throat; flushing; irritation, pain, or swelling at the injection site; numbness of an arm or leg; red, swollen, or blistered skin; severe diarrhoea; severe stomach pain; sudden leg pain; sudden severe dizziness, nausea, headache, or vomiting; sudden shortness of breath; unusual bruising or bleeding and wheezing). I simply intended to outline the most frequent and severe side effects, which may render difficult the use of this important antibiotic in dialysis patients.
Conflict of interest statement. Claudio Ponticelli is Consultant Novartis, Italy.
Istituto Auxologico Italiano, Italy
References
- Barada K, Hanaki H, Yamaguchi Y, et al. Trends of beta-lactam antibiotic susceptibility in blood-borne methicillin-resistant Staphylococcus aureus (MRSA) and their linkage to the staphylococcal cassette chromosome mec (SCCmec) type. J Infect Chemother (2007) 13:213–218.[CrossRef][Medline]
- Labriola L, Crott R, Jadoul M. Preventing haemodialysis catheter-related bacteraemia with an antimicrobial lock solution: a meta-analysis of prospective randomized trials. Nephrol Dial Transplant (2007) 23:1666–1672.[CrossRef]
- Von Drygalski A, Curtis BR, Bougie DW, et al. Vancomycin induced immune thrombocytopenia. N Engl J Med (2007) 356:904–910.
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