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Reply to Beheshti et al
0
Center for Clinical Infectious Diseases, Jichi Medical University
,
Yakushiji, Shimotsuke, Tochigi
,
Japan
1
(Emeritus), University of Cincinnati College of Medicine
,
231 Albert B. Sabin Way, Cincinnati, Ohio 45267-0558
2
University of Cincinnati College of Medicine
,
Ohio
CORRESPONDENCE
-
Reply to Beheshti et al
TO THE EDITORWe very much
appreciate the writers careful review and
comments regarding both the original
SIS/IDSA (Surgical Infection Society/
Infectious Diseases Society of America)
guidelines for complicated
intra-abdominal infections and the Tokyo guidelines
for biliary infections [14]. The concerns
regarding the wording that describes the
addition of metronidazole to
gramnegative agents were addressed in an
erratum (Clin Infect Dis 2010. 50(12):1695.)
The Tokyo biliary guidelines were
generated by a Japanese panel that
authored the manuscripts, with a larger
audience of Japanese hepatobiliary
surgeons voting. The extent of consensus
among this group was used to make
recommendations, with comments from
the more formal Japanese and
international panelists added to the manuscripts.
Therefore, these guidelines reflected
Japanese practice in 2006. A new set of
guidelines have been developed using an
evidence-based approach and will be
available within six months.
The recommendations for anaerobic
therapy (moderate to severe cholangitis)
that exist in the published guidelines will
be maintained. The new guidelines add
the specific condition of bilio-enteric
anastomosis as an indication for
anaerobic treatment at all severity levels.
The strength of these
recommendations are confounded by the absence of
sufficient randomized clinical anaerobic
therapy trials. There are randomized
trials in the cited references that compare
regimens with considerable anaerobic
activity vs regimens with little such activity.
These studies were relatively small, were
intended to address the use of specific
gram-negative agents, and did not use
research level methodologies to detect
anaerobes. They showed no differences in
outcomes. Recommendations in this area
are based on high quality bacteriologic
studies where anaerobes, particularly
Bacteroides fragilis, exist within the
framework of specific clinical circumstances
and are generally accepted as pathogens.
We believe that patient safety requires the
use of anaerobic therapy in an identified
subset of patients.
Potential conflicts of interest. Both authors:
No potential conflicts of interest.
Both authors have submitted the ICMJE Form
for Disclosure of Potential Conflicts of Interest.
Conflicts that the editors consider relevant to
the content of the manuscript have been
disclosed.
Joseph S. Solomkin1 and Harumi Gomi2
(...truncated)