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a Thoracic Department, Institut Mutualiste Montsouris, 42 bd Jourdan, Paris, 75014 France
b Microbiology, Institut Mutualiste Montsouris, Paris, 75014 France
(Email: jean-baptiste.stern{at}imm.fr).
We read with great interest the article of Schussler and colleagues [1] focusing on antibiotic prophylaxis for the prevention of postoperative pneumonia (POP) after lung resection. This meticulous analysis deserves some comments.
First, the rates of documented and undocumented POP of 25% in the first period of the study and 14% in the second period appear too high. Most experienced teams reporting large series show POP rates of less than 10% [2–4]. The observed high rates may artificially increase the reported benefit of the change in the antibiotic prophylaxis.
Second, the rationale to use a high dose of amoxicillin-clavulanate (6 g/24 h) in this study is unclear. Ten of 12 patients with POP had Streptococcus pneumoniae with minimum inhibitory concentrations exceeding 0.125 mg/mL, higher than usually found in France in pneumococcal isolates (44% in 2006) [5]. Recent French consensus conference recommend treating low- and intermediate-sensitivity S pneumoniae pneumonia with amoxicillin at 3 g/d [6]. Only 0.3% of strains isolated from pneumococcal bacteriemia have minimum inhibitory concentrations exceeding 2 mg/mL, which requires cefotaxime. In patients with acute exacerbation of chronic obstructive pulmonary disease (COPD), the recommendation is also amoxicillin-clavulanate at 3 g/d [6].
Third, it is disturbing to see that COPD was slightly less frequent in the cefamandole group (52%) than in the amoxicillin-clavulanate group (58%), and that smoking cessation within 60 days was significantly more frequent in the cefamandole group (52%) than in amoxicillin-clavulanate group (43%). Despite these facts, intrabronchial colonization was less frequent in the amoxicillin-clavulanate group than in the cefamandole group (22% vs 14%). These data suggest that patients were more appropriately prepared for their operation, or may have more frequently received a preoperative course of an antibiotic to partially explain these results. Whether patients received antibiotics preoperatively was not reported. In addition, the idea that a single dose of amoxicillin-clavulanate approximately 30 minutes before bronchial sampling may decrease bronchial colonization of COPD patients seems more theoretic than clinically pertinent.
Finally, the most important message of this study is that decreasing bronchial colonization before the operation may reduce POP. This may encourage physicians caring for such patients to detect high levels of bronchial colonization—but what is the critical level?—and to take adequate measures to decrease colonization before operation. Thus, we prefer to say, "Bronchial colonization is the critical issue."
For these reasons, the data provided by this interesting study are not sufficient to conclude that the change of antibiotic prophylaxis during the second period was by itself the only factor responsible for the observed decrease in POP rate. Thus, in the absence of a prospective randomized trial, it is difficult to recommend a routine dose of 6 g of amoxicillin-clavulanate as antibiotic prophylaxis in clinical practice.
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  O. Schussler, H. Dermine, M. Alifano, N. Roche, S. Strano, A. Casetta, A. Meunier, S. Coignard, M. Salvi, P. Magdeleinat, et al. Reply Ann. Thorac. Surg., September 1, 2009; 88(3): 1052 - 1052. [Full Text] [PDF]
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