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a Department of Thoracic Surgery, Hôpital Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris V University, 1 place Parvis de Notre Dame, Paris, 75004 France
b Anaesthesia and Surgical Intensive Care, Hôpital Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris V University, 1 place Parvis de Notre Dame, Paris, 75004 France
c Department of Thoracic Surgery, Hôpital Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris V University, 1 place Parvis de Notre Dame, Paris, 75004 France
d Respiratory and Critical Care Medicine, Hôpital Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris V University, 1 place Parvis de Notre Dame, Paris, 75004 France
e Department of Thoracic Surgery, Hôpital Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris V University, 1 place Parvis de Notre Dame, Paris, 75004 France
f Microbiology, Hôpital Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris V University, 1 place Parvis de Notre Dame, Paris, 75004 France
g Anaesthesia and Surgical Intensive Care, Hôpital Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris V University, 1 place Parvis de Notre Dame, Paris, 75004 France
h Microbiology, Hôpital Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris V University, 1 place Parvis de Notre Dame, Paris, 75004 France
i Department of Thoracic Surgery, Hôpital Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris V University, 1 place Parvis de Notre Dame, Paris, 75004 France
j Respiratory and Critical Care Medicine, Hôpital Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris V University, 1 place Parvis de Notre Dame, Paris, 75004 France
k Department of Thoracic Surgery, Hôpital Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris V University, 1 place Parvis de Notre Dame, Paris, 75004 France
(Email: schussler.olivier{at}neuf.fr).
We thank Stern and Pean [1] for their interest in our study [2]. Although all the questions raised by the authors have already been answered either in the cited article or in our previous one dealing with the first part of this prospective study (antibiotic prophylaxis by cefamandole) [3], we will take the opportunity of clenching some important concepts.
First, a detailed analysis of literature [3] allowed us to show that the reported incidence of pneumonia after lung operations was extremely variable, depending not only on the extent of resection and the type of antibiotic prophylaxis but also on the modalities of microbiologic sampling (when done) and on the type of study design (prospective or retrospective). For comparison, in the retrospective study by Stephan and colleagues [4] cited by Stern and Pean, the incidence of postoperative pneumonia was 6.4%, but 12 of 17 occurred in patients under mechanical ventilation. Furthermore in that study, pneumonias occurred invariably late in mechanically ventilated patients. In the same series, 6% of patients had respiratory distress in the early postoperative period, and its infectious origin cannot be excluded.
It is evident that a retrospective study ineluctably leads to loss of information with subsequent prevalent identification of more serious cases requiring intensive care unit monitoring for respiratory insufficiency. On the other hand, in our prospective study, the same strict criteria were used to define pneumonia in both periods; thus the "artificial" increase in the rate of pneumonia suspected by Stern and Pean is very unlikely. Furthermore, we performed not only a multivariate analysis but also a case-control study to avoid risks of bias related to a study with a before-and-after design.
Second, in their opinion, the rationale for the use of high dose (6 g/24 h) amoxicillin-clavulanate is unclear. For us, two major reasons support this choice: the need to respect the principle of double dose, in agreement with good rules of surgical antibiotic prophylaxis, and the necessity of 24-hour maintenance of concentrations higher than the minimum inhibitory concentration by using a dose taking into account the high frequency of Streptococcus pneumoniae with reduced sensitivity to penicillin, a characteristic observed in our study as well as in different national surveys [5, 6].
Third, there was no difference in terms of impaired forced expiratory volume in 1 second between the two study periods. Chronic obstructive pulmonary disease (all stages) was slightly more frequent in the amoxicillin-clavulanate period and smoking cessation of less than 60 days was more frequent in the cefamandole period, but in both cases, the differences did not reach statistical significance. Thus, if one also considers these nonstatistically significant differences as clinically relevant, colonization and development of postoperative pneumonia would have been more likely in patients in the second period. Exactly the contrary occurred, and in agreement with findings of previous studies [7], we do think that the rapid and potent bactericidal action of amoxicillin-clavulanate was responsible for the observed lowered incidence of bronchial colonization in the second period.
We thank Stern and Pean for acknowledging our finding that bronchial colonization is an important risk factor for postoperative pneumonia, but we do think that antibiotic prophylaxis remains the critical issue. As suggested in the conclusion of our article, we agree that a randomized study should be done to validate the efficacy of an antibiotic prophylaxis that targets organisms responsible for the initial bronchial colonization.
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