Dear Editor:

       Congratulations to Professor Gardner and colleagues (Gardner S, Frantz R, Hillis SL, Park H, Scherubel M. Diagnostic validity of semiquantitative swab cultures. WOUNDS. 2007;19(2):31–38) for again writing about and promoting an old, perhaps neglected, technique for wound culture—the Levine technique. We were able to confirm the work that Norman Levine did while at Brooke Army Medical Center with work at the Burn Unit at Kansas University Medical Center in the late 1970s.¹ Rather than using the tip of the swab and “rotating” as described by Gardner et al, we used the side and rubbed back and forth with pressure, rotated and repeated, in order to increase surface area and tissue juice capture.² The crux of Levine’s message is that if you are going to swab for culture, then obtaining tissue juice is the critical component of a meaningful culture.
       However, I would like to ask about a specific point of methodology in the current article because it draws into question the conclusions.
       On page 34, the methodology described to obtain the quantitative and semiquantitative swabs for the experiment was to use the “first swab” for quantitative and the “second swab” in the “same 1-cm² area” for semiquantitative procedures. If in fact this order of swabbing was maintained throughout the study (rather than randomizing the order), then none of the proposed study questions can be addressed; rather, this study shows us not the difference between quantitative and semiquantitative techniques, but the difference between first and second swabs and the amount of tissue juice they are able to obtain.
       Strict quantitative cultures are not available to most practitioners. Therapy decisions for chronic wounds must weigh many clinical factors and culture results with identification of pathogens and their antibiotic resistance profile and even just qualitative growth estimates are always useful information.

David S. Zamierowski, MD
Founder, Wound Care Centers of Kansas City
Overland Park, KS