Dear Editor:

  We read with interest the report by Shklyar et al¹ about the efficacy of ertapenem for treatment of diabetic foot infections. While ertapenem is an important part of the therapeutic armamentarium for these infections, the data presented do not justify the statement that “its use should be strongly considered in individuals with non-healing diabetic foot ulcers.”

  At the author’s center cephalexin is first-line therapy for mild infections (not defined) and a combination of a quinolone with clindamycin is the second line regimen. Sixty consecutive patients failing these regimens were included in this study. No criteria for response / failure are provided making it difficult to determine the nature of the infection when patients first received ertapenem. Twenty patients (33%) were excluded from the analysis because of isolation of ertapenem resistant organisms (MRSA, Enterococcus faecalis, Pseudomonas aeruginosa). It is likely that these organisms were responsible for failure of the other regimens. Consequently, they should also be regarded as failures of ertapenem.

  No clear definitions are provided for success or failure of ertapenem therapy. We are merely told that individuals with soft-tissue infections continued antibiotics until significant clinical improvement or ulcer healing, and patients with osteomyelitis continued therapy for 6–9 weeks according to clinical response. No microbiologic or radiographic criteria are mentioned. These loose criteria do not give the reader a clear idea of the actual outcome.

  Finally, we are given no information about any follow-up after stoppage of ertapenem therapy. Did any of these patients have relapses or recurrent infections? This is an important aspect of the overall success of a particular drug or regimen. Due to these issues, we remain less enthusiastic than the authors about ertapenem for salvage therapy of diabetic foot infections.

  Kenneth V. I. Rolston, MD
  Professor of Medicine
  Department of Infectious Diseases, Infection Control and Employee Health (Unit 402)
  Phone: 713-792-0043
  Email: krolston@mdanderson.org

References

1. Shklyar A, Miller EB, Landau Z. Efficacy of ertapenem for secondary treatment of diabetic foot infections. WOUNDS. 2010;22(6): 158–160.

Dear Editor:

  I am very happy that my friend and colleague Laura Bolton addresses pain and pain relief in her August Evidence Corner (WOUNDS. 2010;22(8):A10–A12).

  The Royal College of Surgeons states, “Failure to relieve pain is morally and ethically unacceptable.”¹ Indeed, pain and its impact on a patient’s well being and on the healing of his or her wounds has been the topic of many articles.^2,3 Still, pain quite often is not considered to be of true (or at least, enough) importance, and sometimes even a consequence of being wounded that has to be accepted: many patients are sent home after major surgery with just a Tylenol too often. Certain categories of patients (ie, neonates) are even believed by some not to be able to feel pain (hence, the cruel and unacceptable practice of performing circumcision without pain prevention or treatment.)⁴

  True, strong pain relievers, particularly opioids, have some serious side effects, such as respiratory depression. Moreover, many people in the general population have become addicted to opioids and this may cause fear to the prescribing physician.
There is a big difference, however, between “recreational use” and medical indications.