Ciprofloxacin for Treatment of Tularemia

Reply Sir—We would like to address Dr. Ise-man's concern [1] that our study [2] may be misleading. Dr. Iseman expresses his concern by emphasizing the absence of evidence that slow conversion of sputum smear results from positive to negative status is associated with an increased risk for transmission of Mycobacterium tuberculosis , treatment failure, and acquired drug resistance so long as appropriate therapy is maintained. We wish to stress that the patients in our study were expectorating high concentrations of viable organisms for months on end. Even in the absence of published evidence to the contrary, we would consider it cavalier to assume that such patients did not pose a risk to others in the community. Where the reader may be misled is in assuming that our study proved that our intervention prevented transmission. We do, however, respectfully suggest that the absence of positive stain and culture results for many months is somewhat reassuring. Whether the patients in our study had " treatment failure " depends on the definition of the term. We do not dispute that, for many patients with multidrug-resistant tuberculosis, positive sputum smear results ultimately convert to negative when the patients receive only conventional therapy. Unfortunately, the prolonged interval of sputum smear pos-itivity and the requirement for protracted therapy, with the attendant problems of infectiousness, poor compliance, and development of drug resistance, are part of a global failure of tuberculosis management , if not a failure in the treatment of specific individuals. Although our intention was not to promote the use of aerosol therapy on the basis of our very preliminary evidence, we believe that the disruption to patients' lives and the expense that occur as a result of this intervention (if it is confirmed to be effective in future studies) compete favorably with the punitive and costly isolation requirements supported by the Centers for Disease Control and Prevention (Atlanta) for patients with tuberculosis who have persistently positive sputum smear results [3]. We did not in any way wish to imply that aerosol therapy should be considered a substitute for systemic therapy. For no patient was traditional treatment abandoned once sterilization of secretions in the airways was achieved. We fully agree that aerosol therapy is unlikely to have any impact on organisms that are buried in the lymphatic system and the walls of the airways. However, we suggest that the presence of viable organisms in sputum is …