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To the Editor: We read with great interest the article published in a recent issue of Critical Care by Grahl et al. [1]. The authors illustrated that there is no association between delirium and cefepime, penicillin, carbapenems, fluoroquinolones, or macrolides. We would like to point out following concerns about this study. We believe sample was not representative of general population and sample size was not powered enough to draw these conclusions. Study sample does not include all consecutive subjects from a time frame; a large portion of subjects 96 records (18%) were excluded because medication data was not available. Intention to include analysis might change results significantly. Authors did not mention if excluded patients’ profile was similar to included patients’ profile. Delirium was documented in 318 (76%), which is significantly more than expected from a typical ICU which suggests that sample may not be representative of general population. Sample predominantly comprises of Caucasian population (88%) so results may not be applicable to African American population. This study found no association between delirium and cefipime. Although the analysis is performed for cefipime as individual drug, actual number of patients treated with cefipime was not provided; the key

critical care

Quality and quantity of sample size is crucial in clinical studies to exclude association: antimicrobial exposure and the risk of delirium in critically ill patients