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Re: Commentaries - Read with caution!

The commentary by Lenney correctly points out that clinicians are often slow to apply good research evidence to clinical practice.[1] However, the choice of once-daily intravenous gentamicin to illustrate this point is unfortunate. Extended interval aminoglycoside dosing is widely used in paediatric and neonatal practice for the treatment of serious gram negative infections, the treatment of newborn infants with sepsis and the treatment of chronic Pseudomonas aeruginosa infection in patients with cystic fibrosis. However, the implementation of extended interval dosing has not been based on the results of appropriately designed trials in children and neonates.

The largest meta-analysis of single vs multiple daily dosing of aminoglycosides for the treatment of gram negative sepsis included only 2 paediatric studies.[2] The use of once-daily aminoglycosides in children and the newborn is still currently unlicensed. Finally a recent systematic review of once-daily versus multiple-daily dosing of aminoglycosides in CF concluded that there was insufficient evidence to recommend a change in practice.[3] This was because most clinical trials were of insufficient quality or were performed in adults and so the results should not be extrapolated to children.

There is a danger that expert commentaries may be read by some readers of ADC with the same unquestioning belief of second century Greeks. We would argue that the presence of evidence from “a number of studies from numerous countries” should not be the basis on which implementations in practice should be founded. Instead quality of evidence should be of paramount importance, even if there is little of it.

Dr Kelvin Tan
Clinical Research Fellow Paediatrics
Academic Division of Child Health
University of Nottingham
Nottingham, UK

Dr Alan Smyth
Consultant Paediatrian Respiratory Medicine
Nottingham City Hospital NHS Trust
Nottingham, UK

References
(1) Lenney W. Successful implementation of spacer treatment guidelines for acute asthma [Commentary]. Arch Dis Child 2001;84:145-6.

(2) Barza M, Ioannidis JPA, Cappelleri JC, Lau J. Single or multiple daily doses of aminoglycosides: a meta-analysis. BMJ 1996;312:338-45.