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Empiric Therapy for Febrile Neutropenia
- John F. Inciardi, PharmD
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TO THE EDITOR:
The large effort by the Intercontinental Antimicrobial Study Group to compare single-agent and combination therapy for febrile neutropenia [1] appears long on data and short on analysis. Consequently, this otherwise impressive report leaves unanswered several important issues that should be extracted from the raw data.
First, how is the reported odds ratio (1.07) for a satisfactory response (ceftazidime compared with tobramycin plus piperacillin) affected by important patient variables such as age, underlying disease, and granulocyte count? Although the authors list and compare such items in a table, the odds ratio appears to be unadjusted for any of these potentially important outcome variables. (This impression is easily verified: If P1 = 0.627 [the probability of success given ceftazidime] and P2 = 0.611 (the probability given combination therapy), the odds ratio = (P1/1-P1)/[P2/1-P2] = 1.07.) Simply comparing potential confounders using a table of demographics (or even using direct hypothesis testing) does not absolve such variables, either alone or in combination, from significant effects on the odds ratio [2]. Modeling the data by logistic regression (binary or polychotomous), however, would give the clinician a more useful assessment of the odds ratio by adjusting the antimicrobial effects for important patient-related factors.
Second, aside from “satisfactory response,” did the study have sufficient power to draw conclusions regarding any of the other nonsignificant results?
Third, odds ratios with confidence intervals can convey much information. Unfortunately, the authors' Figure 4 is difficult to interpret because the abscissa is scaled differently with respect to therapy (1 to ∞ for ceftazidime, 0 to 1 for combination therapy). Plotting the data against the log odds ratio, however, would make this Figure visually interpretable.
John F. Inciardi, PharmD
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
