LAUSR

To the Editor:We read with great interest the article titled by Kumar et al. The authors have demonstrated in this study that in low-risk febrile neutropenic patients, early discontinuation of intravenous antibiotics might be a feasible and equally efficacious option [1]. However, we wish to add some points. The authors have mentioned that in both groups defervescence occurred on an average after 16–18 h of intravenous antibiotic administration. From the clinical profile of these patients, most of them appear to be suffering from some viral infection, as the defervescence occurred only after 16–18 h of intravenous antibiotic administration. In such a context, it would have been more informative for authors to mention, howmany patients had a cold, cough, and upper respiratory symptoms, which is the most common fever associated symptom in seasonal viral infections. In such patients often oral oseltamivir and azithromycin are added in clinical practice, to treat possible influenza and atypical microorganisms like mycoplasma. Authors did not mention serum procalcitonin value, which is currently being used in most centers for monitoring and guiding the duration of antibiotics in febrile neutropenia patients. As the authors have mentioned poor yield of blood culture in their clinical setting, serum procalcitonin would have helped in guiding the duration of intravenous antibiotics more judiciously [2]. This information would have provided a better clinical and microbiological picture of the participants in both arms and whether continuing intravenous antibiotics in one of the arms was justified. The authors have preferred cefoperazone-sulbactam with or without amikacin as the initial intravenous antibiotic of choice, depending on the local microbiota sensitivity patterns, and from the choice of intravenous antibiotics, it appears to cover more for the gram-negative organisms. In such a context, a cephalosporin like cefixime/cefpodoxime alonemight have been preferred. The exact hypothesis behind choosing the combination is not clear from the article and levofloxacin is known to have better coverage for infections caused by gram-positive microorganisms than gram-negative organisms [3, 4]. The authors have used the non-inferiority design for the RCT. An appropriate statistical statement for such design is to determine whether the 95% confidence interval of the effect size (risk difference in this context) crosses the non-inferiority margin or not, rather than mentioning the p value (0.59), which the authors mentioned in the result section [5]. Lastly, the authors need to recheck once the p-values calculated for any significant difference between age and sex distribution in both arms, as the pvalues came out to be 0.03 (two-tailed) and 0.07 in place of 0.08 and 0.45 respectively. In such a case, the authors need to adjust age and sex variables while calculating the primary outcome.