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From the authors

¹ Alfa Institute of Biomedical Sciences, and ² Intensive Care Unit, Attikon University Hospital, and ³ Dept of Medicine, Henry Dunant Hospital, Athens, Greece. ⁴ Dept of Medicine, Tufts University School of Medicine, Boston, MA, USA.

We thank K.C. Chang and C.C. Leung for their interest in our meta-analysis 1 and we welcome their comments.

As our respectful colleagues acknowledged, a well-designed and carefully performed meta-analysis is graded at the highest level of scientific quality by evidence-based movement 2. It has been stated that a systematic review "faithfully summarizes the evidence from all relevant studies on a topic, and it does so concisely and transparently" 3. Thus, meta-analyses are consistently used as the basis for a grade A recommendation in clinical practice guidelines, including those dealing with antimicrobial therapy 4. Convinced by the principles of evidence-based medicine, we attempted to perform several meticulous meta-analyses in the field of antimicrobial treatment for acute bacterial exacerbations of chronic bronchitis (ABECB) 1, 5, as well as for other lower respiratory tract infections 6, 7.

We are aware that simple pooling of data is not sufficient to ensure the internal validity and, therefore, the generalisability of the findings of a meta-analysis 8. Thus, we have critically appraised the evidence derived from systematic reviews 9. For example, in our meta-analysis of the various antimicrobials for ABECB, we insisted on assessing its potential limitations 1; a great proportion of the Discussion section is devoted to this. We emphasised that "antimicrobial resistance is a moving target and only data from local surveillance studies on this major clinical and public health problem provide information that helps the clinician in decision making regarding the choice of the appropriate antibiotic for a given patient with ABECB" 1. In addition, in table 1 of the manuscript we carefully listed the characteristics of the subjects included in the individual randomised controlled trials, in order to help the reader determine whether its findings are applicable to his/her patient population 1. Taking these issues into consideration, we believe that clinicians will find our meta-analysis results valuable while treating patients with ABECB.

Finally, we agree with K.C. Chang and C.C. Leung that several concerns have arisen regarding the usage of fluoroquinolones for the treatment of patients with lower respiratory tract infections in areas with endemicity of tuberculosis 10. Actually, it could be argued that this fact further underscores the usefulness of the present meta-analysis. Indeed, if clinicians acknowledge that fluoroquinolones are equivalent to macrolides or amoxicillin/clavulanate for the treatment of patients with acute bacterial exacerbations of chronic bronchitis in terms of their short period of effectiveness, they may prefer to use macrolides or amoxicillin/clavulanate rather than fluoroquinolones in areas with endemicity of tuberculosis.

Statement of interest

None declared.

REFERENCES

1. Siempos II, Dimopoulos G, Korbila IP, Manta K, Falagas ME. Macrolides, quinolones and amoxicillin/clavulanate for chronic bronchitis: a meta-analysis. Eur Respir J 2007;29:1127–1137.[Abstract/Free Full Text]
2. Cook DJ, Guyatt GH, Laupacis A, Sackett DL, Goldberg RJ. Clinical recommendations using levels of evidence for antithrombotic agents. Chest 1995;108: Suppl. 4 227S–230S.[CrossRef][Medline] [Order article via Infotrieve]
3. Cook DJ, Murlow CD, Haynes RB. Systematic reviews: synthesis of best evidence for clinical decisions. Ann Intern Med 1997;126:376–380.[Abstract/Free Full Text]
4. Woodhead M, Blasi F, Ewig S, et al. Guidelines for the management of adult lower respiratory tract infections. Eur Respir J 2005;26:1138–1180.[Abstract/Free Full Text]
5. Dimopoulos G, Siempos II, Korbila IP, Manta K, Falagas ME. Comparison of first-line with second-line antibiotics for acute exacerbations of chronic bronchitis: a meta-analysis of randomized controlled trials. Chest 2007;132:447–455.[Abstract/Free Full Text]
6. Siempos II, Vardakas KZ, Manta KG, Falagas ME. Carbapenems for the treatment of immunocompetent adult patients with nosocomial pneumonia. Eur Respir J 2007;29:548–560.[Abstract/Free Full Text]
7. Falagas ME, Siempos II, Vardakas KZ. Linezolid versus glycopeptide or β-lactam for treatment of gram-positive bacterial infections: meta-analysis of randomised controlled trials. Lancet Infect Dis 2008;8:53–66.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
8. Tobin MJ, Jubran A. Meta-analysis under the spotlight: focused on a meta-analysis of ventilator weaning. Crit Care Med 2008;36:1–7.[Web of Science][Medline] [Order article via Infotrieve]
9. Falagas ME, Vardakas KZ, Samonis G. Decreasing the incidence and impact of infections in neutropenic patients: evidence from meta-analyses of randomized controlled trials. Curr Med Res Opin 2008;24:215–235.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
10. Singh A. Fluoroquinolones should not be the first-line antibiotics to treat community-acquired pneumonia in areas of tuberculosis endemicity. Clin Infect Dis 2007;45:133[Web of Science][Medline] [Order article via Infotrieve]

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