We appreciate the comments of Dr Johnson. As he notes, recent guidelines suggest that TMP-SMZ should be first-line therapy for urinary tract infection when the prevalence of resistance to this agent is less than 10% to 20%.1 During our study, the prevalence of TMP-SMZ resistance among outpatient Escherichia coli isolates at our health system was 7%, supporting the choice of TMP-SMZ as first-line therapy for urinary tract infections. In addition to antibiotic allergy history, other potentially mitigating factors were considered in deciding whether fluoroquinolone use was appropriate. These included a review of concurrent medications, recent antimicrobial use, and recent hospitalization. Fluoroquinolone use was considered acceptable if the patient was taking a drug that might interact with TMP-SMZ, received TMP-SMZ within the past month, or was hospitalized within the past 2 weeks. Finally, after further consideration, it may be preferable to categorize fluoroquinolone use as occurring "outside of guidelines" rather than as "inappropriate" given the obvious value judgment associated with the latter term and the fact that what is "appropriate" at one institution or setting may be "inappropriate" elsewhere.
Lautenbach E, Larosa LA, Kasbekar N, Peng HP, Maniglia RJ, Fishman NO. Nonspecific Guidelines Lead to Inappropriate Fluoroquinolone Use—Reply. Arch Intern Med. 2003;163(13):1618. doi:10.1001/archinte.163.13.1617-a
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