Catheter-associated urinary tract infection IDSA guidelines: why the levofloxacin?

cant role. Nevertheless, there were several areas in Dr Aggarwal’s letter that we wish to clarify. First, we believe that, in this epidemic, which continued over many incubation periods, there must have been either a continuing common source or person-toperson transmission. During the period of this investigation, there were several prevention and control measures implemented to ensure safe drinking water and hygienic practices. In addition to hepatitis E virus testing of water sources, testing for coliforms was conducted. Although we agree with Dr Aggarwal regarding the low sensitivity of hepatitis E virus detection techniques from water sources, the absence of hepatitis E virus RNA and significant coliforms from protected water sources argues against any fecal contamination that would contribute to an ongoing common source. Given that there was no evidence of any contamination of these sources while hand lavage yielded hepatitis E virus [2], we believe that person-to-person transmission likely played a significant role. Second, we believe that the assumption of secondary cases representing person-toperson transmission is conservative in that this route could also have contributed to transmission among primary cases. Unlike in Asia, where there may be a higher prevalence of immunity to hepatitis E virus, we believe that a significant proportion of the population was susceptible to hepatitis E virus prior to the widespread outbreak. In our population, this could have contributed to the secondary attack rate, which was much higher than those reported in most studies [3], which were conducted in populations with higher preexisting immunity to hepatitis E virus and where person-to-person transmission was considered insignificant. If there had been a continually contaminated common water source, then we would have expected an even higher attack rate and a shorter outbreak. Regarding Dr Aggarwal’s concern about the range of time periods between primary and secondary cases (ie, 8– 20 weeks), we believe that infection could have been propagated by infected but asymptomatic family members. Another issue regarding household transmission that was raised by Dr Aggarwal deserves comment. In many settings, we would agree with him that household size is associated with socioeconomic status and standard of living. However, in the setting of this outbreak, the socioeconomic status of all residents was uniformly poor, and there was no substantial variation in the living conditions. Although we cannot exclude the possibility that a proportion of secondary cases may have acquired infection from an unidentified common source, we still believe that significant hepatitis E virus personto-person transmission occurred during this large epidemic in northern Uganda.