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To the Editor: In their meta-analysis, Dr Safdar and colleagues¹ concluded that antibiotic exposure during Escherichia coli O157:H7 colitis was not associated with an increased risk of hemolytic uremic syndrome (HUS). Because the included studies were very heterogeneous, however, conclusions based on a single risk estimate may be misleading.

In Figure 1 of the article, 2 of 9 studies reported significantly increased odds ratios (ORs); 6 studies showed no association; and 1 study, which treated patients with fosfomycin, showed a decreased risk of HUS. Safdar et al treated the 2 studies with increased ORs as statistical outliers and averaged these effects against the much larger studies.

Part of this heterogeneity may be related to underlying biological mechanisms. Different strains of E coli O157:H7 respond differently in their production of Shiga-toxin with exposure to subinhibitory concentrations of antibiotics; some strains increase Shiga-toxin production while others do not.² This is believed to . . . [Full Text of this Article]

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