LETTERS TO THE EDITOR Emergency Department Diagnosis of ACL Tears: A Response to Guillodo et al. To the Editor: T he novel study by Guillodo et al. 1 should be applauded for attempting to define the ability of emergency phy- sicians to diagnose anterior cruciate ligament (ACL) tears in acute presenta- tions of knee injuries. The long list of studies performed on the initial diagno- sis of “acute” ligamentous injuries of the knee do not focus on the evaluation of “fresh” knee injuries usually encountered in the emergency department, those oc- curring generally less than 12 hours af- ter injury. Although the authors record but do not state time from injury to initial emergency department evalua- tion, it can be inferred that most of these patients presented within hours of their injuries. The conclusions reached in this study calling for efforts among emer- gency physicians to raise awareness of clinical signs and symptoms of ACL tears may or may not have merit. Al- though much is known about the pro- gression of ACL tears in the days after acute injuries and during postrecon- struction and rehabilitation, the natural history of these injuries in humans from time zero has not been studied. This leaves an undefined hole in our knowl- edge base regarding initial clinical ex- amination findings in these patients in the hours after injury. Furthermore, as specialists in Emergency Medicine, our primary goal in assessing acute, isolated knee injuries is to determine which of these patients require near-term referral. A study prospectively focusing on these initial presentations and appropriate re- ferral patterns for the injured knee might better define the true need for “efforts” to improve emergency medicine special- ists’ skills in this area of medicine. Michael A. Miller, MD Troy P. Coon, MD Department of Emergency Medicine Tripler Army Medical Center Honolulu, HI REFERENCE 1. Guillodo Y, Rannou N, Dubrana F, Lefe `vre C, Saraux A. Diagnosis of anterior cruciate liga- ment rupture in an emergency department. J Trauma. 2008;65:1078 –1082. The Authors’ Reply: W e thank Dr. Miller for his interest in our article 1 and welcome his com- ments. 2 We agree that the evaluation at the emergency department is crucial to determine which patients require near- term referral. Currently, the ability of emergency room physicians to diagnose anterior cruciate ligament (ACL) rup- ture has not been fully evaluated. In our study, we observed a poor agreement between emergency physicians and the sports medicine specialists for ACL rup- ture diagnosis. This result raises two hypothesis. First, the examination has been modified by the time elapsed between the two evaluations. In this hypothesis, we could suppose that the examination is more clearly modified for patients who had a fresh knee injury. Stratifica- tion on the time from injury to initial emergency department evaluation may confirm this supposition or not. In our study, all patients had fresh knee injuries (less than 24 hours), but the time elapsed between the injury and the examination has not been computerized. Second, emergency physicians and sports medicine specialists do not have a good agreement. To clarify this hy- pothesis, studies are needed to compare emergency physicians and sports medi- cine specialists the same day in the emergency department and then 3– 8 days after. In our opinion, Lachman’s test is probably not modified by the time, and the difficulty to interpret this test for a nonspecialist explains the dif- ference between emergency physicians and sports medicine specialists. In con- trast, clinical evaluation of other signs (instability or joint effusion for exam- ple) is generally modified by the time. Alain Saraux, MD, PhD Yannick Guillodo, MD Brest University Medical School, CHU Brest, France REFERENCES 1. Guillodo Y, Rannou N, Dubrana F, Lefe `vre C, Saraux A. Diagnosis of anterior cruciate liga- ment rupture in an emergency department. J Trauma. 2008;65:1078 –1082. 2. Miller MA. Emergency department diagnosis of ACL tears: a response to Guillodo et al. J Trauma. 2009;67:893. Could De-escalation of Antibiotic Therapy be Feasible Even for Documented Methicillin-Resistant Staphylococcus aureus Ventilator-Associated Pneumonia? To the Editor: W e read with interest the study of Eachempati et al. 1 describing the relationship between de-escalation of antibiotic therapy for ventilator-associated pneumonia (VAP) and clinical outcome in critically ill surgical patients. In this prospective clinical study, it was shown that among 128 of 1,596 surgical inten- sive care unit patients who developed VAP and who received appropriate an- tibiotic therapy, no difference in both recurrent pneumonia rate and mortality rate was observed between patients re- ceiving de-escalation therapy (27.3% and 33.8%, respectively) or not (35.1% and 42.1%, respectively). These findings lead the authors to conclude that de- escalation of antibiotic therapy should be performed whenever possible in crit- ically ill patients with VAP because of its acknowledged benefits and lack of demonstrable risks. Although we fully agree, it should be highlighted that de- escalation of antibiotic therapy is usu- ally based on the concept of changing the antibiotic chosen for empiric use to another antibiotic with a narrower spec- trum of activity in presence of specific culture data. 1 This strategy applies for VAP due to susceptible gram-negative pathogens or methicillin-susceptible Federico Pea has been on the speakers’ bureau for Pfizer. Pierluigi Viale has been a consultant to, has been on the speakers’ bureau for, and has received grant support from Pfizer. The Journal of TRAUMA ® Injury, Infection, and Critical Care • Volume 67, Number 4, October 2009 893