We thank Dr. Hassid for his interest in our article and appreciate the comments that highlight the subsequent key advances on this topic. One goal of this article was to further expose the importance of the sessile biofilm over the free-floating planktonic model. The use of injectable soft-tissue filling agents in cosmetic medicine is relatively early in its evolution compared with other aspects of medicine that have experienced issues related to similar tissue reactions to implantable substances, and we are now beginning to understand the relationships and benefit from those before us. We agree that this fundamental understanding highlights why current culture techniques fail to identify biofilm organisms and why pyrosequencing, polymerase chain reaction, fluorescent in situ hybridization, and ultrasound sonication are essential advances that should be considered when biofilms are suspected.
While we await advances in culture techniques to reach mainstream clinical practice, double antibiotic coverage improves the likelihood that patients will receive effective empiric therapy. Here, too, the risks are high with regard to consequences of delayed treatment, and effective treatment, despite an oftentimes educated empiric approach, more often trumps the practical and theoretical risks of promoting antibiotic resistance. Evidence that combination therapy may prevent resistance is limited to tuberculosis and human immunodeficiency virus, diseases synonymous with high resistance, but further research needs to elicit the best antibiotic approach against the resistance provided by biofilms in addition to avoiding the emergence of antimicrobial resistance.1 Once culture yields improve with the newer techniques discussed, antibiotic therapy deescalation should be practiced.
We also agree that alternate or adjunctive approaches should be considered, such as the use of laser-assisted liquefaction and thermal/chemical bioburden reduction procedures, and may offer a promising minimally invasive option that should be investigated further. Once again, we are grateful for Dr. Hassid's comments, which emphasize the next steps in biofilm care.
Alexander T. Nguyen, M.D.
Rod J. Rohrich, M.D.
Department of Plastic Surgery
University of Texas Southwestern Medical Center
Steven Fagien, M.D.
Boca Raton, Fla.
1. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis
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