I applaud the novel approach used by Dang et al. (1) to eradicate methicillin-resistant Staphylococcus aureus (MRSA) in patients with a diabetic foot ulcer. These Manchester Royal Infirmary clinicians have been leaders in documenting the problem of MRSA in diabetic foot lesions. As the incidence of colonization and subsequent infection with this virulent pathogen is rising in both the hospital and community, we need approaches to eradication that will not further drive antibiotic resistance (2).

There are several issues, however, that the briefly recorded observation left unclear. First, what was the target of the Biogun? I presume it was directed at a foot ulcer, but the authors only state “… patients without clinically infected foot ulcers but with MRSA colonization were treated.” So, was the treatment directed at a clinically uninfected foot ulcer in each case? Was the MRSA colonization of the foot ulcer? Second, MRSA colonization of the skin is most often associated with, and follows, MRSA anterior nares colonization (3). Did the authors check if the enrolled patients had nasal colonization? Did any of the patients receive topical therapy (e.g., mupirocin ointment) to their nares? Finally, antimicrobial therapy can eradicate S. aureus colonization (4); did any of the patients receive topical (to the wound) or systemic antibiotic therapy during the time they were treated with the Biogun? If so, did this correlate with MRSA eradication?

The nonantimicrobial method of eradication described by Dang et al. (1), with its promising preliminary results, deserves further evaluation. I look forward to the results of the properly designed randomized trial of this new technology that the authors rightfully suggest.

Dang CN, Anwar R, Thomas G, Prasad, YDM, Boulton AJM, Malik RA: The Biogun: a novel way of eradicating methicillin-resistant Staphylococcus aureus colonization in diabetic foot ulcers (Letter).
Diabetes Care
Tentolouris N, Petrikkos G, Vallianou N, Zachos C, Daikos GL, Tsapogas P, Markou G, Katsilambros N: Prevalence of methicillin-resistant Staphylococcus aureus in infected and uninfected diabetic foot ulcers.
Clin Microbiol Infect
Unzeitigova M, Benes J, Gabrielova A, Horova B, Podzimkova M: [Practical experience with patients infected or colonized with a methicillin-resistant strain of Staphylococcus aureus (MRSA)].
Klin Mikrobiol Infekc Lek
[article in Czech]
Lipsky BA, Pecoraro RE, Ahroni JH, Peugeot RL: Immediate and long-term efficacy of systemic antibiotic for eradicating nasal colonization with Staphylococcus aureus.
Eur J Clin Microbiol Infect Dis