To the Editor: We read with interest the case report of Ward and colleagues, describing methicillin-resistant Staphylococcus aureus with reduced susceptibility to vancomycin in a patient being treated for lower-limb ischaemia.1 We conclude that this antibiotic resistance may not have developed if the patient had been treated with conventional vascular therapy.

The patient had diabetes, was haemodialysis-dependent and continued to smoke. Bilateral lower-limb ischaemia in such a patient is an indication for early vascular assessment, including angiography, debridement of non-viable tissue and, if possible, revascularisation. The option of early below-knee amputation should always be considered for such a patient.

Broad-spectrum antibiotics administered over a long period to patients with ischaemic tissue can provide the ideal medium for development of multiresistant organisms. In this patient, 41 days of chronic infection, combined with the decreasing nutritional status typical of haemodialysis patients, contributed to the breakdown of both below-knee amputation sites and the ongoing sepsis.

The difficult decision to preserve or amputate an ischaemic limb is best made by a vascular surgeon in consultation with the patient. Amputation should not be seen as treatment failure but as another stage of vascular disease. Early amputation preserves the physical condition and nutrition of patients and allows earlier transfer to rehabilitation units, with an improved result.2