I have read with great interest the original article by López Medrano et al.1 regarding the high incidence of bacteremia due to Gram-negative bacteria (GNB) in patients with pulmonary arterial hypertension (PAH) treated with intravenous (IV) treprostinil compared with IV epoprostenol. This is a known finding in the literature and has been confirmed in a Spanish center with extensive experience in the management of PAH. They also suggest initial empirical therapeutic management until the pathogen is correctly identified. In their conclusions, the authors invite us to carefully weigh the risks and benefits of treatment with IV treprostinil.

Recently, Kitterman et al.2 have published data about the incidence of bloodstream infection in 1146 patients with PAH from the REVEAL Registry in the United States. They had been treated with either IV epoprostenol or treprostinil, and a greater incidence of infection due to GNB was found in the IV treprostinil group (0.20 vs 0.03 per 1000 days of treatment, P<.001). However, this US series shows that the rate of infection has dropped drastically in recent years since the publication and approval of the Clinical Practice Guidelines for the prevention of bacteremia due to central venous catheter in the treatment of PAH with prostanoids.3 Our own center had also experienced a reduction in the rates of infection in recent years since guidelines were adopted, but this analysis is not reflected in the paper by López Medrano et al.1

In other studies aimed at reducing these infections, the use of a high-pH diluent (like epoprostenol) and additional measures for venous catheter care have been shown to be effective.4–6 The design of the Kitterman et al. study cannot discern between the superiority of one or another measure to reduce the number of bloodstream infections. Given that in Europe it is not possible to prepare treprostinil with a high-pH solvent, patients must be educated to avoid infections through simple but effective techniques such as strict compliance with proper hygiene, placement of the bacterial filter not in the perfusion line, the introduction of a closed connector (closed-hub system) and, above all, maintaining central venous catheter connections clean and dry at all times.

Finally, as for the conclusions of López Medrano et al.,1 the decision to use one or another form of IV prostacyclin is based on the results of an observational, non-controlled study with a small sample population, with no reference to the changes in practice that may have taken place from the introduction of local standards for catheter care, as previously indicated. A more extensive, controlled study designed to this effect is necessary, as it has been suggested by Clinical Practice Guidelines with regards to recommendations and level of evidence.

Improved treatment management with parenteral prostacyclin is one of the current challenges that could have repercussions on the morbidity, mortality and general quality of life of patients with PAH.