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First-line vs Second-line Antibiotics for Treatment of Sinusitis—Reply

Jay F. Piccirillo, MD; Douglas E. Mager, BS; Mark E. Frisse, MD, MS, MBA
JAMA. 2002;287(11):1395-1396. doi:10.1001/jama.287.11.1395.
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In Reply: We clearly acknowledged all of the methodological limitations cited by Dr Anon and colleagues. For example, we were unable to confirm the actual diagnosis of acute bacterial sinusitis and therefore patients included in our study may not have had this diagnosis. However, it is common in clinical practice to initiate antimicrobial therapy for presumed sinusitis without confirmation from radiological or microbiological studies. Time to resolution of symptoms is but one of many reasonable outcomes to select for the definition of treatment response in sinusitis. We selected the absence of a claim for a second antibiotic within 28 days as our primary outcome measure. This outcome is clinically reasonable and has been used in other studies using pharmacy and administrative databases.1 We agree that the failure to define severity of disease was a limitation of our study. However, given the particular subset of patients with sinusitis in our study, we believe this was a minor limitation. For example, the Sinus and Allergy Health Partnership (SAHP)2 antibiotic treatment guidelines for patients similar to ours—those with acute sinusitis and no antibiotic use in the prior 4 to 6 weeks—make no distinction in recommended antibiotics based on symptom severity. The SAHP-recommended antibiotics are amoxicillin, amoxicillin/clavulanate potassium, cefpodoxime proxetil, and cefuroxime axetil.

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Figure. Relationship Between Success Rates and Direct Charges for Commonly Prescribed Antibiotics for Acute Uncomplicated Sinusitis
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