To the Editor: Rather than represent a lack of antimicrobial efficacy, the null results reported by Dr Williamson and colleagues1 in their trial of antibiotics and topical nasal steroid for treatment of acute maxillary sinusitis more likely stem from inappropriate use of diagnostic criteria proposed by Berg and Carenfelt2 in a sample for which they were never intended.
Of the patients in the study by Berg and Carenfelt, 100% presented to an emergency department compared with 0% for Williamson et al (all were primary care); 25% had symptoms for 3 weeks to 3 months compared with a median of 7 days (maximum, 28 days) for Williamson et al; and 20% had used antibiotics in the past 2 weeks compared with 0% (none in the past month) for Williamson et al. The study by Berg and Carenfelt did not exclude patients with recurrent sinusitis, but potential participants with 2 or more episodes in the prior 12 months were excluded by Williamson et al.
In the study by Berg and Carenfelt, 2 of 4 diagnostic criteria were present in only 10 of 68 participants with sinusitis (15%) compared with 159 of 233 (68%) for Williamson et al. Based on antral puncture, the positive predictive value of 2 of 4 criteria was 10 of 20 participants2 (50%; 95% confidence interval, 27%-73%). Applied to the patients with less severe illness seen in the study of Williamson et al, the positive predictive value would be even lower: likely no better than 50% or potentially worse based on the lower limit of the 95% confidence interval.
These considerations make the current study more relevant to managing acute purulent rhinitis, not maxillary sinusitis as suggested in the title. For example, a patient with 3 days of purulent rhinitis (first criterion) with pus in the nasal cavity (second criterion) would qualify as “acute maxillary sinusitis.” However, purulent rhinitis should not be the preeminent diagnostic factor for presumed bacterial illness because it is most often associated with viral infection.3 - 4 Rather, it is one of several cardinal symptoms that are combined with illness duration and temporal pattern to increase diagnostic certainty.5
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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