Reply to “Acute Sinusitis and Pharyngitis as Inappropriate Indications for Antibiotic Use”

REPLY

We thank Drs. Sanchez and Hicks for their constructive comments, which underscore current limitations of diagnostic coding data (1, 2). While we were not able to determine with certainty if patients were immunocompromised, we excluded any patient admitted to the hospital, which likely eliminated many immunocompromised patients as well as those with more-complex medical conditions.

We also agree that misclassification may have occurred with some diagnoses, such as sinusitis or pharyngitis. However, we focused on more conservative definitions to ascertain the clearer instances of inappropriate antibiotic prescribing in U.S. emergency departments (3). Several factors limit our ability to determine the appropriateness of antibiotic utilization. First, it is unclear how frequently ED physicians adhere to antimicrobial guidelines for acute respiratory tract infections, such as those specified by the Infectious Diseases Society of America (4). Second, the National Hospital Ambulatory Medical Care Survey does not contain information to clearly indicate patient disease severity, duration of symptoms, or diagnostic measures. Such granularity would certainly help to better identify “antibiotic-appropriate” infections. These are intriguing topics in need of further investigation.