Are amoxycillin and folate inhibitors as effective as other antibiotics for acute sinusitis? A meta-analysis
BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7159.632 (Published 05 September 1998) Cite this as: BMJ 1998;317:632All rapid responses
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In the interest of applying science to practical medicine, could we
all PLEASE stop using relative risk/odds ratios to present data. I would
love to see the absolute risks, absolute risk reductions and numbers
needed to treat for antibiotics versus placebo in acute sinusitis in your
data set. Also, the lack of defined inclusion criteria for patients,
whether there is heterogeneity or not, does severely limit the
applicability of the results to clinical practice. It would also be
interesting to see side effects in antibiotics versus placebo (i.e. for
any patients that got better with antibiotics, how many felt worse?), and
were there any differences in more serious complications (meningitis,
periorbital cellulitis), if in fact they are related...
YS
Competing interests: No competing interests
de Ferranti et al 1 conclude that because
of a lack of statistical heterogeneity a pooled risk ratio of clinical
failure is the best estimate of the effectiveness of antibiotics in acute
sinusitis. In fact the statistical test they used to evaluate the
hypothesis of homogeneity, with a P<_0.1 xmlns:antibiotics="urn:x-prefix:antibiotics" to="to" indicate="indicate" significance="significance" has="has" a="a" very="very" low="low" power="power" reveal="reveal" statistical="statistical" heterogeneity2.="heterogeneity2." as="as" many="many" authors="authors" stated="stated" before="before" testing="testing" for="for" high="high" degree="degree" of="of" heterogeneity="heterogeneity" is="is" necessary="necessary" criterion="criterion" but="but" not="not" sufficient="sufficient" assessing="assessing" the="the" clinical="clinical" importance="importance" differences="differences" in="in" inclusion="inclusion" criteria="criteria" and="and" methodology3.="methodology3." six="six" included="included" placebo="placebo" controlled="controlled" randomized="randomized" trials="trials" showed="showed" important="important" heterogeneity.="heterogeneity." particular="particular" concerning="concerning" setting="setting" studies="studies" extent="extent" disease="disease" patients="patients" diagnosis="diagnosis" sinusitis="sinusitis" duration="duration" therapy.="therapy." these="these" incorporate="incorporate" more="more" than="than" only="only" difference="difference" prior="prior" chance="chance" or="or" prevalence="prevalence" acute="acute" sinusitis.="sinusitis." severity="severity" may="may" affect="affect" ability="ability" antibiotics="antibiotics" improve="improve" symptoms.="symptoms." therapy="therapy" antibiotics:_="antibiotics:_" symptoms="symptoms" within="within" _48="_48" hours="hours" after="after" end="end" pooled="pooled" estimate="estimate" risk="risk" ratio="ratio" failure="failure" therefore="therefore" tries="tries" create="create" apple-oranges5.="apple-oranges5." our="our" opinion="opinion" conclusion="conclusion" this="this" analysis="analysis" should="should" be="be" that="that" evidence="evidence" effectiveness="effectiveness" sparse="sparse" even="even" rather="rather" doubtful="doubtful" were="were" defined="defined" by="by" alone="alone" general="general" practitioner.="practitioner." p="p"/> Marjolein Y Berger General practitioner, Research fellow
Roos Bernsen Research fellow
Department of General Practice, Room Fe315 Erasmus University Rotterdam,
P.O. Box 1738, 3000 DR Rotterdam The Netherlands.
1 De Ferranti SD, Ioannidis PA, Lau J, Anninger V, Barza M. Are
amoxycillin and folate inhibitors as effective as other antibiotics for
acute sinusitis? A meta-analysis.BMJ, 1998;317:632-36.
2 Van Houwelingen HC. Meta-analysis; methods, limitations and
applications. Biocybernetics Biomed Eng 1995;15:53-61.
3 Naylor CD. Meta-analysis and the meta-epidemiology of clinical
research. BMJ 1997;315:617-19.
4 Greenhalgh T, Commentary: Meta-analysis is a blunt and potentially
misleading instrument for analysing models of service delivery. BMJ
1998;317:390.
Competing interests: No competing interests
Antibiotics for acute sinusitis in general practice
The paper "Meta-analysis on antibiotics in acute sinusitis?" in a
section headed 'General Practice'1 could be criticised in many ways. This
paper is presumably aimed at general practitioners in the United Kingdom
to guide them in their use or non-use of antibiotics in patients with
acute sinusitus. The authors rightly try and answer this by first looking
at the RCT's on the effectiveness of antibiotics against non-antibiotic
management and carried out a meta-analysis in the six placebo controlled
trials they identified. By doing so it is implied that the patients being
randomised were similar in each of the six studies to allow a meta-
analysis to be performed. This is not the case. One of the papers (Wald
et al, 1986) treated children, and cannot be combined with the other five
papers that are adult studies. Table 1 shows the clinical settings and
the entry criterion for the other five studies. In looking at this, a
reader has to identify which study is applicable to their own clinical
setting. The first study required a positive diagnostic irrigation, the
second a positive bacteriological culture, the third a positive CT scan,
and the fourth a positive straight X-ray for a patient to be included.
The entry criterion in these four studies are thus grossly different and
invalidate them being combined. The fifth study was the only one that had
clearly defined symptomatic entry criteria that a reader could apply to
their own practice and did not rely on investigation, which is likely to
be the case in the majority of British primary care centres. The title of
this paper2 embodies the most usual situation that general practitioners
face 'adults with acute sinusitus-like complaints'. This study showed no
effect of antibiotic (deoxycycline) versus placebo on the mean day of
resolution of facial pain, and resumption of daily activities in 192
randomised patients. Though a power analysis is not reported to have been
performed to exclude a type I error, the number of patients in this study
is sufficiently large to exclude a clinically material difference. Hence
this RCT should be the main evidence on which most general practitioners
should base their practice until other studies in similar situations show
otherwise - that antibiotics have no effect in 'adults with acute
sinusitus-like complaints'. A meta-analysis of which antibiotic is best
in acute sinusitus is thus made redundant and the rest of the paper
irrelevant.
Browning GG, Professor of Otolaryngology and Hear & Neck Surgery,
University of Glasgow, Royal Infirmary, Glasgow G31 2ER
1. de Ferranti SD, Ioannidis JPA, Lau J, Anninger WV, Barza M. Are
amoxycillin and folate inhibitors as effective as other antibiotics for
acute sinusitis? A meta-analysis. BMJ 1998;317:632-7
2. Stalman W, van Essen GA, van der Graaf Y, de Melker RA. The end
of antibiotic treatment in adults with acute sinusitis-like complaints in
general practice? A placebo-controlled double-blind randomixed
doxycycline trial. Br J Gen Pract 1997;47:794-9
Table
Competing interests: No competing interests