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correspondence

tioners Aetna Health Inc. et al., 2002 U.S. Briefs No. 02-1845, p. 27, note 13. 3. Brief for the United States as amicus curiae supporting petitioners Aetna Health Inc. et al., 2002 U.S. Briefs No. 02-1845, p. 26.

dr. bloche replies: Erb and Rich are right to point

out that the question of managed-care liability is hardly settled and that the Supreme Court has issued varied rulings with respect to regulation of health plans. Over the past few years, for example, the Court has upheld state laws mandating independent review of denials of coverage and requiring insurers to include any willing provider in their networks. But the Courts decision last June, in Aetna v. Davila, to immunize employer-provided health plans against tort liability for wrongful denial of coverage is likely to stand for a long time. Congress could, in theory, nullify the decision by allowing patients to seek damage awards in state or federal court for the consequences of coverage that has been denied, but after last years election results, the chances of this happening are minimal. Alternatively, as Zinberg points out, federal courts could reinterpret ERISA, the labyrinthine statute that governs employment-based health coverage,

to permit federal suits against health plans for harm resulting from denial of coverage. But this would require a wholesale rewriting of existing case law, something judges are disinclined to do. A large body of federal-court decisions treats ERISA as precluding such suits. The Bush administrations brief in Aetna v. Davila did not propose that ERISA be reinterpreted to permit them. On the contrary, the administration has argued, in its Aetna v. Davila brief and elsewhere, that allowing damage suits against health plans would increase the cost of medical coverage and thereby discourage employers from offering it. To be sure, a footnote in the brief alludes vaguely to the possibility that ERISA allows at least some forms of make whole relief against plan administrators. Justices Ruth Bader Ginsburg and Stephen Breyer (in a concurring opinion in Aetna v. Davila) encouraged future plaintiffs to pursue this prospect. But a Supreme Court majority in support of this view and in favor of healthplan liability for the consequences of care that has been denied is unlikely in the foreseeable future. M. Gregg Bloche, M.D., J.D.
Georgetown University Law Center Washington, DC 20001

Sinusitis
to the editor: Piccirillo (Aug. 26 issue)1 recom- al agents5 for example, by not treating mild cas-

mends that acute bacterial sinusitis be treated with 500 mg of amoxicillin three times daily. Pneumococcus is an important cause of this condition and, at present, 40 percent of pneumococci in the United States have reduced susceptibility to penicillin.2 This reduced susceptibility has prompted physicians to recommend amoxicillin, 90 mg per kilogram of body weight per day in divided doses, to treat otitis media,3 and daily doses of amoxicillin ranging from 1.5 to 4 g daily for treating acute bacterial sinusitis in adults.4 For sinusitis, the lower dosage is recommended in geographic areas with a low prevalence of antibiotic-resistant pneumococci, and for patients with mild disease.4 However, almost no area in the United States has less than 25 percent resistance among pneumococci.2 Given the high rate of spontaneous resolution of symptoms associated with sinusitis, on the one hand, and the cost (financial and otherwise) of failed therapy, on the other, it seems reasonable to be conservative about deciding to use antimicrobi-

es, but then prescribing higher doses of amoxicillin, such as 1 g three to four times daily, if one chooses to treat. Daniel Musher, M.D.
Veterans Affairs Medical Center Houston, TX 77030 daniel.musher@med.va.gov

Rebecca Musher Gross, M.D.


Potomac Physician Associates Kensington, MD 20895
1. Piccirillo JF. Acute bacterial sinusitis. N Engl J Med 2004;351:

902-10.
2. Gordon KA, Biedenbach DJ, Jones RN. Comparison of Strepto-

coccus pneumoniae and Haemophilus influenzae susceptibilities from community-acquired respiratory tract infections and hospitalized patients with pneumonia: five-year results for the SENTRY Antimicrobial Surveillance Program. Diagn Microbiol Infect Dis 2003; 46:285-9. 3. Dowell SF, Butler JC, Giebink GS, et al. Acute otitis media: management and surveillance in an era of pneumococcal resistance a report from the Drug-resistant Streptococcus pneumoniae Therapeutic Working Group. Pediatr Infect Dis J 1999;18:1-9. [Erratum, Pediatr Infect Dis J 1999;18:341.] 4. Anon JB, Jacobs MR, Poole MD, et al. Antimicrobial treatment

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guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2004;130:Suppl:1-45. [Erratum, Otolaryngol Head Neck Surg 2004;130:794-6.] 5. Snow V, Mottur-Pilson C, Hickner JM. Principles of appropriate antibiotic use for acute sinusitis in adults. Ann Intern Med 2001; 134:495-7.

2. American Academy of Pediatrics, Subcommittee on Manage-

ment of Sinusitis. Clinical practice guideline: management of sinusitis. Pediatrics 2001;108:798-808. [Errata, Pediatrics 2001;108:A24, 2002;109:40.]

dr. piccirillo replies: I appreciate the comments to the editor: Piccirillos recommendations for

antibiotic treatment for bacterial sinusitis are not based on appropriate methods or current microbiologic data and are not consistent with recent guidelines.1,2 Many of the studies cited to support his recommendations were of small patient populations and were published before resistance developed in the bacterial pathogens. The current guidelines of the Sinus and Allergy Health Partnership1 do not support the use of doxycycline and trimethoprimsulfamethoxazole as reasonable first-line options, nor do they support some of the recommended antibiotic agents for patients who have not improved after 72 hours; respiratory fluoroquinolones and high-dose amoxicillinclavulanate are appropriate, but azithromycin is considered a poor choice for second-line treatment because of the intrinsic resistance of Haemophilus influenzae and the 30 percent rate of resistance in Streptococcus pneumoniae.1 Contemporary recommendations for antibiotic use in bacterial rhinosinusitis should be based on the probability of bacterial disease, the susceptibility of pathogens, the spontaneous-resolution rates, the risk-to-benefit ratios of various antimicrobial agents against the prevalent organisms, and pharmacokinetic and pharmacodynamic principles.2 Jack B. Anon, M.D.
University of Pittsburgh School of Medicine Erie, PA 16508 janonmd@velocity.net

Michael D. Poole, M.D., Ph.D.


University of Texas at Houston Medical School Houston, TX 77030

Michael R. Jacobs, M.D., Ph.D.


Case Western Reserve Medical School Cleveland, OH 44106 Dr. Anon reports having served on the speakers bureau for Bayer and GlaxoSmithKline. Dr. Poole reports having served as a consultant for Bayer, Bristol-Myers Squibb, GlaxoSmithKline, Pfizer, and OrthoMcNeil. Dr. Jacobs reports having served as a consultant for Bayer, having received research grants from Abbott Laboratories, Bayer, Bristol-Myers Squibb, GlaxoSmithKline, Ortho-McNeil, and Pfizer, and having served on a speakers bureau for Bayer, GlaxoSmithKline, and Ortho-McNeil.
1. Anon JB, Jacobs MR, Poole MD, et al. Antimicrobial treatment

of Drs. Musher and Gross regarding the use of higher doses of amoxicillin when choosing to treat acute bacterial sinusitis. It should be noted that telithromycin (Ketek) was approved by the Food and Drug Administration (FDA) for the treatment of acute bacterial rhinosinusitis in April 2004 and was widely available by August 1, 2004. I disagree with Dr. Anon and colleagues that the recommendations in my Clinical Practice article were not based on appropriate methods or current microbiologic data and were not consistent with recently developed guidelines.1,2 In preparation for this review, a thorough search of the published medical literature was performed and all relevant articles of sufficient methodologic quality were evaluated. Antibiotic recommendations were obtained from the FDA, the Centers for Disease Control and Prevention (CDC), the Cochrane Database, and the Clinical Practice Guidelines of the American College of Physicians (ACP). The ACP guidelines were endorsed by the CDC, the American Academy of Family Physicians, the American College of PhysiciansAmerican Society of Internal Medicine, and the Infectious Diseases Society of America. The Sinus and Allergy Health Partnership1 is supported by generous contributions from several pharmaceutical companies, as detailed on its Web site (www.sahp.org/sponsorship.html). As a result, I elected not to include recommendations based on its guidelines. The guidelines developed by the Subcommittee on Management of Sinusitis and Committee on Quality Improvement of the American Academy of Pediatrics2 were developed for patients from 1 to 21 years of age. I did not include these guidelines because I do not think they are generalizable to adults. Jay F. Piccirillo, M.D.
Washington University School of Medicine St. Louis, MO 63110 piccirij@msnotes.wustl.edu
1. Anon JB, Jacobs MR, Poole MD, et al. Antimicrobial treatment

guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2004;130:Suppl:1-45. [Erratum, Otolaryngol Head Neck Surg 2004;130:794-6.]

guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2004;130:Suppl:1-45. [Erratum, Otolaryngol Head Neck Surg 2004;130:794-6.] 2. American Academy of Pediatrics, Subcommittee on Management of Sinusitis. Clinical practice guideline: management of sinusitis. Pediatrics 2001;108:798-808. [Errata, Pediatrics 2001;108: A24, 2002;109:40.]
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