To the Editor.

The case-control study by Zerr et al is an attempt to ascertain whether an outbreak of necrotizing fasciitis (NF) among children with primary varicella was linked to ibuprofen use. The authors concluded that there was an association, requiring additional studies to determine whether the association was causal. The authors attempted to control for biases to which case-control studies are susceptible, but some may have occurred.

All but 2 of the 9 cases who were administered ibuprofen used itafter the onset of symptoms of the secondary infection. Thus, ibuprofen could not have caused the infection; rather, the symptoms associated with the infection probably resulted in the ibuprofen use. Furthermore, the authors acknowledge that ibuprofen may have been more likely used as a result of a serious secondary infection. Because the serious infection is a predictor of NF, the resulting association of ibuprofen with NF is spurious....

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