Use of antibiotics

NICE advises that bacterial sinusitis is usually self-limiting and does not routinely need antibiotics. 

A recently updated systematic Cochrane Review indicated only a small benefit from antibiotics even in acute sinusitis that had lasted for longer than seven days. The NNT was 15 for one additional person with acute sinusitis to be ‘cured’ with antibiotics, based on a meta-analysis. 

NICE says that antibiotics may be recommended if:

• Symptoms of sinusitis persist for more than 10 days
• Symptoms are severe with fever (>38˚C)
• There is severe local pain
• Discoloured or purulent nasal discharge
• There is marked deterioration after an initial milder form of the illness (double sickening).

NICE states that: “An immediate antibiotic prescription is not recommended unless people are systemically very unwell, have symptoms and signs of a more serious illness, or are at high risk of serious complications because of pre-existing comorbidity.” 

Where an antibiotic is recommended, NICE advises penicillin is used as first-line unless there is a reported penicillin allergy via the NHS National Care record or stated by the patient/carer. 

Under the Pharmacy First scheme, antibiotics via a PGD can be provided by pharmacists where there are still persistent symptoms despite the use of a high dose nasal corticosteroid for 14 days, or if high dose nasal corticosteroids are unsuitable.

The antibiotics available to pharmacists to provide via a PGD are penicillin-V (first-line), with clarithromycin or doxycycline, or erythromycin in pregnancy, if the patient has penicillin allergy. 

The main contraindication is allergy/hypersensitivity to the antibiotic – usually penicillin. Those with a known allergy to phenoxymethylpenicillin (penicillin-V) or any penicillin, or a history of severe immediate allergic reaction (e.g. anaphylaxis) to another beta-lactam antibiotic (e.g. a cephalosporin, carbapenem or monobactam) must not be prescribed penicillin-V. 

Remote consultations

Remote consultations are permitted in the Pharmacy First service in England for sinusitis but there is a view that where an antibiotic might be prescribed, a remote consultation should only be carried out in exceptional circumstances.