NICE publishes guidance on prescribing for acute sinusitis
NICE has published final guidance on antimicrobial prescribing for acute sinusitis (NG79). The guideline, developed in partnership with Public Health England, is one of NICE’s new series of antimicrobial prescribing guidelines covering the management of common infections; other guidelines in development include acute sore throat, acute otitis media and lower urinary tract infections.
The guideline emphasises that antibiotics are not needed to treat the majority of acute sinus infections (which are usually viral); the condition is usually self-limiting and most people with sinusitis will start to feel better without antibiotic treatment within two to three weeks. Complications are rare (2.5 to 4.3 per million people per year) and withholding antibiotics is unlikely to lead to complications, adds NICE.
In people presenting with symptoms for around 10 days or less, an antibiotic prescription should not be offered, but instead the patient should be given advice on self-managing symptoms, including pain and fever, with paracetamol or ibuprofen. Nasal saline or nasal decongestants can be tried, although there is little evidence to show that they are effective. There is no evidence that oral decongestants, antihistamines, mucolytics or steam inhalation are effective in the management of acute sinusitis. Patients should seek medical help if symptoms worsen rapidly or do not improve after three weeks, or if they become systemically very unwell.
In patients who have had symptoms for about 10 days or more with no improvement, a two-week course of a high-dose nasal corticosteroid can be tried (if over the age of 12 years), or a back-up antibiotic prescription considered, together with advice on using it if symptoms rapidly worsen or do not improve within seven days.
An immediate antibiotic prescription (or further investigation) should still be offered to patients who are systemically very unwell or who show symptoms of a more serious condition. Phenoxymethylpenicillin should be the antibiotic of first choice, or co-amoxiclav for patients who are very unwell or at high risk of complications. For those with penicillin allergy, doxycycline or clarithromycin are the antibiotics of choice. A five-day course should be sufficient for efficacy while minimising the risk of resistance.
NICE cites evidence showing that antibiotics are currently given to 91% of people who visit their GP with symptoms of sinusitis, despite the fact that taking antibiotics for viral conditions is known to fuel resistance.