Recommended mx for acute sinusitis in primary care, including when to prescribe

Recommended management for acute sinusitis in primary care:

• Most cases of acute sinusitis are viral and self-limiting, resolving within 12 weeks without antibiotics. Advise patients that bacterial sinusitis is usually self-limiting and does not routinely require antibiotics.
• Offer symptomatic treatment with paracetamol or ibuprofen for pain or fever relief.
• Consider nasal saline irrigation or nasal decongestants for nasal congestion, although evidence for their effectiveness is limited.
• For adults and children aged 12 years and over, a high-dose nasal corticosteroid (e.g., mometasone 200 micrograms twice daily for 14 days) may be considered to improve symptoms, but it is unlikely to shorten illness duration.
• Do not routinely prescribe oral corticosteroids, oral decongestants, antihistamines, mucolytics, steam inhalation, or warm face packs as these are not recommended due to lack of evidence of benefit.
• Antibiotic prescribing guidance:
• Do not routinely prescribe antibiotics for acute sinusitis.
• Consider a back-up (delayed) antibiotic prescription if symptoms persist beyond 10 days, or if there is a marked deterioration after an initial milder phase ("double sickening"), or if symptoms are severe (e.g., fever >38°C, severe localized unilateral pain, discoloured or purulent nasal discharge).
• Immediate antibiotic prescription is reserved for patients who are systemically very unwell, have signs of a more serious illness, or are at high risk of complications due to comorbidities or immunosuppression.
• If antibiotics are indicated in adults, phenoxymethylpenicillin 500 mg four times daily for 5 days is the first-line treatment.
• Advise patients given a back-up antibiotic to start it only if symptoms do not improve within 7 days or worsen rapidly or significantly at any time.
• Reassess patients if symptoms worsen rapidly or significantly despite treatment, considering alternative diagnoses and referral to specialists if needed.

Provide written advice and safety-netting information, including when to seek further medical help if symptoms worsen or do not improve after 3 weeks.

This approach balances effective symptom management with antimicrobial stewardship to reduce unnecessary antibiotic use and adverse effects.

References: NICE CKS,NICE NG15