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a sinusitis imageOctober 30 2017

Patients with acute sinusitis should be advised the condition will normally clear up without antibiotics, NICE has said. In addition, its new guidelines say there is little evidence to support the use of decongestants.

NICE guideline NG79 sets out recommendations on antimicrobial prescribing for acute sinusitis. It notes that “acute sinusitis is usually caused by a virus, lasts for about two to three weeks, and most people get better without antibiotics. Withholding antibiotics rarely leads to complications.”

It estimates only 2% of cases are complicated by a bacterial infection, and that “complications of acute sinusitis are rare,” affecting about 2.5 to 4.3 per million people per year.

The guidelines covers three aspects:

  • managing symptoms, including advice when an antibiotic is not needed and the use of corticosteroids and nasal sprays;
  • choice of antibiotic when a back-up or immediate prescription is needed;
  • self-care.

Recommendation 1.1.1. states: “Do not offer an antibiotic prescription.” Instead, the guidelines say the patients presenting within the first 10 days of symptoms starting should be told about the likely 2-3 week course of the infection, how to manage symptoms and when to seek further advice if the infection is not clearing.

For those presenting with symptoms that have lasted longer than 10 days, and with no signs of improvement, options include to consider nasal corticosteroids, not to consider an antibiotic at that point, or to issue a back-up antibiotic prescription but with very clear advice about self-care and when or if the prescription should be dispensed.

However, the guidance also considers patients “presenting at any time who are systemically very unwell, have symptoms and signs of a more serious illness or condition, or are at high risk of complications.” In such cases, Recommendation 1.1.8 states: “Offer an immediate antibiotic prescription (see the recommendations on choice of antibiotic) or further appropriate investigation and management in line with the NICE guideline on respiratory tract infections (self-limiting): prescribing antibiotics.” NG79 includes a table of antibiotics and prescribing conditions.

It may also be necessary to refer people to hospital, “if they have symptoms and signs of acute sinusitis associated with any of the following:

  • a severe systemic infection (see the NICE guideline on sepsis);
  • intra-orbital or periorbital complications, including periorbital oedema or cellulitis, a displaced eyeball, double vision, ophthalmoplegia, or newly reduced visual acuity;
  • intracranial complications, including swelling over the frontal bone, symptoms or signs of meningitis, severe frontal headache, or focal neurological signs.”

Self-care options include to consider paracetamol or ibuprofen for pain or fever. Health professionals should “explain that some people may wish to try nasal saline or nasal decongestants, although there is not enough evidence to show that they help to relieve nasal congestion.”

In addition, they should “explain that no evidence was found for using oral decongestants, antihistamines, mucolytics, steam inhalation, or warm face packs.”

Links:
NICE announcement     
NICE NG79 ‘Sinusitis (acute): antimicrobial prescribing’

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