Sinusitis treatment down to five days

This is a NICE guideline from a couple of months ago in the use of antibiotics in sinusitis. I must say that this has changed my practice significantly, so well worth a read, especially the background information. Main learning points:

  • 1st line antibiotic is now penicillin.
  • Length of treatment is five days.
  • Only consider antibiotics after 10 days of symptoms and even then, most people will not need them.
  • A handy patient information leaflet can be found here, explaining why you are not prescribing them antibiotics.

Background Information

Only 2% of cases are bacterial and complications of sinusitis are rare (only about 4.3 per million per year!). Symptoms generally only last 2-3w, whether it is viral or bacterial and whether you use antibiotics or not.

The NNT (number needed to treat) for antibiotics to improve symptoms in 1 person is 7 - 21. The NNH (number needed to harm) is 8 to 11 and 18 for diarrhoea. Note that antibiotics have little effect on the duration of illness, only on symptom improvement.

Bacterial or viral?

These symptoms may make it more likely to be bacterial:

  • Symptoms more than 10 days.
  • Purulent nasal discharge.
  • Severe localised unilateral pain (especially over teeth or jaw).
  • Fever.
  • Marked deterioration after an initial milder phase.

Self-care advice

  • Paracetamol and ibuprofen.
  • Nasal saline or decongestants (however, there is not actually enough evidence to show that these reduce congestion, and in children the only study done suggests that they are not effective).
  • There is no evidence for the use of steam inhalation, warm face packs, oral decongestants, antihistamines or mucolytics. Beware that 'no evidence' here means that no studies have been done, not that these have been found to be ineffective...

Managing patients with symptoms of 10 days or less:

Do not offer antibiotics. Explain why as above. Safety net with advice to return if it has not settled by 3w, if they become unwell, or if symptoms worsen rapidly or significantly.

Managing patients with symptoms of 10 days or more if they are not improving.

Nasal steroids - consider these for 14d in adults and children over 12. They are unlikely to affect the duration of the illness.

Antibiotic - consider not prescribing (see the background info above). If you consider prescribing, do a delayed script. This should be used by the patient if their symptoms haven't improved after a further 7d, or if they worsen rapidly or significantly. In  the latter case, patients should also seek review. Note that there is no difference in the rate of complications between not prescribing, giving a delayed script and giving an immediate script.

Managing patients who are systemically very unwell or have a high risk of complications.

Give immediate antibiotics.

Refer immediately to hospital if there is concern about significant complications (e.g. orbital or intracranial complications) . I haven't listed all these here, but they are in the guideline if you want a refresher.

Choice of antibiotics

  • 1st line - phenoxymethylpenicillin QDS for 5d (if allergic then clarithromycin or doxycycline for 5d, and if pregnant then erythromycin for 5d).
  • 2nd line (i.e. worsening after 2-3d), or if systemically very unwell or if they are high risk of complications, then co-amoxiclav for 5d.
  • NB - don't use doxycycline in children under 12.

Why this choice? Studies suggest that penicillin is as effective as amoxicillin, but with less chance of resistance. It is worth noting that there is a risk of resistance to amoxicillin for 12m after it is used. Five days of treatment is as effective as longer courses, but with significantly fewer side-effects.


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