Acute Sinusitis (Adults) - delayed antibiotic strategy

Comments from Expert Advisory Committee

• Acute sinusitis usually follows a common cold, and symptoms for around 10 days or less are more likely to be associated with a cold rather than viral or bacterial acute sinusitis.
• Prolonged symptoms (for around 10 days or more with no improvement) could be due to either viral or bacterial acute sinusitis.
• Bacterial sinusitis is usually self-limiting and does not routinely need antibiotics. 80% resolve in 14 days without antibiotics and they only offer marginal benefit after 7 days.
• Consider high dose intranasal steroids.
• Consider self-care measures and a no antibiotic strategy for patients with symptoms < 10 days unless systemically very unwell.
• Consider a no antibiotic or delayed antibiotic prescription for symptoms > 10 days without clinical improvement.
• Offer an immediate antibiotic prescription for patients systemically very unwell, with signs of severe infection or high risk of complications.
• Refer to hospital if symptoms of sinusitis with a severe systemic infection, intraorbital or periorbital complications.
• Reassess if symptoms worsen rapidly or significantly despite taking treatment.

Bacterial cause may be more likely if several of the following are present:

• Symptoms for more than 10 days
• Discoloured or purulent nasal discharge
• Severe localised unilateral pain (particularly pain over teeth and jaw)
• Fever
• Marked deterioration after an initial milder phase

Symptom relief:

• For pain or fever, consider paracetamol (or ibuprofen where appropriate).
• Little evidence of benefit but patients may wish to try systemic decongestants, topical decongestants or saline preparations for local irrigation (e.g. nasal rinses, sprays, drops).
• Advise to consult pharmacist for symptom relief.

Treatment

* Alternative doxycycline dose: 100mg every 12 hours. 
In non-severe infection, 200mg stat then 100mg every 24 hours can be considered.

Patient Information

We recommend patients use the website developed by HSE/ICGP/IPU partnership www.undertheweather.ie for tips on how to get better from common infections without using antibiotics, what you can do for yourself or a loved one and when to seek help.

Safe Prescribing (visit the safe prescribing page)

• Doses are oral and for adults unless otherwise stated
• Clarithromycin and other macrolides warning
• Penicillin allergy – tips on prescribing in penicillin allergy
• Renal impairment dosing table
• Safety in Pregnancy and Lactation
• Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
• Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed October 2021