Guidance

Recommendations

Recommendations

1.1 Managing acute sinusitis

People presenting with symptoms for around 10 days or less

1.1.1

Do not offer an antibiotic prescription.

1.1.2

Give advice about:

  • the usual course of acute sinusitis (2 to 3 weeks)

  • an antibiotic not being needed

  • managing symptoms, including fever, with self-care (see the recommendations on self-care)

  • seeking medical help if symptoms worsen rapidly or significantly, do not improve after 3 weeks, or they become systemically very unwell.

1.1.3

Reassess if symptoms worsen rapidly or significantly, taking account of:

  • alternative diagnoses such as a dental infection

  • any symptoms or signs suggesting a more serious illness or condition.

See symptoms and signs of acute sinusitis and the evidence and committee discussion on no antibiotic.

People presenting with symptoms for around 10 days or more with no improvement

1.1.4

Consider prescribing a high-dose nasal corticosteroid for 14 days for adults and children aged 12 years and over, being aware that nasal corticosteroids:

  • may improve symptoms but are not likely to affect how long they last

  • could cause systemic effects, particularly in people already taking another corticosteroid

  • may be difficult for people to use correctly.

    High-dose nasal corticosteroids used in the studies were mometasone 200 micrograms twice a day and fluticasone 110 micrograms twice a day. This is an off-label use of nasal corticosteroids See NICE's information on prescribing medicines.

    See the evidence and committee discussion on nasal corticosteroids.

1.1.5

Consider no antibiotic prescription or a back-up antibiotic prescription (see the recommendations on choice of antibiotic), taking account of:

  • evidence that antibiotics make little difference to how long symptoms last, or the proportion of people with improved symptoms

  • withholding antibiotics is unlikely to lead to complications

  • possible adverse effects, particularly diarrhoea and nausea

  • factors that might make a bacterial cause more likely (see symptoms and signs).

1.1.6

When a back-up antibiotic prescription is given, give verbal and written advice about:

  • managing symptoms, including fever, with self-care (see the recommendations on self-care)

  • an antibiotic not being needed immediately

  • using the back-up prescription if symptoms do not improve within 7 days or if they worsen rapidly or significantly at any time

  • seeking medical help if symptoms worsen rapidly or significantly despite taking the antibiotic, or the antibiotic has been stopped because it was not tolerated.

1.1.7

Reassess if symptoms worsen rapidly or significantly despite taking treatment, taking account of:

  • alternative diagnoses such as a dental infection

  • any signs or symptoms suggesting a more serious illness or condition

  • previous antibiotic use, which may lead to resistant organisms.

See the evidence and committee discussion on back-up antibiotics.

People 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

1.1.9

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)

  • intraorbital 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.

See the evidence and committee discussion on choice of antibiotic.

1.2 Choice of antibiotic

1.2.1

When prescribing antibiotics for acute sinusitis:

  • follow the recommendations in table 1 for adults aged 18 years and over

  • follow the recommendations in table 2 for children and young people under 18 years.

Table 1 Antibiotics for adults aged 18 years and over
Treatment Antibiotic, dosage and course length

First-choice oral antibiotic

Phenoxymethylpenicillin:

500 mg four times a day for 5 days

First choice if systemically very unwell, symptoms and signs of a more serious illness or condition, or at high risk of complications

Co‑amoxiclav:

500/125 mg three times a day for 5 days

Alternative first choices for penicillin allergy or intolerance (for people who are not pregnant)

Doxycycline:

200 mg on first day, then 100 mg once a day for 4 days (5-day course in total)

Clarithromycin:

500 mg twice a day for 5 days

Alternative first choice for penicillin allergy in pregnancy

Erythromycin:

250 mg to 500 mg four times a day or 500 mg to 1,000 mg twice a day for 5 days

Erythromycin is preferred if a macrolide is needed in pregnancy, for example, if there is true penicillin allergy and the benefits of antibiotic treatment outweigh the harms. See the Medicines and Healthcare products Regulatory Agency (MHRA) Public Assessment Report on the safety of macrolide antibiotics in pregnancy.

Second-choice oral antibiotic (worsening symptoms on first choice taken for at least 2 to 3 days)

Co‑amoxiclav:

500/125 mg three times a day for 5 days

Alternative second choice for penicillin allergy or intolerance, or worsening symptoms on second choice taken for at least 2 to 3 days

Consult a local microbiologist

See the BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breast-feeding.

If co‑amoxiclav has been used first choice, consult a local microbiologist for advice on second choice.

Table 2 Antibiotics for children and young people under 18 years
Treatment Antibiotic, dosage and course length

First-choice oral antibiotic

Phenoxymethylpenicillin:

1 months to 11 months, 62.5 mg four times a day for 5 days

1 year to 5 years, 125 mg four times a day for 5 days

6 years to 11 years, 250 mg four times a day for 5 days

12 years to 17 years, 500 mg four times a day for 5 days

First choice if systemically very unwell, symptoms and signs of a more serious illness or condition, or at high risk of complications

Co‑amoxiclav:

1 month to 11 months, 0.25 ml/kg of 125/31 suspension three times a day for 5 days

1 year to 5 years, 5 ml of 125/31 suspension three times a day or 0.25 ml/kg of 125/31 suspension three times a day for 5 days

6 years to 11 years, 5 ml of 250/62 suspension three times a day or 0.15 ml/kg of 250/62 suspension three times a day for 5 days

12 years to 17 years, 250/125 mg three times a day or 500/125 mg three times a day for 5 days

Alternative first choices for penicillin allergy or intolerance (for people who are not pregnant)

Clarithromycin:

Under 8 kg, 7.5 mg/kg twice a day for 5 days

8 kg to 11 kg, 62.5 mg twice a day for 5 days

12 kg to 19 kg, 125 mg twice a day for 5 days

20 kg to 29 kg, 187.5 mg twice a day for 5 days

30 kg to 40 kg, 250 mg twice a day for 5 days

12 years to 17 years, 250 mg twice a day or 500 mg twice a day for 5 days

Doxycycline:

12 years to 17 years, 200 mg on first day, then 100 mg once a day for 4 days (5-day course in total)

Doxycycline is contraindicated in children under 12 years

Alternative first choice for penicillin allergy in pregnancy

Erythromycin:

8 years to 17 years, 250 mg to 500 mg four times a day or 500 mg to 1,000 mg twice a day for 5 days

Erythromycin is preferred if a macrolide is needed in pregnancy, for example, if there is true penicillin allergy and the benefits of antibiotic treatment outweigh the harms. See the Medicines and Healthcare products Regulatory Agency (MHRA) Public Assessment Report on the safety of macrolide antibiotics in pregnancy.

Second-choice oral antibiotic (worsening symptoms on first choice taken for at least 2 to 3 days)

Co-amoxiclav:

1 month to 11 months, 0.25 ml/kg of 125/31 suspension three times a day for 5 days

1 year to 5 years, 5 ml of 125/31 suspension three times a day or 0.25 ml/kg of 125/31 suspension three times a day for 5 days

6 years to 11 years, 5 ml of 250/62 suspension three times a day or 0.15 ml/kg of 250/62 suspension three times a day for 5 days

12 years to 17 years, 250/125 mg three times a day or 500/125 mg three times a day for 5 days

Alternative second choice for penicillin allergy or intolerance, or worsening symptoms on second choice taken for at least 2 to 3 days

Consult a local microbiologist

See the BNF for children for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment.

The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition being treated and the child's size in relation to the average size of children of the same age.

If co‑amoxiclav used as first choice, consult a local microbiologist for advice on second choice.

See the evidence and committee discussion on choice of antibiotic and antibiotic course length.

1.3 Self-care

1.3.1

Consider paracetamol or ibuprofen for pain or fever (assess and manage children aged under 5 who present with fever as outlined in the NICE guideline on fever in under 5s).

1.3.2

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.

1.3.3

Explain that no evidence was found for using oral decongestants, antihistamines, mucolytics, steam inhalation, or warm face packs.

See the evidence and committee discussion on self-care.