Pharmacy First: Acute Sinusitis

About this service

Acute sinusitis (rhinosinusitis) is one of the seven conditions covered by the NHS Pharmacy First service. Unlike the sore throat pathway, there is no single scoring tool. Assessment is based on symptom pattern, duration, and the presence of features that increase the likelihood of bacterial rather than viral infection.

The large majority of sinusitis presentations are viral and most cases resolve spontaneously within 2 to 3 weeks without antibiotics. The Pharmacy First pathway allows pharmacists to supply antibiotics where specific clinical criteria are met, or to supply a high-dose nasal corticosteroid (off-label, where permitted under the current Pharmacy First PGD) as a first step where the criteria for antibiotics are not yet met but symptoms are significant.

This article covers the inclusion and exclusion criteria, the two clinical pathways to antibiotic supply, antibiotic choice, and the key pitfalls identified in Pharmacy First audits for sinusitis.

Who to offer the service to

Include

• Aged 12 years and over
• Signs and symptoms consistent with acute sinusitis (see assessment criteria below)
• Symptom duration of more than 10 days with no improvement (note: exactly 10 days does not qualify)
• OR presence of 2 or more features suggesting bacterial infection (see features table below)
• OR persistent symptoms despite high-dose nasal corticosteroid for 14 days, or nasal corticosteroid unsuitable
• NHS eligibility requirements apply

Exclude

• Under 12 years old: outside the Pharmacy First pathway. Refer appropriately.
• Pregnancy under 16: excluded from all sinusitis PGDs. For pregnant individuals aged 16 and over, an erythromycin PGD is available. Follow the current Pharmacy First sinusitis PGD.
• Breastfeeding: phenoxymethylpenicillin and clarithromycin may be used with monitoring (see PGD cautions). Doxycycline is excluded in breastfeeding.
• Severely immunocompromised: refer to GP same day
• Recurrent sinusitis (4 or more annual episodes without persistent symptoms in the intervening periods): refer to GP
• Chronic sinusitis (symptoms lasting more than 12 weeks): refer to GP
• Nasal polyps, nasal trauma, epistaxis, or foreign body in nasal passage: refer to GP
• Suspected allergic or immunological cause of sinusitis: refer to GP
• Suspected cancer (unilateral polyp or mass, bloody nasal discharge, persistent unilateral symptoms): refer urgently to GP
• Orbital or intracranial complications present: refer to A&E urgently (see red flags)
• Sepsis suspected: call 999
• Failed previous antibiotic for this episode of sinusitis: refer to GP

How to deliver the service

1. Confirm eligibility and check for red flags first Before taking a history, confirm the patient is aged 12 or over and screen for red flags. Orbital complications (eye swelling or redness, displaced eyeball, double vision, visual changes) and signs of intracranial spread (severe frontal headache, neck stiffness, swelling over the forehead) require urgent referral to A&E. Sepsis signs require 999. Do not proceed with a Pharmacy First assessment if any red flag is present.
2. Establish the symptom pattern and duration Ask about onset, duration, and whether symptoms have improved, stayed the same, or worsened. The key thresholds are: more than 10 days with no improvement (exact 10 days does not qualify), or the presence of 2 or more bacterial features. Ask specifically about double-sickening (initial mild illness followed by distinct worsening), fever above 38 degrees Celsius, purulent nasal discharge, and unilateral jaw or tooth pain.
3. Check exclusion criteria Ask about previous sinusitis episodes this year (4 or more annual episodes indicates recurrent sinusitis: refer to GP), symptom duration (more than 12 weeks indicates chronic sinusitis: refer to GP), nasal polyps, trauma, or epistaxis. Check for pregnancy or breastfeeding and apply the relevant PGD. Check for severely immunocompromising conditions.
4. Check for drug interactions before selecting antibiotic Before supplying phenoxymethylpenicillin, check for methotrexate and probenecid (significant interactions: must not be supplied under this PGD. Refer to prescriber). Before supplying clarithromycin, check for simvastatin (must not be supplied under this PGD due to rhabdomyolysis risk), QT-prolonging medicines (must not be supplied), direct oral anticoagulants (caution: increased bleeding risk; advise patient to seek help if bleeding occurs), warfarin (caution: INR monitoring needed), and digoxin (caution: toxicity risk). Before supplying doxycycline, check for antacids, calcium, iron, magnesium, or zinc supplements (separate by 2-3 hours), retinoids such as isotretinoin or acitretin (significant interaction: must not supply under this PGD), and ciclosporin (significant interaction: must not supply under this PGD).
5. Supply or advise self-care and counsel thoroughly If the PGD criteria are met, supply the appropriate antibiotic and counsel on: dose, frequency, duration, how and when to take it, completing the full course, common side effects. For all patients, advise self-care: paracetamol or ibuprofen for pain and fever. There is insufficient evidence to recommend steam inhalation for sinusitis, and there is a risk of scalding injury. Do not recommend it. The Pharmacy First PGD also states no evidence supports oral decongestants, antihistamines, or mucolytics for this indication. Nasal saline has little evidence but is low risk if patients wish to try it.
6. Safety net and document Advise patients that symptoms should start to improve within 3-5 days of starting antibiotics. If no improvement within this time, seek medical advice. Safety net for red flags: seek urgent help if eye swelling or visual changes develop, if there is severe frontal headache, neck stiffness, or signs of sepsis. Record the consultation contemporaneously on PharmOutcomes and submit the claim promptly.

Assessment outcome: what to do

Step 1: Confirm Acute Sinusitis is Present

The patient must have at least one symptom from Group A and at least one from Group B to meet the diagnostic criteria for acute sinusitis.

Step 2: Assess for Features Suggesting Bacterial Infection

The presence of 2 or more of the features below increases the likelihood of acute bacterial sinusitis and may support antibiotic supply where the full PGD criteria are met. This is not a standalone trigger: all inclusion and exclusion criteria still apply. If fewer than 2 bacterial features are present, symptoms must have been present for more than 10 days with no improvement.

Antibiotic Choices

Supply the antibiotic according to the current Pharmacy First PGD. All doses below are for children aged 12-17 and adults unless stated otherwise.

Recording and submission

• Complete the consultation record contemporaneously and submit the claim promptly. All Pharmacy First sinusitis consultations require a record, including those where self-care advice only is given.
• Key information to record:
  • Patient name, date of birth, NHS number
  • Presenting complaint and exact duration of symptoms in days
  • Acute sinusitis diagnostic criteria confirmed (Group A and Group B symptoms present)
  • Bacterial features assessed: which of the 4 features were present and the total count
  • Eligibility criteria confirmed and exclusions checked (including recurrent/chronic sinusitis, pregnancy, immunosuppression)
  • Supply decision and rationale (duration >10 days, or bacterial features, or post-corticosteroid)
  • Antibiotic supplied: name, strength, dose, frequency, duration, quantity, batch number, expiry date
  • Penicillin allergy status confirmed
  • Drug interaction check documented
  • Self-care and safety-netting advice given
  • Referral made if applicable
• Submit the claim promptly after the consultation. Contemporaneous documentation reduces audit risk.

Key takeaways

• Antibiotic supply requires either more than 10 days of symptoms with no improvement (exactly 10 days does not qualify), or 2 or more bacterial features (double-sickening, fever above 38 degrees Celsius, unremitting purulent discharge, or unilateral jaw or tooth pain).
• Clarithromycin for sinusitis is 500mg twice daily for 5 days (not 250mg), and doxycycline is excluded in both pregnancy and breastfeeding. Check the correct alternative carefully before supplying.
• Orbital signs (eye swelling, displaced eyeball, double vision, visual changes) and intracranial signs (severe frontal headache, neck stiffness) are red flags requiring immediate referral to A&E. Do not supply an antibiotic and do not delay referral.

Download the checklist