Pharmacy First: Acute Sinusitis

About this service

Acute sinusitis (rhinosinusitis) is one of the seven conditions covered by the NHS Pharmacy First service.¹ 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.

Most sinusitis presentations are viral and resolve spontaneously within 2 to 3 weeks without antibiotics. The Pharmacy First pathway allows pharmacists to supply antibiotics where specific PGD criteria are met.² Where the PGD-specific inclusion criteria are also met, including symptom duration of more than 10 days with no improvement, pharmacists may consider supplying a high-dose nasal corticosteroid under PGD 6a (fluticasone furoate)⁷ or PGD 6b (mometasone furoate).⁶ Patients taking oral, inhaled, topical or parenteral corticosteroids for any indication, or with known adrenal insufficiency or glaucoma, must not receive nasal corticosteroids under these PGDs without prescriber review.

This article covers the inclusion and exclusion criteria, the antibiotic and nasal corticosteroid pathways, 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)[1][2]
• OR presence of 2 or more features suggesting bacterial infection (see features table below)[1][2]
• 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: outside all sinusitis PGDs. Safeguarding considerations apply to any pregnancy in a person aged under 16. Discuss appropriate support and, where clinically indicated, refer to a GP or safeguarding services. For pregnant individuals aged 16 and over, an erythromycin PGD (6f) is available.[5]
• Breastfeeding: phenoxymethylpenicillin and clarithromycin may be used with monitoring (see PGD cautions). Doxycycline is excluded in breastfeeding.[4]
• Severely immunocompromised: refer urgently to a prescriber or, if severe infection or sepsis features are present, to A&E or call 999
• 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 immediately (see red flags in Step 1)
• Sepsis suspected: call 999
• Failed previous antibiotic for this episode of sinusitis: do not supply a further antibiotic under Pharmacy First. This is not a repeatable PGD pathway for the same episode. Refer to a GP.
• Oral, inhaled, topical or parenteral corticosteroid use (for any indication) or known adrenal insufficiency: excluded from nasal corticosteroid PGDs 6a and 6b. Refer to a GP or prescriber before considering nasal corticosteroid supply.

How to deliver the service

1. Confirm eligibility and screen for red flags first Confirm the patient is aged 12 or over before proceeding. Screen explicitly for red flags before taking a full history.¹ Orbital complications requiring immediate A&E referral include: periorbital oedema or erythema (eyelid swelling or redness), a displaced globe or proptosis, ophthalmoplegia or pain on eye movement, and reduced or altered visual acuity. Intracranial complications requiring immediate A&E referral include: severe frontal headache, neck stiffness or meningism, neurological signs, and forehead swelling or bossing (which may indicate Potts puffy tumour, a subperiosteal abscess of the frontal bone). Do not supply an antibiotic and do not delay referral if any of these features are present. Call 999 if sepsis signs are present.
2. Establish the symptom pattern and duration Ask about onset, duration, and whether symptoms have improved, stayed the same, or worsened. The key PGD thresholds are: more than 10 days with no improvement (exactly 10 days does not qualify), or the presence of 2 or more bacterial features.¹² Ask specifically about double-sickening (an initial mild illness followed by distinct worsening), fever above 38 degrees Celsius, purulent nasal discharge that is unremitting, and unilateral jaw or tooth pain. Coloured nasal discharge alone does not confirm bacterial infection and must not be used in isolation to justify antibiotic supply.
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. For any pregnancy under 16, safeguarding considerations apply: refer to a GP and discuss appropriate support. Check for severely immunocompromising conditions: if severe infection or sepsis features are present, refer to A&E or call 999 rather than waiting for a GP appointment. If the patient has already received an antibiotic for this episode, do not supply another under Pharmacy First: refer to a GP.
4. Check for drug interactions before selecting antibiotic Before supplying phenoxymethylpenicillin, check for methotrexate and probenecid: both are significant interactions and phenoxymethylpenicillin must not be supplied under this PGD to patients taking either medicine. Refer to a prescriber.² Before supplying clarithromycin, check for simvastatin (must not be supplied: rhabdomyolysis risk), QT-prolonging medicines (must not be supplied), direct oral anticoagulants (caution: increased bleeding risk), warfarin (caution: INR monitoring needed), and digoxin (caution: toxicity risk).³ Before supplying doxycycline, check for antacids, calcium, iron, magnesium, or zinc supplements (separate by 2 to 3 hours), retinoids such as isotretinoin or acitretin (significant interaction: must not supply), and ciclosporin (significant interaction: must not supply).⁴ If considering nasal corticosteroid PGD 6a (fluticasone), additionally check for potent CYP3A4 inhibitors including clarithromycin, azole antifungals such as itraconazole or ketoconazole, ritonavir, and cobicistat: fluticasone PGD 6a must not be supplied to patients taking any of these medicines.⁷
5. Supply or advise self-care and counsel thoroughly If the PGD antibiotic criteria are met, supply the appropriate antibiotic and counsel on: dose, frequency, duration, how and when to take it, completing the full course, and common side effects. If supplying a nasal corticosteroid under PGD 6a or 6b, confirm the PGD inclusion criteria are met (including symptom duration threshold), complete all PGD-required checks, and counsel on: the nature of the supply under a Pharmacy First PGD; how to prime and use the spray correctly; that symptom improvement may take up to 2 to 3 weeks; and to return promptly if symptoms worsen rather than improve. For all patients, advise self-care: paracetamol or ibuprofen for pain and fever. The Pharmacy First PGDs state there is no evidence to support steam inhalation for sinusitis and there is a scalding injury risk: do not recommend it. Oral decongestants, antihistamines, and mucolytics are not supported for this indication under the current PGD.
6. Safety net and document Advise patients that symptoms should start to improve within 3 to 5 days of starting antibiotics. If no improvement within this time, seek medical advice. Safety net for all patients: seek urgent help if eye swelling, redness, or visual changes develop; if there is severe frontal headache or neck stiffness; or if there are signs of sepsis. Record the consultation contemporaneously on PharmOutcomes and submit the claim promptly. All Pharmacy First sinusitis consultations require a record, including those where only self-care advice is given.

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.¹

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.¹² 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. Doses below apply to children aged 12-17 and adults unless stated otherwise. Always verify against the current PGD before supplying.

Nasal Corticosteroid Pathway (PGDs 6a and 6b)

Where the PGD-specific inclusion criteria are met, including symptom duration of more than 10 days with no improvement, pharmacists may supply a high-dose nasal corticosteroid under PGD 6a (fluticasone furoate)⁷ or PGD 6b (mometasone furoate).⁶ These are off-label supplies with their own eligibility criteria, exclusions, and counselling requirements. The PGD inclusion criteria must be met before supply: significant symptoms alone are not sufficient. Always refer to the current PGD before supplying.

Recording and submission

• Complete the consultation record contemporaneously and submit the claim promptly. All Pharmacy First sinusitis consultations require a record, including those where only self-care advice 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 or chronic sinusitis, pregnancy and safeguarding, immunosuppression)
  • Supply decision and rationale (duration more than 10 days, or bacterial features, or post-corticosteroid)
  • Medicine supplied: name, strength, dose, frequency, duration, quantity, batch number, expiry date
  • PGD reference number and version under which the medicine was supplied
  • Penicillin allergy status confirmed
  • Drug interaction check completed and documented (including CYP3A4 inhibitor check if nasal corticosteroid considered)
  • Self-care and safety-netting advice given
  • Referral made if applicable, with reason documented
• 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.[1][2]
• Nasal corticosteroid PGD supply (PGD 6a fluticasone or PGD 6b mometasone) requires the PGD-specific inclusion criteria to be met, including the duration threshold. Significant symptoms alone are not sufficient. Oral, inhaled, topical or parenteral corticosteroids and potent CYP3A4 inhibitors (including clarithromycin) are key exclusions for PGD 6a.
• Orbital signs (periorbital swelling or redness, displaced globe, restricted or painful eye movement, visual changes) and intracranial signs (severe frontal headache, neck stiffness, neurological signs) are red flags for serious sinusitis complications. Refer immediately to A&E. Do not supply an antibiotic.

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