The Pharmacy First sinusitis pathway

The Pharmacy First service for acute sinusitis is for adults and children aged 12 years and over, and excludes immunosuppressed individuals, people with chronic sinusitis, and people under 16 years of age who are pregnant.

Whether patients have been referred into the pharmacy for the service, or have walked in, they might ask for an explanation from a pharmacy team member about what the Pharmacy First consultation for sinusitis involves.

The first step comprises a consultation with the pharmacist in a separate consultation room. They may perform an examination or ask to access the patient’s medical records, in order to recommend the best course of action for the individual, including by issuing prescriptions for antibiotics where clinically appropriate.

Patients can be reassured that the appointment and advice from a pharmacist are free to access, but if they are supplied with a prescription-only medication, usual prescription charges will apply unless they qualify for free prescriptions, and they will also have to pay if they choose to buy any recommended P or OTC medication.

During the consultation the pharmacist will diagnose acute sinusitis by the presence of ONE or more of the following complaints:

• Nasal blockage (obstruction/congestion)

or

• Nasal discharge (anterior/posterior nasal drip).

Accompanied by ONE or more of:

• Facial pain/pressure (or headache)
• Reduction (or loss) of the sense of smell (in adults)
• Or cough during the day or at night (in children).

If the patient doesn’t meet these criteria and the pharmacist considers it to be less likely that they are suffering from acute sinusitis they will consider an alternative diagnosis and proceed appropriately – which may include referral back to the person’s GP.

If the pharmacist thinks acute sinusitis is a potential differential diagnosis but the patient has had symptoms for less than 10 days they will recommend that an antibiotic is not needed and advise the person that sinusitis usually lasts two to three weeks and they can manage their symptoms with self care.

If the pharmacist decides that acute sinusitis is a potential differential diagnosis and the patient has had symptoms for more than 10 days with no improvement, this triggers the ‘gateway point’ for the Pharmacy First sinusitis service.

At this point, the pharmacist will ask the patient if they have two or more of the following symptoms, which would suggest acute bacterial sinusitis:

• A marked deterioration after an initial milder phase
• Fever of more than 38°c
• Unremitting purulent nasal discharge – discharge that is thick, opaque and coloured
• Severe localised unilateral pain, particularly over the teeth and jaw.

If the patient does not have two or more of these symptoms the pharmacist will offer self care and pain relief advice based on the severity of their symptoms, and can also offer high dose nasal corticosteroid for 14 days. They will also advise the patient that since acute sinusitis is usually caused by a virus, antibiotics make little difference to how long their symptoms will last or the number of people whose symptoms improve. The pharmacist will also encourage the patient to return to the pharmacy if their symptoms have not improved in a further seven days for another reassessment.

If the patient does have two or more of these symptoms the pharmacist will take a shared decision-making approach with the person, based on the severity of their symptoms, to decide on the next course of action. As a first line this could be to offer them a high dose nasal corticosteroid for 14 days, plus self care and pain relief instead of antibiotics. If this option is unsuitable or ineffective, the pharmacist will offer phenoxymethylpenicillin (if the person has no allergy to this) for five days along with self-care advice. If the patient has a reported penicillin allergy they can be offered clarithromycin or doxycycline for five days plus self care advice, or if they are pregnant they can be offered five days of erythromycin along with appropriate self care advice.

All patients will be given self care and safety-netting advice using the TARGET Respiratory Tract Infection leaflets, with additional advice that if their symptoms worsen rapidly or significantly at any time, or do not improve after completion of the treatment course, the pharmacist can instigate an onward referral to their GP or other healthcare provider as appropriate.