National Institute for Health and Care Excellence APG Sinusitis (acute) Sinusitis (acute): antimicrobial prescribing guideline Evidence review October 2017 Final version Contents Disclaimer The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties. NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn. Copyright © NICE 2017. All rights reserved. Subject to Notice of rights. Contents Contents Contents .............................................................................................................................. 4 1 Context .......................................................................................................................... 6 1.1 Background ........................................................................................................... 6 1.2 Managing self-limiting infections ............................................................................ 7 1.2.1 Self-care .................................................................................................... 7 1.2.2 No antibiotic prescribing strategies ............................................................. 8 1.2.3 Antibiotic prescribing strategies .................................................................. 8 1.3 Safety netting advice ............................................................................................. 8 1.4 Symptoms and signs of a more serious illness or condition (red flags) .................. 9 2 Evidence selection ..................................................................................................... 10 2.1 Literature search ................................................................................................. 10 2.2 Summary of included studies............................................................................... 10 3 Clinical effectiveness ................................................................................................. 15 3.1 Non-pharmacological interventions ..................................................................... 15 3.1.1 Nasal saline in adults and children ........................................................... 15 3.1.2 Other non-pharmacological interventions ................................................. 15 3.2 Non-antimicrobial pharmacological interventions ................................................. 15 3.2.1 Nasal decongestants in adults and children ............................................. 15 3.2.2 Nasal corticosteroids in adults and children ............................................. 16 3.2.3 Other non-antimicrobial pharmacological interventions ............................ 17 3.3 Antimicrobials in adults ........................................................................................ 17 3.3.1 Back-up antibiotics ................................................................................... 17 3.3.2 Antibiotics compared with placebo ........................................................... 18 3.3.3 Identifying people more likely to have a bacterial infection ....................... 20 3.3.4 Choice of antibiotic ................................................................................... 21 3.3.5 Frequency of antibiotic dosing .................................................................. 22 3.3.6 Antibiotic course length ............................................................................ 22 3.4 Antimicrobials in children ..................................................................................... 22 3.4.1 Back-up antibiotics ................................................................................... 22 3.4.2 Antibiotics compared with placebo ........................................................... 23 3.4.3 Choice of antibiotic ................................................................................... 23 3.4.4 Frequency of antibiotic dosing .................................................................. 23 3.4.5 Antibiotic course length ............................................................................ 23 4 Safety and tolerability ................................................................................................ 24 4.1 Non-pharmacological interventions ..................................................................... 24 4.1.1 Nasal saline ............................................................................................. 24 4.2 Non-antimicrobial pharmacological interventions ................................................. 24 4.2.1 Oral analgesia .......................................................................................... 24 4.2.2 Nasal decongestants................................................................................ 24 4 Contents 4.2.3 Nasal corticosteroids ................................................................................ 25 4.3 Antimicrobials ...................................................................................................... 25 4.3.1 Back-up antibiotics ................................................................................... 26 4.3.2 Antibiotics in adults .................................................................................. 26 4.3.3 Antibiotics in children ............................................................................... 27 5 Antimicrobial resistance ............................................................................................ 29 6 Other considerations ................................................................................................. 30 6.1 Resource impact ................................................................................................. 30 6.1.1 Nasal corticosteroids ................................................................................ 30 6.1.2 Antibiotics ................................................................................................ 30 6.2 Medicines adherence .......................................................................................... 30 6.3 Regulatory status ................................................................................................ 30 6.3.1 Nasal corticosteroids ................................................................................ 30 7 Terms used in the guideline ...................................................................................... 31 7.1.1 Major symptom score ............................................................................... 31 7.1.2 Sino nasal outcome test ........................................................................... 31 Appendices ........................................................................................................................ 32 Appendix A: Evidence sources .................................................................................. 32 Appendix B: Review protocol ..................................................................................... 35 Appendix C: Literature search strategy ..................................................................... 42 Appendix D: Study flow diagram ................................................................................ 46 Appendix E: Evidence prioritisation .......................................................................... 47 Appendix F: Included studies ..................................................................................... 50 Appendix G: Quality assessment of included studies .............................................. 52 G.1 Nasal saline................................................................................................................. 52 G.2 Nasal decongestants .................................................................................................. 52 G.3 Nasal corticosteroids ................................................................................................. 53 G.4 Antimicrobials ............................................................................................................ 54 Appendix H: GRADE profiles ...................................................................................... 57 H.1 Nasal saline................................................................................................................