Pharmacy First: Top tips for diagnosing and treating acute sinusitis

CLINICAL UPDATE

The Pharmacy First service in England enables pharmacists to diagnose and treat seven specific conditions, with the aim of reducing current pressures on general practice.

This series of guides assumes that pharmacists are familiar with the clinical pathways and requirements for Pharmacy First. The articles explore some key aspects of each service to support and enhance pharmacists’ knowledge.

Here, GP Dr David Coleman offers his tips on managing acute sinusitis in line with the Pharmacy First service.

 

Acute sinusitis

Sinusitis is a common infection of the upper respiratory tract. The majority of cases are caused by viruses and are self-limiting, with most sufferers improving within 2-3 weeks. Common symptoms include headache, facial pain (around the eyes and cheeks), nasal congestion/discharge, and a temperature.¹

NICE advises that around 2% of cases are complicated by bacterial infection, but acknowledges that these can be very difficult to distinguish.² Complications are rare, with NICE citing a rate of 2.5 to 4.3 per million people per year.

Here are seven tips on how to assess and manage presentations of suspected acute sinusitis appropriately and in line with the new Pharmacy First service.

1. Safety first: exclude concerning features

There is a reason the first stage of the clinical algorithm³ for sinusitis outlines symptoms of concern. A small number of patients who believe they have sinusitis may have more serious pathology.

If the patient has any of the symptoms of concern outlined – visual disturbance, redness around the eye, eye swelling, swelling over the frontal bone, unusual neurological signs or severe headache – they are not eligible for this pathway and escalation to an emergency service may be indicated. It also vital to always offer safety netting advice in case of deterioration. Safety first is key as in all of the Pharmacy First pathways.

A GP colleague recently shared the story of a patient who presented with headache, particularly around the eyes, and a temperature. The patient’s expectation was to be given a course of antibiotics for sinusitis. Unfortunately, they were subsequently found to have cavernous sinus thrombosis,⁴ a potentially life-threatening blood clot. I share this not with the intention of provoking fear, but to emphasise the importance of this part of the clinical history and of safety netting – while this patient didn’t have any typical red flag features at the point of consultation, they did subsequently develop visual disturbance.

2. Develop strategies to explain why antibiotics won’t help sinusitis

GPs have in some cases been over-liberal in treating acute sinusitis with antibiotics, so if the patient is a recurrent sufferer, a precedent may well have been set.⁵ All aspects of primary care will need to work together on antimicrobial stewardship to limit prescribing to cases where it is indicated, as inappropriate antibiotic use may lead to resistant organisms. Communication is key here.

NICE is clear that ‘only about 10 out of every 100 people with sinusitis benefit from an antibiotic and the benefit is small’.^2,6

A key message to patients is that acute sinusitis will generally improve within 2-3 weeks regardless of whether antibiotics are used. If they appeared to work for a previous infection, it was most likely coincidental. Another factor I try to emphasise is side effects – any chance of symptom improvement with antibiotics is effectively cancelled out by the prospect of side effects like nausea and diarrhoea. I have found patients respond better to the personal message (they won’t help and may make you feel worse) more than the societal one (resistance), which feels quite abstract to them.

Concepts such as number needed to treat (NNT) can be challenging for patients to understand, and some may benefit from a visual aid. It is very useful to keep to hand laminated copies of visual aids, such as the graphics provided by NICE,⁶ to support tricky discussions.

The NICE information nicely illustrates how out of every 100 people with sinusitis who receive antibiotics, only 10 will get actually get better or experience symptom improvement due to having the antibiotic – while on the flipside, eight out of the 100 will experience unpleasant side effects from the treatment, such as nausea or diarrhoea.

3. Manage expectations – nasal steroids will ease symptoms

The algorithm recommends a first-line approach of high-dose nasal corticosteroid (off-label) for 14 days (subject to inclusion/exclusion criteria in the PGD), in addition to self-care and pain relief, instead of antibiotics. This is unlikely to be the expectation of patients, particularly those who have received antibiotics previously. However, it is the recommended approach outlined in NICE guidance and on the CKS pages.^1,2

I would advocate an approach emphasising that this is based on the same national guidance that GPs and hospital teams are also advised to follow.

Another key message is that the goal of nasal steroids is to improve symptoms, not to reduce the duration of symptoms. Managing expectations effectively reduces repeat attendances.

4. Don’t be swayed by ‘my GP normally gives me…’

The clinical algorithm is quite clear and follows the NICE guidance. Unfortunately, some patients will have had consultations for similar symptoms that deviated significantly from the guidelines. You may encounter phrases such as ‘penicillin doesn’t work for me, I need co-amoxiclav’ or ‘my GP always gives me a course of oral steroids’. Perhaps they’ve been prescribed decongestants or nasal saline sprays.

Being clear about how Pharmacy First works at the outset is key. This is a clinical pathway based on evidence; there is no scope for deviation. Decongestants and nasal saline may be purchased over the counter, but evidence of their effectiveness is lacking. Penicillin is the clear first line antibiotic treatment, with alternative options reserved for cases of allergy.

5. Provide patient leaflets when safety-netting

The sinusitis algorithm has specific recommendations for safety-netting, with a link provided to TARGET Respiratory Tract Infection leaflets.⁷ This provides an expected time frame of 14-21 days for sinusitis, after which ‘most patients are better’. Patients are advised to seek medical advice if they are not better after 3 weeks, but there are also more prominent warnings about potentially concerning symptoms such as severe headache and vomiting, reduced urine output, and chest pain.

The leaflet contains more specific warnings aimed at children under five, but they are not included in the scope of this pathway.

6. Allow time for hand over to GP teams

This is an issue of logistics rather than a clinical matter, but it is of critical importance. General practice and community pharmacy are both vital pillars of UK primary care, but they cannot operate in isolation. Working in silos leads to frustration and increases risk. In my experience, a lack of cohesion and awareness of each other’s systems has been a factor in patchy delivery of previous pharmacy delivered schemes such as the Community Pharmacy Consultation Scheme (CPCS).

We solved significant CPCS issues in our neighbourhood by setting aside time to build bridges between GP and pharmacy and talk about logistics and the patient journey. We agreed it was imperative that patients who were found to be unsuitable for the scheme would be identified in good time for their GP surgery to accommodate them on the same day; this meant skewing the appointments earlier in the day and providing a direct pathway for pharmacies to communicate to surgeries. Obviously this might not help a patient who self-refers in the late afternoon, but it may still be possible for pharmacies to link in to extended access clinics in these scenarios.

Either way, the key is making time to get together to discuss the challenges and break down those boundaries.

7. Trust your gut

I always say to medical students and doctors in training: trust your gut. If you are going home worrying about a patient, thinking ‘I should have done x’, then you probably should have acted on your instincts. If something seems off, you should explore it.

Don’t be afraid to ask for help or to seek a second opinion. I seek second opinions from colleagues all the time. As a GP I am not concerned about patients being handed back for review; I would far prefer this than for anyone to come to harm. There are no stupid questions. If you build good relationships with your GP teams you may even be able to receive feedback on the outcomes, which you can reflect on in turn.

We’re all part of the same team and we’re here to help patients. Circling back to my first tip, this is all part of that safety first approach.

This is the latest in a series of articles on aspects of Pharmacy First from The Pharmacist.  

Dr David Coleman is a GP partner and trainer and PCN clinical director in south Yorkshire