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Knowledge Base

NHSE Pharmacy First PGDs

Characteristics of staff
Qualifications and professional registration
  • Registered healthcare professional listed in the legislation as able to practice under Patient Group Directions.
Initial training
  • The registered healthcare professional authorised to operate under this PGD must have undertaken appropriate education and training and be competent to undertake clinical assessment of patients ensuring safe provision of the medicines listed in accordance with the specification.
  • To deliver this service, the registered healthcare professional should have evidence of competence in the clinical skills and knowledge covered in the Centre for Pharmacy Postgraduate Education (CPPE) Pharmacy First Service self-assessment framework.
  • Before commencement of the service, the pharmacy contractor must ensure that pharmacists and pharmacy staff providing the service are competent to do so and be familiar with the clinical pathways, clinical protocol and PGDs. This may involve completion of training
Competency assessment
  • Individuals operating under this PGD must be assessed as competent or complete a self-declaration of competence to operate under this PGD (see an example authorisation record sheet in Appendix A) [Pharmacy First PGD master authorisation sheet]
  • Individuals operating under this PGD are advised to review their competency using the NICE Competency Framework for health professionals using patient group directions.
Ongoing training and competency
  • Individuals operating under this PGD are personally responsible for ensuring they remain up to date with the use of all medicines and guidance included in the PGD - if any training needs are identified these should be discussed with the senior individual responsible for authorising individuals to act under the PGD and further training provided as required.

The decision to supply any medication rests with the individual registered health professional who must abide by the PGD and any associated organisational policies.

Fluticasone | Mometasone
Fluticasone | Mometasone
Clinical condition or situation to which this PGD applies

Acute sinusitis (rhinosinusitis) in children aged 12 years and over and adults.

Criteria for inclusion
  • Informed consent
  • Individuals aged 12 years and over
  • Signs and symptoms of acute sinusitis using the appropriate NICE guidance
  • Diagnosis of acute sinusitis using the appropriate NICE CKS guidance.
  • Presence of ONE of the following signs/symptoms (which suggests acute sinusitis is more likely):
    • Nasal blockage (obstruction/congestion) OR
    • Nasal discharge (anterior/posterior nasal drip)
      AND ONE or more of the following:
    • Facial pain/pressure (or headache) OR
    • Reduction (or loss) of the sense of smell (in adults) OR
    • Cough during the day or at night (in children)
  • Symptom duration of 10 days of more with little improvement
  • Presence of TWO or more of the following signs/symptoms (which suggests acute bacterial sinusitis is more likely):
    • Marked deterioration after an initial milder phase
    • Fever (>38°C)
    • Unremitting purulent nasal discharge
    • Severe localised unilateral pain, particularly pain over the teeth (toothache) and jaw
Exclusions & Additional Prescribing Details Links
  • Criteria for exclusion: Fluticasone | Mometasone
  • Cautions including any relevant action to be taken: Fluticasone | Mometasone
  • Specific information for suspected infection to be provided: Fluticasone | Mometasone
  • Action to be taken if the individual is excluded: Fluticasone | Mometasone
  • Action to be taken if the individual/carer/parent/guardian declines treatment: Fluticasone | Mometasone
  • Arrangements for referral for medical advice: Refer to the appropriate medical practitioner in the care pathway.
Description of treatment Fluticasone
  • Name, strength & formulation of drug
    • Fluticasone furoate 27.5 micrograms/dose nasal spray
  • Legal category
    • POM
  • Route / method of administration
    • Intranasal
  • Off-label use
    • Fluticasone furoate 27.5 micrograms/dose nasal spray is not licensed for the treatment of sinusitis but use for this indication and at this dose is supported by NICE guidance......more
  • Dose and frequency of administration
    • Children 12–17 years and adults:
      • Two actuations (27.5 micrograms/actuation) in each nostril twice daily (total dose 110 micrograms twice daily)
  • Duration of treatment
    • 14 days
  • Quantity to be supplied
  • Storage
  • Drug interactions
  • Identification & management of adverse reactions
  • Management of and reporting procedure for adverse reactions
  • Written information to be given to individual/carer/parent/guardian
  • Individual advice / follow up treatment
  • Records
Description of treatment Mometasone
  • Name, strength & formulation of drug
    • Mometasone furoate monohydrate 50 micrograms/dose nasal spray
  • Legal category
    • POM
    • Note: ONLY the supply of the prescription-only medicine (POM) (and not pharmacy only (P)) is permitted under this PGD.
  • Route / method of administration
    • Intranasal
  • Off-label use
    • Mometasone furoate monohydrate 50 micrograms/dose nasal spray is not licensed for the treatment of sinusitis but use for this indication and at this dose is supported by NICE guidance......more
  • Dose and frequency of administration
    • Children 12–17 years and adults:
      • Two actuations (50 micrograms/actuation) in each nostril twice daily (total dose 200 micrograms twice daily).
  • Duration of treatment
    • 14 days
  • Quantity to be supplied
  • Storage
  • Drug interactions
  • Identification & management of adverse reactions
  • Management of and reporting procedure for adverse reactions
  • Written information to be given to individual/carer/parent/guardian
  • Individual advice / follow up treatment
  • Records
Phenoxymethylpenicillin (Penicillin V)
Phenoxymethylpenicillin (Penicillin V)
Clinical condition or situation to which this PGD applies

Acute bacterial sinusitis (rhinosinusitis) in children aged 12 years and over and adults.

Criteria for inclusion
  • Informed consent
  • Individuals aged 12 years and over
  • Signs and symptoms of acute sinusitis using the appropriate NICE guidance
  • Diagnosis of acute sinusitis using the appropriate NICE CKS guidance.
  • Presence of ONE of the following signs/symptoms (which suggests acute sinusitis is more likely):
    • Nasal blockage (obstruction/congestion) OR
    • Nasal discharge (anterior/posterior nasal drip)
      AND ONE or more of the following:
    • Facial pain/pressure (or headache) OR
    • Reduction (or loss) of the sense of smell (in adults) OR
    • Cough during the day or at night (in children)
  • Symptom duration of 10 days of more with little improvement
  • Presence of TWO or more of the following signs/symptoms (which suggests acute bacterial sinusitis is more likely):
    • Marked deterioration after an initial milder phase
    • Fever (>38°C)
    • Unremitting purulent nasal discharge
    • Severe localised unilateral pain, particularly pain over the teeth (toothache) and jaw
  • Persistent symptoms despite use of high-dose nasal corticosteroid (off-label) for 14 days
    OR
  • High-dose nasal corticosteroid (off-label) unsuitable
Exclusions & Additional Prescribing Details Links
  • Criteria for exclusion
  • Cautions including any relevant action to be taken
  • Specific information for suspected infection to be provided
  • Action to be taken if the individual is excluded
  • Action to be taken if the individual/carer/parent/guardian declines treatment
  • Arrangements for referral for medical advice: Refer to the appropriate medical practitioner in the care pathway.
Description of treatment
  • Name, strength & formulation of drug
    • Phenoxymethylpenicillin 250mg tablets
    • Phenoxymethylpenicillin 125mg/5mL oral solution (or oral suspension) x 100mL
    • Phenoxymethylpenicillin 125mg/5mL sugar free oral solution (or oral suspension) x 100mL
    • Phenoxymethylpenicillin 250mg/5mL oral solution (or oral suspension) x 100mL
    • Phenoxymethylpenicillin 250mg/5mL sugar free oral solution (or oral suspension) x 100mL
  • Legal category
    • POM
  • Route / method of administration
    • Orally, on an empty stomach (30 minutes before food or 2 hours after food).
    • Tablets should be swallowed whole with water.
  • Off-label use
  • Dose and frequency of administration
    • Children 12–17 years and adults:
      • 500 mg four times a day
  • Duration of treatment
    • 5 days
    • Treatment should be started immediately and 5 days of treatment completed.
  • Quantity to be supplied
  • Storage
  • Drug interactions
  • Identification & management of adverse reactions
  • Management of and reporting procedure for adverse reactions
  • Written information to be given to individual/carer/parent/guardian
  • Individual advice / follow up treatment
  • Records
Clarithromycin
Clarithromycin
Clinical condition or situation to which this PGD applies

Acute bacterial sinusitis (sinusitis) in children aged 12 years and over and adults where phenoxymethylpenicillin is not appropriate due to hypersensitivity.

Criteria for inclusion
  • Informed consent
  • Individuals aged 12 years and over
  • Signs and symptoms of acute sinusitis using the appropriate NICE guidance
  • Diagnosis of acute sinusitis using the appropriate NICE CKS guidance.
  • Presence of ONE of the following signs/symptoms (which suggests acute sinusitis is more likely):
    • Nasal blockage (obstruction/congestion) OR
    • Nasal discharge (anterior/posterior nasal drip)
      AND ONE or more of the following:
    • Facial pain/pressure (or headache) OR
    • Reduction (or loss) of the sense of smell (in adults) OR
    • Cough during the day or at night (in children)
  • Symptom duration of 10 days of more with little improvement
  • Presence of TWO or more of the following signs/symptoms (which suggests acute bacterial sinusitis is more likely):
    • Marked deterioration after an initial milder phase
    • Fever (>38°C)
    • Unremitting purulent nasal discharge
    • Severe localised unilateral pain, particularly pain over the teeth (toothache) and jaw
  • Persistent symptoms despite use of high-dose nasal corticosteroid (off-label) for 14 days
    OR
  • High-dose nasal corticosteroid (off-label) unsuitable
  • Known hypersensitivity to phenoxymethylpenicillin (penicillin V), any penicillin or any of the components within the formulation of phenoxymethylpenicillin formulations - see Summary of Product Characteristics. Acceptable sources of allergy information include individual/carer/parent/guardian or National Care Record
    OR
  • History of severe immediate hypersensitivity reaction (e.g. anaphylaxis) to another beta-lactam antibiotic (e.g. cephalosporin, carbapenem or monobactam). Acceptable sources of allergy information include individual/carer/parent/guardian or National Care Record
Exclusions & Additional Prescribing Details Links
  • Criteria for exclusion
  • Cautions including any relevant action to be taken
  • Specific information for suspected infection to be provided
  • Action to be taken if the individual is excluded
  • Action to be taken if the individual/carer/parent/guardian declines treatment
  • Arrangements for referral for medical advice: Refer to the appropriate medical practitioner in the care pathway.
Description of treatment
  • Name, strength & formulation of drug
    • Clarithromycin 250mg tablets
    • Clarithromycin 500mg tablets
    • Clarithromycin 125mg/5mL oral suspension (or oral solution) x 70mL
    • Clarithromycin 250mg/5mL oral suspension (or oral solution) x 70mL
  • Legal category
    • POM
  • Route / method of administration
    • Orally, with water (taken with or without food). Tablets should be swallowed whole.
    • Note: Clarithromycin oral suspension (or oral solution) can cause a bitter after-taste. This can be avoided by drinking juice or water soon after intake of the oral suspension (or oral solution).
  • Off-label use
  • Dose and frequency of administration
    • Children 12–17 years and adults:
      • 500mg twice daily (every 12 hours)
  • Duration of treatment
    • 5 days
    • Treatment should be started immediately and 5 days of treatment completed.
  • Quantity to be supplied
  • Storage
  • Drug interactions
  • Identification & management of adverse reactions
  • Management of and reporting procedure for adverse reactions
  • Written information to be given to individual/carer/parent/guardian
  • Individual advice / follow up treatment
  • Records
Erythromycin
Erythromycin
Clinical condition or situation to which this PGD applies

Acute bacterial sinusitis (sinusitis) in adults 16 years and over who are pregnant or where pregnancy is suspected and where phenoxymethylpenicillin is not appropriate due to hypersensitivity.

Criteria for inclusion
  • Informed consent
  • Individuals aged 16 years and over
  • Signs and symptoms of acute sinusitis using the appropriate NICE guidance
  • Diagnosis of acute sinusitis using the appropriate NICE CKS guidance.
  • Presence of ONE of the following signs/symptoms (which suggests acute sinusitis is more likely):
    • Nasal blockage (obstruction/congestion) OR
    • Nasal discharge (anterior/posterior nasal drip)
      AND ONE or more of the following:
    • Facial pain/pressure (or headache) OR
    • Reduction (or loss) of the sense of smell (in adults) OR
    • Cough during the day or at night (in children)
  • Symptom duration of 10 days of more with little improvement
  • Presence of TWO or more of the following signs/symptoms (which suggests acute bacterial sinusitis is more likely):
    • Marked deterioration after an initial milder phase
    • Fever (>38°C)
    • Unremitting purulent nasal discharge
    • Severe localised unilateral pain, particularly pain over the teeth (toothache) and jaw
  • Persistent symptoms despite use of high-dose nasal corticosteroid (off-label) for 14 days
    OR
  • High-dose nasal corticosteroid (off-label) unsuitable
  • Pregnancy or suspected pregnancy
  • Known hypersensitivity to phenoxymethylpenicillin (penicillin V), any penicillin or any of the components within the formulation of phenoxymethylpenicillin formulations - see Summary of Product Characteristics. Acceptable sources of allergy information include individual/carer/parent/guardian or National Care Record
    OR
  • History of severe immediate hypersensitivity reaction (e.g. anaphylaxis) to another beta-lactam antibiotic (e.g. cephalosporin, carbapenem or monobactam). Acceptable sources of allergy information include individual/carer/parent/guardian or National Care Record
Exclusions & Additional Prescribing Details Links
  • Criteria for exclusion
  • Cautions including any relevant action to be taken
  • Specific information for suspected infection to be provided
  • Action to be taken if the individual is excluded
  • Action to be taken if the individual/carer/parent/guardian declines treatment
  • Arrangements for referral for medical advice: Refer to the appropriate medical practitioner in the care pathway.
Description of treatment
  • Name, strength & formulation of drug
    • Erythromycin 250mg tablets
    • Erythromycin 250mg gastro-resistant tablets
    • Erythromycin 500mg tablets
    • Erythromycin 125mg/5mL oral suspension (or oral solution) x 100mL
    • Erythromycin 125mg/5mL sugar free oral suspension (or oral solution) x 100mL
    • Erythromycin 250mg/5mL oral suspension (or oral solution) x 100mL
    • Erythromycin 250mg/5mL sugar free oral suspension (or oral solution) x 100mL
    • Erythromycin 500mg/5mL oral suspension (or oral solution) x 100mL
    • Erythromycin 500mg/5mL sugar free oral suspension (or oral solution) x 100mL
  • Legal category
    • POM
  • Route / method of administration
    • Orally, with water (just before or with food).
    • Tablets should be swallowed whole.
  • Off-label use
  • Dose and frequency of administration
    • Young people and adults aged 16 years and over:
      • 500mg four times daily
  • Duration of treatment
    • 5 days
    • Treatment should be started immediately and 5 days of treatment completed.
  • Quantity to be supplied
  • Storage
  • Drug interactions
  • Identification & management of adverse reactions
  • Management of and reporting procedure for adverse reactions
  • Written information to be given to individual/carer/parent/guardian
  • Individual advice / follow up treatment
  • Records
Doxycycline
Doxycycline
Clinical condition or situation to which this PGD applies

Acute bacterial sinusitis (rhinosinusitis) in children 12 years and over and adults where phenoxymethylpenicillin is not appropriate due to hypersensitivity.

Criteria for inclusion
  • Informed consent
  • Individuals aged 12 years and over
  • Signs and symptoms of acute sinusitis using the appropriate NICE guidance
  • Diagnosis of acute sinusitis using the appropriate NICE CKS guidance.
  • Presence of ONE of the following signs/symptoms (which suggests acute sinusitis is more likely):
    • Nasal blockage (obstruction/congestion) OR
    • Nasal discharge (anterior/posterior nasal drip)
      AND ONE or more of the following:
    • Facial pain/pressure (or headache) OR
    • Reduction (or loss) of the sense of smell (in adults) OR
    • Cough during the day or at night (in children)
  • Symptom duration of 10 days of more with little improvement
  • Presence of TWO or more of the following signs/symptoms (which suggests acute bacterial sinusitis is more likely):
    • Marked deterioration after an initial milder phase
    • Fever (>38°C)
    • Unremitting purulent nasal discharge
    • Severe localised unilateral pain, particularly pain over the teeth (toothache) and jaw
  • Persistent symptoms despite use of high-dose nasal corticosteroid (off-label) for 14 days
    OR
  • High-dose nasal corticosteroid (off-label) unsuitable
  • Known hypersensitivity to phenoxymethylpenicillin (penicillin V), any penicillin or any of the components within the formulation of phenoxymethylpenicillin formulations - see Summary of Product Characteristics. Acceptable sources of allergy information include individual/carer/parent/guardian or National Care Record
    OR
  • History of severe immediate hypersensitivity reaction (e.g. anaphylaxis) to another beta-lactam antibiotic (e.g. cephalosporin, carbapenem or monobactam). Acceptable sources of allergy information include individual/carer/parent/guardian or National Care Record
Exclusions & Additional Prescribing Details Links
  • Criteria for exclusion
  • Cautions including any relevant action to be taken
  • Specific information for suspected infection to be provided
  • Action to be taken if the individual is excluded
  • Action to be taken if the individual/carer/parent/guardian declines treatment
  • Arrangements for referral for medical advice: Refer to the appropriate medical practitioner in the care pathway.
  • Doxycycline 100mg capsules
  • Doxycycline 100mg dispersible tablets
    • Description of treatment
    • Name, strength & formulation of drug
      • Doxycycline 100mg capsules
      • Doxycycline 50mg capsules
      • Doxycycline 100mg dispersible tablets
    • Legal category
      • POM
    • Route / method of administration
      • 50mg or 100mg capsules: Orally, swallowed whole with plenty of water while sitting or standing well before (at least one hour before) bedtime.
      • 100mg dispersible tablets: Orally, after allowing to disperse in a small amount of water, while sitting or standing well before (at least one hour before) bedtime.
      • If gastric irritation occurs, doxycycline can be taken with food or milk.
    • Off-label use
    • Dose and frequency of administration
      • Children 12–17 years and adults:
        • 200mg as a single dose on the first day and then 100mg once daily for 4 days
    • Duration of treatment
      • 5 days
      • Treatment should be started immediately and 5 days of treatment completed.
    • Quantity to be supplied
    • Storage
    • Drug interactions
    • Identification & management of adverse reactions
    • Management of and reporting procedure for adverse reactions
    • Written information to be given to individual/carer/parent/guardian
    • Individual advice / follow up treatment
    • Records
    Key references

    Key references

    • Fluticasone furoate
    • Mometasone furoate monohydrate
    • Phenoxymethylpenicillin (penicillin V)
    • Clarithromycin
    • Doxycycline
    • Clarithromycin
    Exclude: immunosuppressed individuals, chronic sinusitis (sinusitis that causes symptoms that last for more than 12 weeks), pregnant individuals under 16 years
    Exclude: immunosuppressed individuals, chronic sinusitis (sinusitis that causes symptoms that last for more than 12 we...
    NHSE PATHWAY
    NHSE PATHWAY
    Acute Sinusitis
    Acute Sinusitis
    (For adults and children aged 12 years and over)
    (For adults and children aged 12 years and over)

    Complications or high risk?
    Complications or...
    Gateway Point
    Gateway Point
    YES
    YES
    NO
    NO
    YES
    YES
    NO
    NO
    YES
    YES
    NO
    NO
     Offer Clarithromycin OR Doxycycline for 5 days
    (subject to inclusion / exclusion criteria in PGD)
    plus self care
    Offer Clarithromycin OR Doxycycline for 5 days...
    if pregnant
    if pregnant
    Acute sinusitis is a potential differential diagnosis
    Acute sinusitis is a potential differential di...
    NO
    NO
    YES
    YES
    NO
    NO
    YES
    YES

    Acute sinusitis less likely
    Acute sinusitis less likely
    Has the patient had symptoms for ≤10 days?
    Has the patient had symptoms for ≤10 days?



    or if unsuitable or ineffective offer antibiotics
    or if unsuitable or ineffective offer antibiotics
    FOR ALL PATIENTS: share self-care and safety-netting advice using TARGET Respiratory Tract Infection leaflets
    FOR ALL PATIENTS: share self-care and safety-netting advice using TARGET Respiratory Tract Infection...

    Content sourced and adapted from NHS Pharmacy First – Clinical Pathways and Patient Group Directions (PGDs) on the NHS England website, licensed under the Open Government Licence v3.0.

    Content sourced and adapted from NHS Pharmacy First – Clinical Pa...
    With ONE or more of:
    ☐ Facial pain/pressure (or headache) or
    ☐ Reduction (or loss) of the sense of smell (in adults)
    ☐ Cough during the day or at night (in children)
    With ONE or more of:...
    Diagnose acute sinusitis by the presence of ONE or more of:
    ☐ Nasal blockage (obstruction/congestion) or
    ☐ Nasal discharge (anterior/posterior nasal drip)
    Diagnose acute sinusitis by the presence of ONE or more of:...
    Acute sinusitis is usually caused by a virus and is only complicated by bacterial infection in about 2 in 100 cases. It takes 2–3 weeks to resolve, and most people will get better without antibiotics. Please share NICE information for the public.
    Acute sinusitis is usually caused by a virus and is only complicated by bacterial infection in about 2 in 10...
    Patients presenting with signs and symptoms of acute sinusitis
    Patients presenting with signs and symptoms of acute sinusitis
    15
    15
    Consider the risk of deterioration or serious illness
    Consider the risk of deterioration or serious illne...
    Consider calculating NEWS2 Score ahead of signposting patient to A&E or calling 999 in a life threatening emergency
    Consider calculating NEWS2 Scor...
    Consider alternative diagnosis and proceed appropriately
    Consider alternative diagnosis and proceed a...
    Self-care and pain relief
    Self-care and pain relief
    ☐ Antibiotic is not needed
    ☐ Sinusitis usually lasts 2-3 weeks
    ☐ Manage symptoms with self-care
    ☐ Safety netting advice
    ☐ Antibiotic is not needed...
    Does the patient have 2 or more of the following symptoms to suggest acute bacterial sinusitis:

    ☐ Marked deterioration after an initial milder phase
    ☐ Fever (>38°C)
    ☐ Unremitting purulent nasal discharge
    ☐ Severe localised unilateral pain, particularly pain over the teeth (toothache) and jaw
    Does the patient have 2 or more of the following symptoms to sug...
    Has the patient had symptoms for >10 days with no improvement
    Has the patient had symptoms for >10 days with no improvement
    Ask patient to return to Community Pharmacy if symptoms do not improve in 7 days for pharmacist reassessment
    Ask patient to return to Community Pharma...
    ☐ Acute sinusitis is usually caused by a virus.
    ☐ Antibiotics make little difference to how long symptoms last or the number of people whose symptoms improve
    ☐ Acute sinusitis is usually caused by a v...
    Offer high dose nasal corticosteroid (offlabel) for 14 days
    (subject to inclusion/exclusion criteria in PGD)
    Offer high dose nasal corticosteroid (offl...
    Shared decision making 
    approach based on severity of symptoms
    Shared decision making...
    Self-care and pain relief
    Self-care and pain relief
    Reported penicillin allergy
    (via National Care Record or Patient/Carer)
    Reported penicillin allergy...
    Offer high dose nasal corticosteroid (off-label) for 14 days 
    (subject to inclusion/exclusion criteria in PGD) 
    plus self care and pain relief instead of antibiotics first line
    Offer high dose nasal corticosteroid (off-label) for 1...
    Shared decision making 
    approach based on severity of symptoms
    Shared decision making...
    If symptoms worsen rapidly or significantly at any time,
    OR do not improve after completion of 7 days treatment course
    If symptoms worsen rapidly or significantly at any time,...
    Onward referral
    • General practice
    • Other provider as appropriate
    Onward referral...
    Offer Erythromycin for 5 days
    (subject to inclusion / exclusion criteria in PGD)
    plus self care
    Offer Erythromycin for 5 days...
     Offer Clarithromycin OR Doxycycline for 5 days
    (subject to inclusion / exclusion criteria in PGD)
    plus self care
    Offer Clarithromycin OR Doxycycline for 5 days...
    Offer Phenoxymethylpenicillin (if no allergy) for 5 days (subject to inclusion / exclusion criteria in PGD)
    plus self care
    Offer Phenoxymethylpenicillin (if no allergy) for 5 days...    Text is not SVG - cannot display
    3 Serious illness info
    Signs of meningitis, severe frontal headache, or focal neurological signs
    Signs of meningitis, severe frontal headache, or focal neurologica...
    Intraorbital or periorbital complications such as orbital cellulitis, displaced eyeball, reduced vision
    Intraorbital or periorbital complications such as orbital cellulit...
    Intracranial complications, including swelling over the frontal bone
    Intracranial complications, including swelling over the frontal bo...
    Consider calculating NEWS2 Score ahead of signposting patient to A&E or calling 999 in a life threatening emergency
    Consider calculating NEWS2 Scor...    Text is not SVG - cannot display
    5 Y/N toggle High risk
    With ONE or more of:
    ☐ Facial pain/pressure (or headache) or
    ☐ Reduction (or loss) of the sense of smell (in adults)
    ☐ Cough during the day or at night (in children)
    With ONE or more of:...
    Diagnose acute sinusitis by the presence of ONE or more of:
    ☐ Nasal blockage (obstruction/congestion) or
    ☐ Nasal discharge (anterior/posterior nasal drip)
    Diagnose acute sinusitis by the presence of ONE or more of:...
    NO
    NO    Text is not SVG - cannot display

    YES
    YES
    Consider calculating NEWS2 Score ahead of signposting patient to A&E or calling 999 in a life threatening emergency
    Consider calculating NEWS2 Scor...    Text is not SVG - cannot display
    Hidden
    8 Admit
    Hidden
    10 More clinical features
    12 Y/N toggle
    NO
    NO
    Acute sinusitis less likely
    Acute sinusitis less likely
    Consider alternative diagnosis and proceed appropriately
    Consider alternative diagnosis and proceed a...    Text is not SVG - cannot display
    Acute sinusitis is a potential differential diagnosis
    Acute sinusitis is a potential differential di...
    YES
    YES
    Has the patient had symptoms for ≤10 days?
    Has the patient had symptoms for ≤10 days?    Text is not SVG - cannot display
    15 Y/N toggle
    NO
    NO
    Has the patient had symptoms for >10 days with no improvement
    Has the patient had symptoms for >10 days with no improvement
    Does the patient have 2 or more of the following symptoms to suggest acute bacterial sinusitis:

    ☐ Marked deterioration after an initial milder phase
    ☐ Fever (>38°C)
    ☐ Unremitting purulent nasal discharge
    ☐ Severe localised unilateral pain, particularly pain over the teeth (toothache) and jaw
    Does the patient have 2 or more of the following symptoms to sug...    Text is not SVG - cannot display
    YES
    YES
    Self-care and pain relief
    Self-care and pain relief
    ☐ Antibiotic is not needed
    ☐ Sinusitis usually lasts 2-3 weeks
    ☐ Manage symptoms with self-care
    ☐ Safety netting advice
    ☐ Antibiotic is not needed...    Text is not SVG - cannot display
    18 + Gateway
    19 - Gateway
    20 Y/N toggle
    NO
    NO


    Ask patient to return to Community Pharmacy if symptoms do not improve in 7 days for pharmacist reassessment
    Ask patient to return to Community Pharma...
    ☐ Acute sinusitis is usually caused by a virus.
    ☐ Antibiotics make little difference to how long symptoms last or the number of people whose symptoms improve
    ☐ Acute sinusitis is usually caused by a v...
    Offer high dose nasal corticosteroid (offlabel) for 14 days
    (subject to inclusion/exclusion criteria in PGD)
    Offer high dose nasal corticosteroid (offl...
    Shared decision making 
    approach based on severity of symptoms
    Shared decision making...
    Self-care and pain relief
    Self-care and pain relief    Text is not SVG - cannot display
    YES
    YES
    or if unsuitable or ineffective offer antibiotics
    or if unsuitable or ineffective offer antibiotics
    Reported penicillin allergy
    (via National Care Record or Patient/Carer)
    Reported penicillin allergy...
    Offer high dose nasal corticosteroid (off-label) for 14 days 
    (subject to inclusion/exclusion criteria in PGD) 
    plus self care and pain relief instead of antibiotics first line
    Offer high dose nasal corticosteroid (off-label) for 1...
    Shared decision making 
    approach based on severity of symptoms
    Shared decision making...    Text is not SVG - cannot display
    23 Y/N toggle
    NO
    NO
    If symptoms worsen rapidly or significantly at any time,
    OR do not improve after completion of 7 days treatment course
    If symptoms worsen rapidly or significantly at any time,...
    Onward referral
    • General practice
    • Other provider as appropriate
    Onward referral...
    Offer Phenoxymethylpenicillin (if no allergy) for 5 days (subject to inclusion / exclusion criteria in PGD)
    plus self care
    Offer Phenoxymethylpenicillin (if no allergy) for 5 days...    Text is not SVG - cannot display

    YES
    YES
     Offer Clarithromycin OR Doxycycline for 5 days
    (subject to inclusion / exclusion criteria in PGD)
    plus self care
    Offer Clarithromycin OR Doxycycline for 5 days...
    if pregnant
    if pregnant
    If symptoms worsen rapidly or significantly at any time,
    OR do not improve after completion of 7 days treatment course
    If symptoms worsen rapidly or significantly at any time,...
    Onward referral
    • General practice
    • Other provider as appropriate
    Onward referral...
    Offer Erythromycin for 5 days
    (subject to inclusion / exclusion criteria in PGD)
    plus self care
    Offer Erythromycin for 5 days...
    Offer Clarithromycin OR Doxycycline for 5 days
    (subject to inclusion / exclusion criteria in PGD)
    plus self care
    Offer Clarithromycin OR Doxycycline for 5 days...    Text is not SVG - cannot display