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Nasal decongestants offered no benefit in children compared with either placebo or mineral salts. This was based on a systematic review of RCTs (Smith et al. 2013; low quality evidence). No systematic reviews or RCTs of nasal decongestants in adults were identified. Nasal decongestants containing sympathomimetics can cause rebound congestion and should not be used for longer than 7 days. Acute sinusitis usually follows a common cold, and symptoms for around 10 days or less are more likely to be associated with a cold rather than viral or bacterial acute sinusitis. Therefore, the committee agreed that an antibiotic prescription should not be offered to people presenting with acute sinusitis symptoms for around 10 days or less. Prolonged symptoms (for around 10 days or more with no improvement) could be due to either viral or bacterial acute sinusitis. Viral acute sinusitis is more likely, but even bacterial sinusitis is usually self-limiting and does not routinely need antibiotics.

The committee acknowledged the recommendations in the previous NICE guideline on upper respiratory tract infections for a 'no' or a back-up antimicrobial prescribing strategy in acute sinusitis. An immediate antibiotic prescription is not recommended unless people are systemically very unwell, have symptoms and signs of a more serious illness, or are at high risk of serious complications because of pre-existing comorbidity. Based on evidence, their experience and resistance data, the committee agreed to recommend co-amoxiclav as the second-choice antibiotic for use only if symptoms get worse on a first-choice antibiotic.