Can I be prescribed antibiotics for my sinusitis or pneumonia without an in-person evaluation?

Do Not Prescribe Antibiotics Without In-Person Evaluation

You should not prescribe antibiotics for suspected sinusitis or pneumonia based solely on remote assessment—arrange a face-to-face evaluation first. 1

Why Remote Prescribing is Inappropriate

The 2024 NICE guidelines explicitly state that when a person is potentially ill enough to require antimicrobials, face-to-face assessment should be usual practice, and antimicrobials should not be routinely prescribed based on remote assessment alone 1. This recommendation exists because:

• No reliable remote indicators exist: No evidence supports identifying specific symptoms by remote assessment as a reliable indicator of severe illness—clinical judgment requires direct examination 1
• Diagnostic accuracy requires examination: Distinguishing bacterial from viral infection, assessing severity, and ruling out complications (like pneumonia with hypoxia or sepsis) necessitates physical findings, vital signs, and potentially point-of-care testing 1
• Patient safety concerns: Missing serious illness carries significant morbidity and mortality risk—pneumonia can rapidly deteriorate, and inappropriate antibiotics contribute to resistance without benefit 1

What You Should Do Instead

Immediate Actions

• Assess for red flags remotely: Ask about confusion, severe breathlessness, chest pain, inability to maintain oral intake, or rapid deterioration—any of these mandate urgent face-to-face evaluation 1
• Determine urgency: Based on symptom severity and rate of deterioration, decide whether same-day, next-day, or routine appointment is needed 1
• Provide safety netting: Explain when to seek immediate care (worsening breathlessness, confusion, high fever >39°C, inability to eat/drink) and expected symptom duration 1

For Suspected Sinusitis

Most acute rhinosinusitis (98-99.5%) is viral and resolves spontaneously within 7-10 days without antibiotics 2. Antibiotics are only indicated when symptoms meet specific criteria:

• Persistent symptoms ≥10 days without improvement 2
• Severe symptoms (fever ≥39°C with purulent discharge) for ≥3 consecutive days 2
• "Double sickening": worsening after initial improvement 2

Recommend over-the-counter management while awaiting evaluation: oral decongestants (not topical >3 days), acetaminophen or NSAIDs for pain, saline nasal irrigation, and adequate hydration 3

For Suspected Pneumonia

Pneumonia requires in-person assessment to:

• Calculate CRB65 score: Confusion, respiratory rate ≥30/min, blood pressure <90/60 mmHg, age ≥65 years stratify mortality risk (0=<1%, 1-2=1-10%, 3-4=>10%) 1
• Assess oxygenation: Pulse oximetry or arterial blood gas if severe 1
• Obtain chest radiograph: Confirms diagnosis and identifies complications (effusions, cavitation, multilobar involvement) 1

Special Considerations for High-Risk Patients

Lower your threshold for urgent face-to-face assessment in patients with:

• Comorbidities (COPD, heart failure, diabetes, immunosuppression) 1
• Age ≥65 years 1
• Frailty or multimorbidity 1

These patients have higher risk of poor outcomes and may require hospitalization even with moderate symptoms 1.

Critical Pitfalls to Avoid

• Never prescribe antibiotics to satisfy patient demands: Inappropriate antibiotic use contributes to resistance and exposes patients to unnecessary adverse effects without clinical benefit 2
• Don't assume purulent discharge means bacterial infection: Mucus color reflects neutrophils, not bacteria—viral infections also produce colored discharge 2
• Avoid "just in case" prescribing: Backup prescriptions without proper evaluation undermine diagnostic accuracy and promote inappropriate antibiotic use 1

Documentation and Communication

Document your clinical reasoning clearly:

• Symptoms reported and their duration
• Red flags assessed and ruled out
• Explanation provided to patient about why face-to-face evaluation is necessary
• Safety netting advice given
• Plan for follow-up if patient continues to decline in-person evaluation

If the patient absolutely refuses in-person evaluation despite your recommendation, document this refusal and the risks explained. Do not prescribe antibiotics in this scenario—instead, provide clear instructions for self-care and when to seek emergency care if symptoms worsen 1.