Definition of severe immunosuppression  

Individuals with primary or acquired immunodeficiency states due to conditions including: 

• Acute and chronic leukaemias, and clinically aggressive lymphomas (including Hodgkin’s lymphoma) who are less than 12 months since achieving cure  
• Individuals under follow up for a chronic lymphoproliferative disorder including haematological malignancies such as indolent lymphoma, chronic lymphoid leukaemia, myeloma, and other plasma cell dyscrasias  
• Immunosuppression due to HIV/AIDS with a current CD4 count of below 200 cells/mcl  
• Primary or acquired cellular and combined immune deficiencies – those with lymphopaenia or with a functional lymphocyte disorder 
• Those who have received an allogeneic (cells from a donor) or an autologous (using their own cells) stem cell transplant in the previous 24 months 
• Those who have received a stem cell transplant more than 24 months ago but have ongoing immunosuppression or graft versus host disease (GVHDI).

Individuals on immunosuppressive or immunomodulating therapy including:  

• Those who are receiving or have received in the past six months immunosuppressive chemotherapy or radiotherapy for any indication  
• Those who are receiving or have received in the previous six months immunosuppressive therapy for a solid organ transplant  
• Those who are receiving or have received in the previous three months targeted therapy for autoimmune disease, such as JAK inhibitors or biologic immune modulators including B-cell targeted therapies, monoclonal tumour necrosis factor inhibitors (TNFi), T-cell co-stimulation modulators, soluble TNF receptors, interleukin (IL)-6 receptor inhibitors., IL-17 inhibitors, IL 12/23 inhibitors, IL 23 inhibitors

Individuals with chronic immune mediated inflammatory disease who are receiving or have received immunosuppressive therapy: 

• Moderate to high dose corticosteroids (equivalent ≥20mg prednisolone per day) for more than 10 days in the previous month 
• Long term moderate dose corticosteroids (equivalent to ≥10mg prednisolone per day for more than 4 weeks) in the previous 3 months 
• Any non-biological oral immune modulating drugs, eg. methotrexate >20mg per week; azothioprine >3.0mg/kg/day; 6-mercaptopurine >1.5mg/kg/day, mycophenolate >1g/day) in the previous 3 months 
• Certain combination therapies at individual doses lower than stated above, including those on ≥7.5mg prednisolone per day in combination with other immunosuppressants (other than hydroxychloroquine or sulfasalazine) and those receiving methotrexate (any dose) with leflunomide in the previous three months.

Individuals who have received a short course of high dose steroids (equivalent >40mg prednisolone per day for more than a week) for any reason in the previous month. 

In addition to medication, each patient treated under a PGD should be: 

• Advised to seek medical advice if they develop blurred vision or other visual disturbances during treatment 
• Provided with the Treating Your Infection Respiratory Tract Infection (TYI-RTI) patient information leaflet (TARGET RTI leaflet)  
• Be given the appropriate medicine patient information leaflet 
• If receiving a nasal spray, given explanation of method of administration including how to use the nasal spray. 
  
  
• Given self-care advice including:  
• Paracetamol and ibuprofen can be used for pain and/or fever (where appropriate)  
• Little evidence that nasal saline (salt water) or OTC nasal decongestants help relieve nasal congestion, but individuals may want to try them.  
• No evidence to support the use of oral decongestants, antihistamines, mucolytics, steam inhalation or warm face packs for acute sinusitis.  

The RCGP’s TARGET antibiotic checklist can be used for counselling individuals/parents/carers (foreign language versions are available).  

 For individuals where treatment is not indicated:  

• Advise acute sinusitis is usually caused by a virus, can take 2-3 weeks to resolve, and most people will get better without treatment 
• Where intranasal steroids are unlikely to be of benefit, provide self-care advice 
• Advise individual to seek medical help if symptoms worsen rapidly or significantly or if they do not improve after 3 weeks.