Background: Epistaxis is a common Emergency Department (ED) complaint with over 450,000 visits per year and a lifetime incidence of 60% (Gifford 2008, Pallin 2005). Posterior epistaxis is considerably less common than anterior epistaxis and represents about 5-10% of all presentations. Many patients with posterior epistaxis will be managed with a posterior pack and admitted for further monitoring. Traditional teaching argues that patients with anterior packs should be given prophylactic antibiotics to prevent serious infectious complications. This post endeavors to review the literature behind the traditional teaching and use the evidence to guide our management. Unfortunately, the literature base is scant on all topics regarding epistaxis. Randomized Double-Blind Control Trials (RDCT) are rare and study quality is overall very poor.

Dogma: Prophylactic antibiotics are necessary for patients with nasal packs.

The concern is that patients with packing in place are at a high risk of developing infectious complications including acute otitis media (AOM), sinusitis and toxic shock syndrome (TSS). A deep dive into the archives resulted in four studies that look at the question (1 on posterior packs, 2 on anterior packs and one non-specified).

Derkay CS et al. Posterior nasal packing. Are Intravenous antibiotics really necessary? Arch Otolaryngol 1989; 115: 439-41. PMID: 2923686

  • Design: Randomized double-blind controlled trial
  • Population: 20 patients with posterior packs (all packs were impregnated with antibiotics)
  • Intervention: Intravenous cefazolin
  • Control: Placebo (exact content not specified)
  • Follow Up Interval: Not Specified
  • Outcome:
    • Neither group had any infectious complications.
    • Packing Growth
      • Placebo group: foul smelling and 8/10 had heavy growth of multiple organisms.
      • Cefazolin group: 8/10 packing had light growth of a single organism.

Pepper C et al. Prospective study of the risk of not using prophylactic antibiotics in nasal packing for epistaxis. J Laryng Otology 2012: 257-9. PMID: 22214602

  • Design: Before and after non-randomized, non-blinded study
  • Population: 149 patients requiring packing for epistaxis
  • Intervention: Amoxicillin/Clavulanic Acid in first 78 patients
  • Control: No antibiotics in 71 patients
  • Follow Up Interval: Not specified
  • Outcome: Neither group had an infectious complication.

Biswas D, Mal RK. Are systemic prophylactic antibiotics indicated with anterior packing for spontaneous epistaxis. Acta Oto-Laryngologica 2009; 129: 179-81. PMID: 18607977

  • Design: Prospective, cohort study
  • Population:
    • 21 patients with anterior packing
    • 9/21 received antibiotics
  • Outcomes: The investigators sent swabs from the packed and unpacked nares and found no difference in bacterial growth in the antibiotic and no antibiotic group.

Biggs TC et al. Should prophylactic antibiotics be used routinely in epistaxis patients with nasal packs? Ann R Coll Surg Engl 2013; 95: 40-2. PMID: 23317726

  • Design: Before and after implementation of an institution wide algorithm (calling for restricted antibiotic use)
  • Population:
    • 38 patients enrolled prior algorithm institution (> 70% received prophylactic antibiotics)
    • 19 patients enrolled after algorithm institution (12% received prophylactic antibiotics)
  • Outcomes: Neither group had any infectious complications despite the change in antibiotic prescription rate.

Summary:

  • Although the identified studies are of varying quality and methods, overall it appears that administration of IV, oral or topical antibiotics was no different than placebo in terms of infectious outcomes.
  • It is important to note that in all studies, packing was removed after 24-48 hours.
  • In the Derkay study, the presence of single organism growth in the antibiotic group raises the concern of selecting out resistant organisms.
  • These results may not apply to patients who are immunosuppressed (i.e. AIDS, chronic immunosuppressant use, poorly controlled diabetes etc) or at higher risk from transient bacteremia (i.e. valvular heart disease)
  • Antibiotics have a number of known nasty side effects including diarrhea (in up to 1 in 8 patients), allergic reactions and severe anaphylaxis (in up to 0.024%).

Bottom Line: The available evidence does not support the routine use of prophylactic antibiotics in patients who require anterior nasal packing for epistaxis.  Consider antibiotics in a select group of patients (immunosuppression, valvular heart disease).

Read More

REBEL EM: Do Patients with Epistaxis Managed by Nasal Packing Require Prophylactic Antibiotics?

Cohn B. Are prophylactic antibiotics necessary for anterior nasal packing in epistaxis? Ann Emerg Med 2015; 65(11): 109-11. PMID: 25220955

References:

Gifford TO, Orlandi RR. Epistaxis. Otolaryngol Clin North Am. 2008;41:525-536. PMID: 18435996

Pallin DJ, Chng YM, McKay MP, et al. Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Ann Emerg Med. 2005;46:77-81. PMID: 15988431

Derkay CS et al. Posterior nasal packing. Are Intravenous antibiotics really necessary? Arch Otolaryngol 1989; 115: 439-41. PMID: 2923686

Pepper C et al. Prospective study of the risk of not using prophylactic antibiotics in nasal packing for epistaxis. J Laryng Otology 2012: 257-9. PMID: 22214602

Biswas D, Mal RK. Are systemic prophylactic antibiotics indicated with anterior packing for spontaneous epistaxis. Acta Oto-Laryngologica 2009; 129: 179-81. PMID: 18607977

Biggs TC et al. Should prophylactic antibiotics be used routinely in epistaxis patients with nasal packs? Ann R Coll Surg Engl 2013; 95: 40-2. PMID: 23317726