Anterior Nasal Packing After Epistaxis: Who Nose Which Patients Need Prophylactic Antibiotics?
CASE
Case Presentation:
44 year-old female with hypertension and end-stage renal disease (on hemodialysis) with 45 minutes of uncontrollable epistaxis.
She denied any inciting trauma, recent surgery, dizziness, lightheadedness, upper respiratory symptoms, or anticoagulant use.
She had a similar episode in the past which resolved after packing with tranexamic acid (TXA) soaked gauze.
Upon arrival to the ED, she was actively bleeding from the right nare and there was no identifiable source from Kiesselbach’s plexus
She was maintaining a patent airway, breathing normally and hemodynamically stable.
We packed the right nare with 4x4 gauze soaked in TXA, but this only minimally slowed the bleeding and pushed more blood towards her nasopharynx.
We then placed a Rapid Rhino soaked in oxymetazoline into the nare which stopped the bleeding successfully.
We planned for her to return to the ED two days later for packing removal and discharged her on amoxicillin-clavulanate.
She returned for packing removal two days later without complications.
Clinical Question:
In which patients should we prescribe prophylactic antibiotics after the placement of anterior nasal packing for epistaxis? Particularly, should we prescribe antibiotics to patients at high-risk for infection, such as those with immunocompromising conditions, and which immunocompromising conditions warrant antibiotics?
SUMMARY OF EVIDENCE
To date, there are no prospective, randomized controlled trials assessing the utility of antibiotics in the setting of anterior nasal packing after epistaxis. Only observational data exists to address the theoretical risk of infection with retained packing.
The practice of many has been to prescribe antibiotics for the duration of packing to prevent theoretical sinus infection, endocarditis[1,2] and toxic shock syndrome (TSS)[3], however, antibiotic use is associated with its own risks.[4]
The strongest data available to answer this specific question is a systematic review and meta-analysis of 383 adults receiving prophylactic antibiotics (primarily amoxicillin-clavulanate) after epistaxis and anterior nasal packing. The review was an analysis of five observational studies: two prospective and three retrospective; two of which were from emergency department populations, and three of which were from otolaryngology inpatients.[5]
The primary outcome of interest was the proportion of “clinically significant infections (CSI)” (skin infections of face/nares, sinusitis, otitis media or TSS).
The Absolute Risk Reduction of CSI when utilizing antibiotics was found to be 0.00175 (95% CI 0.02–5.57) with a Number Needed to Treat of 571. The Odds Ratio of developing CSI in the non-antibiotic group was 1.4, which was non-significant (95% CI 0.9–22, p = 0.99).
The papers cited by this systematic review did not exclude patients with underlying medical conditions such as immunocompromise but did not describe the specific presence or outcomes of these groups. Three studies excluded post-operative epistaxis[6-8], one excluded those with bilateral packing[9], one excluded those under 18, those with traumatic origin and those with multiple visits.[6]
Overall, this study demonstrated scant benefit of prophylactic antibiotics and had significant flaws. For one, the study was limited by its relatively small sample size and the type of packing used was unknown. Also, while there was a low I2 value indicating homogeneity, this may be incorrectly reassuring as all the CSIs came from the same study.[10] Lastly, all the studies in the review were observational so no causal relationship could be determined.
A literature review from 2015{11] included three of these same studies[8-10], all from inpatient otolaryngology departments. The authors came to a similar conclusion that these low-strength studies show little benefit to antibiotics. They acknowledge, however, that patients with immunocompromise or valvular disease may need antibiotics.
The only other major study since the publication of this systematic review was a single-center retrospective study of 275 cases of anterior packing. Approximately half had nonabsorbable nasal packing placed and one quarter had both nares packed.[12]
There was no significant difference in the rate of sinusitis comparing antibiotic vs. no antibiotic groups, regardless of packing type (1% vs 0.56%, p = 0.68), and no other infectious complications occurred.
This study documented the inclusion of five patients with long-term steroid or immunosuppressant use, 14 with prosthetic heart valves and 44 patients with diabetes, so this research has increased applicability to the immunocompromised patient population in question. Interestingly, none of the patients on immunosuppressants, 28% of those with prosthetic heart valves and 41% of the patients with diabetes received prophylactic antibiotics.
With such low rates of complications overall and a sizable amount of patients included with diabetes, it’s likely there was no difference between antibiotic and non-antibiotic group among those with diabetes. But, given the small number of patients with prosthetic valves and on long-term steroid or immunosuppressant use, this same conclusion cannot be strongly made.
Overall, this study provides additional observational evidence against prophylactic antibiotics but was limited in its description of outcomes for immunocompromised patients and those with valvular heart disease.
There is additional relevant literature about antibiotic use after posterior packing and surgery.
In the one RCT on the topic of nasal packing, 20 patients with posterior packing after epistaxis were randomized to receive placebo or cefazolin. There were no infectious complications in either group but packing from the placebo arm was more often foul-smelling and had heavier growth of bacteria, while packing from the antibiotic group more often had no odors and had lighter growth of bacteria. This study was limited by a small sample size.[13]
In a systematic review of 990 patients requiring nasal packing (majority post-surgical, the remaining of which come from studies discussed above), when comparing antibiotic and no antibiotic groups, there were no episodes of TSS overall and among septoplasty patients, there were similar levels of purulent drainage. None of the included post-surgical studies explicitly discussed immunocompromised patients.[14]
Overall, both studies again show no significant patient-oriented benefit to antibiotics after nasal packing, even in posterior and post-surgical packing. They also did not report specific outcomes of patients with infection risk-factors.
RECOMMENDATIONS
There is no high-level evidence supporting universal antibiotic use after placing anterior nasal packing. For low-risk, otherwise-healthy patients it is reasonable to withhold antibiotics and provide close follow up and return precautions. For patients with diabetes, it is also likely safe to withhold antibiotics.
For higher-risk patients with immunocompromising conditions, the decision to provide antibiotics is less clear. Based upon case reports, those with valvular heart disease and prosthetic valves may be at risk for endocarditis and could benefit from antibiotics. Otherwise, studies to date have not provided the outcome data to indicate benefit, or lack thereof, of antibiotic administration in patients with immunocompromising conditions like malignancy, HIV, long-term steroid or immunosuppressant use, genetic syndromes, or end-stage renal disease requiring dialysis. Until stronger evidence is available for which conditions classify as high-risk and which high-risk patients would receive benefit from antibiotics, clinicians should have a risk-benefit discussion with the patient in the context of their specific medical history.
REFERENCES
1. Gungor H, Ayik MF, Gul I, et al. Infective endocarditis and spondylodiscitis due to posterior nasal packing in a patient with a bioprosthetic aortic valve. Cardiovascular Journal of Africa. 2012;23(2):e5-e7. doi: 10.5830/CVJA-2011-002.
2. Jayawardena S, Eisdorfer J, Indulkar S, Zarkaria M. Infective endocarditis of native valve after anterior nasal packing. Am J Ther. 2006;13(5):460-462. doi: 10.1097/01.mjt.0000209683.99205.4f.
3. Guevara EC. Toxic shock syndrome associated with nasal packing: Analogy to tampon-associated illness. Ann Emerg Med. 1984;13(7):574. doi: 10.1016/S0196-0644(84)80551-X.
4. Salvo F, De Sarro A, Caputi AP, Polimeni G. Amoxicillin and amoxicillin plus clavulanate: A safety review. Expert Opin Drug Saf. 2009;8(1):111-118. doi: 10.1517/14740330802527984.
5. Tran QK, Rehan MA, Haase DJ, Matta A, Pourmand A. Prophylactic antibiotics for anterior nasal packing in emergency department: A systematic review and meta-analysis of clinically-significant infections. Am J Emerg Med. 2020;38(5):983-989. doi: 10.1016/j.ajem.2019.11.037.
6. Murano T, Brucato-Duncan D, Ramdin C, Keller S. Prophylactic systemic antibiotics for anterior epistaxis treated with nasal packing in the ED. Am J Emerg Med. 2019;37(4):726-729. doi: 10.1016/j.ajem.2018.12.056.
7. Germann CA, Southall JC. Management of epistaxis and complications associated with anterior nasal packing. Ann Emerg Med. 2004;44(4):S43-S44. doi: 10.1016/j.annemergmed.2004.07.143.
8. Pepper C, Lo S, Toma A. Prospective study of the risk of not using prophylactic antibiotics in nasal packing for epistaxis. J Laryngol Otol. 2012;126(3):257-259. doi: 10.1017/S0022215111003215.
9. Biswas D, Mal RK. Are systemic prophylactic antibiotics indicated with anterior nasal packing for spontaneous epistaxis? Acta Otolaryngol. 2009;129(2):179-181. doi: 10.1080/00016480802043964.
10. Biggs TC, Nightingale K, Patel NN, Salib RJ. Should prophylactic antibiotics be used routinely in epistaxis patients with nasal packs? Ann R Coll Surg Engl. 2013;95(1):40-42. doi: 10.1308/003588413X13511609954734.
11. Cohn B, M.D. Are prophylactic antibiotics necessary for anterior nasal packing in epistaxis? Ann Emerg Med. 2014;65(1):109-111. doi: 10.1016/j.annemergmed.2014.08.011.
12. Hu L, Gordon SA, Swaminathan A, Wu T, Lebowitz R, Lieberman S. Utilization of prophylactic antibiotics after nasal packing for epistaxis. J Emerg Med. 2021;60(2):144-149. doi: 10.1016/j.jemermed.2020.10.011.
13. Derkay CS, Hirsch BE, Johnson JT, Wagner RL. Posterior nasal packing. are intravenous antibiotics really necessary? Arch Otolaryngol Head Neck Surg. 1989;115(4):439-441. doi: 10.1001/archotol.1989.01860280037013.
14. Lange JL, Peeden EH, Stringer SP. Are prophylactic systemic antibiotics necessary with nasal packing? A systematic review. Am J Rhinol Allergy. 2017;31(4):240-247. doi: 10.2500/ajra.2017.31.4454.
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