Do All Packed Noses Get Antibiotics?

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The issue

Due to the fear of toxic shock syndrome (TSS), it has long been considered the standard of care to prescribe antibiotics as prophylaxis for patients who receive packing to treat anterior epistaxis.  This practice originates from case reports in the otolaryngology literature describing patients developing TSS after packing was placed post-operatively for septal surgery without antibiotic prophylaxis.  Additionally, sinusitis and otitis media have been thought to occur at increased frequency in patients with anterior packing, serving as additional justification for antibiotic prophylaxis in this population.

The problem

Toxic shock syndrome can cause multi-system organ failure and occurs in 16.5/100,000 cases following nasal surgery.  Sinusitis and otitis media can lead to deep space infections, meningitis, and sepsis.  Antibiotic overuse, on the other hand, is associated with unnecessary patient costs, antibiotic resistance, c. difficile infections, GI upset, and allergic reactions including Stevens-Johnson Syndrome.

Prior evidence

There has never been a case report of toxic shock syndrome resulting from anterior nasal packing for spontaneous, atraumatic epistaxis.  The only case reports of TSS are from the ENT literature regarding postoperative complications from nasal surgery.  Unfortunately, the number of studies on infections after anterior packing is sparse, but these studies have been summarized in the attached article by Dr. Brian Cohn in Annals of Emergency Medicine (1).  It is important to note that these three articles have studied a combined total of 234 patients:

Biswas et al (2009) found in a prospective study (n=28) that bacterial growth in the nares of patients that received packing for anterior epistaxis did not differ between patients who were given antibiotics and those who were not.  Pepper et al (2012) found in their prospective trial that none of their 149 patients that were admitted for epistaxis with anterior packing developed infectious complications, whether antibiotics were given or withheld.  Biggs et al (2013) studied 57 similar patients, and found that withholding antibiotic prophylaxis did not increase the rate of infective nasal symptoms, re-bleeding, or readmission rates.

Current guidelines

Cohn (AEM, 2015) has recommended that for patients with anterior epistaxis that require packing, antibiotics should be withheld from otherwise healthy patients (though considered for those that are immunocompromised or with valvular heart disease).  UpToDate has a similar stance, only recommending antibiotics for those at greater risk of infection.  Guidelines are lacking in the ENT literature, but around ¾ of patients with packing for epistaxis are treated with antibiotics by otolaryngologists, though most recognize that the data is lacking to either support or refute this practice.

Our otolaryngology department’s stance

I discussed the issue with Dr. John Barrord and Dr. Keith Wilson of otolaryngology, who were kind enough to share their recommendations and preferences.  They acknowledge the lack of evidence in the literature supporting the use of antibiotics, but given that the practice is not refuted by the literature and the severity of TSS and other potential infections that may result, do recommend giving antibiotic prophylaxis for the duration that the nasal packing is left in.  

  • Typical antibiotics used: Keflex, Augmentin (staphylococcal coverage)
  • Typical time course: Duration of packing
  • Typical packing time: Should be removed in 24-72 hours

Obligatory TXA plug

Using tranexamic acid can be extremely helpful in these patients, potentially eliminating the need for packing by allowing eventual visualization of the bleed and cauterization with silver nitrate.  If cautery is successful, packing is unnecessary, and the antibiotic issue is moot.  Please see the attached article on TXA for further information on how to perform this procedure (2). 

Bottom line

  • Antibiotics are given to patients with packing for anterior epistaxis to minimize the incidence of toxic shock syndrome, sinusitis, and otitis media
  • The amount of data supporting or refuting this practice is small, though is enough for the EM literature (and UpToDate) to recommend not administering antibiotic prophylaxis to all of these patients, and only using prophylaxis on the immunocompromised or those with valvular heart disease
  • Strict guidelines do not exist in the otolaryngology literature, but given the potential complications, most otolaryngologists, including our own, do recommend prophylaxis with either Keflex or Augmentin for the duration of the packing, which should be removed in 24-72 hours
  • Antibiotics should always be given when posterior packs are placed.
  • Try TXA and then chemical cautery to make this issue moot (see attached article)

My personal recommendation

The decision to prescribe antibiotics for anterior nasal packing for spontaneous epistaxis should be made on a case-by-case basis.  Prescribe antibiotics for the immunocompromised, those with valvular heart disease, or those patients who may be unreliable regarding following up.  If a patient has a history of c. difficile, adverse reactions to antibiotics, or other relative contraindications, it would not be unreasonable to withhold antibiotics. 

References

  1. MD BC. Are Prophylactic Antibiotics Necessary for Anterior Nasal Packing in Epistaxis? Annals of Emergency Medicine 2015;65(1):109–11.

  2. Biswas D, Mal RK. Are systemic prophylactic antibiotics indicated with anterior nasal packing for spontaneous epistaxis? Acta Oto-Laryngologica 2009;129(2):179–81.

  3. C Pepper et al. Prospective Study of the Risk of Not Using Prophylactic Antibiotics in Nasal Packing for Epistaxis J Laryngol Otol 126 (3), 257-259. 2012 Jan 04

  4. Biggs, T., Nightingale, K., Patel, N., & Salib, R. (2013). Should prophylactic antibiotics be used routinely in epistaxis patients with nasal packs? Annals of The Royal College of Surgeons of England, 95(1), 40–42. http://doi.org/10.1308/003588413X13511609954734

  5. MD RZ, MD PM, MD SA, PhD AG, MD MS. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. American Journal of Emergency Medicine 2013;31(9):1389–92