• 
• 

Three Part Question

Do [prophylactic antibiotics] [prevent infectious complications] in [patients that have nasal packing placed for the treatment of epistaxis]?

Clinical Scenario

A 75 year old female, who is on multiple medications including a daily aspirin, presents to the emergency department for nosebleed that began 2 hours ago. Initial non-invasive treatments to stop the bleeding have been unsuccessful. After placing a nasal tampon you intend to start a five day course of prophylactic antibiotics. The patient complains, "is this medication really necessary?"

Search Strategy

Medline 1950-04/07 using the OVID interface, Cochrane Library (2007), PubMed clinical queries
[(exp epistaxis or nasal packing.mp or nasal tampon.mp) AND (exp anti-Bacterial Agents)]. LIMIT to human AND English

Search Outcome

185 papers found of which only 3 papers were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bandhauer, Florian May 2002 Switzerland	110 patients admitted for septoplasty and/or turbinate surgery Patients were randomized to receive 1 of 3 types of nasal packing: Merocel (polyvinyl acetate sponge) and Nose Fresh (cotton-gauze strips with sea salt ointment)- both antibiotic-free or a third antibiotic-containing packing, cotton gauze strips with polymixin-B-sulfante and oxytetracycline ointment (Terracortil). Nasal cavity smears pre-packing were compared to nasal smears, and culture of nasal packing removed on post-op day three.	Prosective, RCT. Level 2 b	Reduction in potentially infectious nasal flora (PINF), including staph aureus, in antibiotic-containing nasal packing.	Postoperative elimination of PINF was substantially greater in Terracortil group (66.7%) than the Merocel (12.5%) or the Nose Fresh (16.7%) nasal packs.	Patients were unequally divided among the three groups- 42 in the merocel group and 34 patients each in other two groups. This study does not show a direct link that antibiotic-containing nasal packing reduces infectious complications, just the probable association by reducing the isolates of PINF.
Derkay, C S et. al. April 1989 United States	20 patients with epistaxis that required posterior nasal packing that was impregnated with bacitracin ointment prospectively randomized to receive placebo or cefazolin 1 gram q8 during the placement of posterior nasal packing was maintained, for a minimum of 72 hours.	Prospective, double-blind, RCT. Level 2b	Baterial growth and the presence of foul-odor.	Heavy bacterial growth of multiple bacteria was seen in 89% of the placebo group compared to light to moderate growth of a single microorganism in the 90% of the antibiotic group. Foul-odor was present in 89% of the placebo group vs. 10% of the antibiotic group.	Small number of patients were enrolled. No infectious complications occurred in either group, so surrogate endpoints, that may not have a direct cause-effect relationship were used for evaluation.
Herzon, FS October 1971 United States	33 hospitalized patients with posterior nasal packing for control of epistaxis prospective randomization to oxytetracycline and polymixin B (Terracortil) coated vaseline gauze vs. vaseline coated gauze alone for anterior nasal packing combined with a foley catheter for posterior nasal packing. Packing was maintained for five days. Parenteral penicillin was administered while the pack was in place in all patients.	Prospective RCT. Level 2 b	Detection of bacteremia and nasal packing colonization after removal.	4/33 (2 patients in each group) had positive blood cultures (12% bacteremia), one patient in the no antibiotic group had fatal Klebsiella septicemia. The other 3 patients with positive blood cultures did not show signs of systemic illness. Antibiotic-containing packing, reliably demonstrated a single gram-positive organism or Proteus species on removal. Vaseline-only packing demonstrated multiple gram positive and negative bacteria on nasal culture.	The five day duration for nasal packing does not reflect current practices, and therefore, would increase the potential for infectious complications from nasal packing.

Comment(s)

Infectious complications such as staph toxic shock syndrome, sinusitis, and clinically-evident bacteremia following nasal packing occurs infrequently. These randomized control trials seem to lack the power needed to detect differences between prophylactic antibiotics given for nasal packing versus placebo. Indirectly, they all seem to suggest that prophylactic antibiotics decrease the amount and incidence of polymicrobial growth on nasal packing following removal, which may suggest that there is a decreased risk for infectious complications. Polymixin B and oxytetracycline antibiotic-impregnated nasal packing appears decrease potentially infectious nasal flora, including S. aureus.

Clinical Bottom Line

These studies incompletely address whether or not prophylactic antibiotics are needed to prevent infectious complications after nasal packing. It appears that at the very least, antibiotic containing nasal packing should be used to decrease the colonization of nasal packing. Nasal packing removal should be considered typically between 48-72 hours. Longer durations would unnecessarily increase infections complications without providing the additional benefit epistaxis control. Use of systemic antibiotics with nasal packing are important for patients with structural heart disease. Their use for otherwise healthy patients should be considered, but evidence supporting this practice is weak.

References

1. Bandhauer, Florian. Buhl, Daniela. Grossenbacher, Rudolf Antibiotic Prophylaxis in Rhinosurgery American Journal of Rhinology 16 (3) May-June 2002; 135-139
2. Derkay, C S et. al. Posterior Nasal Packing: Are Intravenous Antibiotics Really Necessary? Archives of Otolaryngology Head Neck Surgery April 1989; 439-441
3. Herzon, FS Bacteremia and local infections with nasal packing. Archives of Otolaryngology October 1971; 317-320