Brief Report
Prophylactic systemic antibiotics for anterior epistaxis treated with nasal packing in the ED

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Abstract

Background

Emergency Department (ED) patients presenting with spontaneous epistaxis who have anterior nasal packing are routinely prescribed systemic prophylactic antibiotics in spite of the lack of supporting evidence-based literature. Although there is literature that discusses infection rates with nasal packing for epistaxis and prophylactic antibiotics prescribing practices of otolaryngologists, this is the first study to our knowledge that examines the practices of emergency physicians.

Objectives

The main objective of this study was to compare the infection rate between patients who were and were not prescribed prophylactic systemic antibiotics for anterior nasal packing in spontaneous epistaxis and to examine current management practices of antibiotic prescribing for these patients.

Methods

A retrospective review of ED patients ≥ 18 years old with the discharge diagnosis of epistaxis was performed over a 5-year period. Patients who had multiple visits to the ED for epistaxis or recent nasal or sinus surgery were excluded.

Results

Over half of the patients, 57/106 (53.7%), who had anterior packing were prescribed prophylactic systemic antibiotics. Of these patients, 69/106 (65%) returned for a follow-up visit. There were no documented infections for any of these patients regardless of whether or not they were prescribed antibiotics. There was no significant difference with respect to rate of infection found between these two groups (the p-value = 0.263).

Conclusion

The absence of infection supports previous findings and suggests that prophylactic antibiotic use for nasal packing in spontaneous epistaxis patients is not necessary. Further randomized controlled studies are necessary to definitively support this practice change.

Introduction

Epistaxis is a common condition that can occur at any age, with an increase in the prevalence and severity in individuals 50 years of age and older [1]. There is an approximate 60% lifetime prevalence for having at least one episode of epistaxis and approximately 6% of these individuals seek medical attention accounting for 1 in 200 Emergency Department (ED) visits in the United States [[1], [2], [3], [4], [5], [6], [7], [8]].

Bleeding originating from the anterior nasal septum (at the opening just inside the nares at the Kiesselbach plexus) is most common and accounts for 90% of all epistaxis cases [4,8]. Conversely, posterior epistaxis accounts for approximately 5% to 10% of all cases. The causes of epistaxis can be from something as simple as nose picking, nasal irritants, dry mucous membranes, or can occur from something more significant such as trauma, illicit drug use, anti-inflammatory agents, anti-coagulants, hypertension, or other medical conditions such as cancerous lesions and bleeding disorders [1,4,8]. Treatment options for anterior epistaxis include cautery with silver nitrite, nasal packing with devices such as foam polymer nasal tampons or various balloon-tamponade devices.

Historically, the use of systemic prophylactic antibiotics for patients who had nasal packing was deemed necessary to prevent bacterial infection, specifically Toxic Shock Syndrome (TSS) [1,4,6,8]. Although there are cases of TSS with the use of packing following nasal surgery reported in the literature, there is only one such case reported with spontaneous epistaxis [9,10]. Although there is little supporting literature for the use of prophylactic antibiotics, it is included in some of the current management protocols for epistaxis patients who have anterior nasal packing [[11], [12], [13], [14]].

In 2009, the focus of epistaxis management algorithms started to shift towards creating better methods of controlling bleeding and decreasing the use of systemic prophylactic antibiotics [12]. There has also been recognition of the potential risks of unnecessary antibiotic use, including Clostridium difficile infection, Stevens-Johnson syndrome, anaphylaxis and gastrointestinal disturbances [13]. Along with these potential risks, unnecessary administration of systemic antibiotics is also a cause of antibiotic resistance. In spite of the fact that more recent studies have demonstrated that there are no improved outcomes or decrease in infection rates with the use of systemic prophylactic antibiotics [11,12,15], the practice of prescribing antibiotics continues.

The objective of this study was to compare the infection rate between patients who were and were not prescribed prophylactic systemic antibiotics for anterior nasal packing in spontaneous epistaxis and to examine current management practices of prophylactic antibiotic prescribing for these patients.

Although there is literature that discusses infection rates with nasal packing for epistaxis and prophylactic antibiotics prescribing practices of otolaryngologists, this is the first study to our knowledge that examines the practices of emergency physicians.

Section snippets

Methods

This study was conducted at a level-1 trauma center in an academic institution in an urban setting with an annual Emergency Department (ED) volume of approximately 90,000 visits. A retrospective chart review of Emergency Department patients over a 5-year period between January 1, 2012 and December 31, 2016 was performed. A search of the electronic medical record (EMR) database for patients with a diagnosis of epistaxis was conducted. Inclusion criteria included patients who were ≥18 years of

Results

During the 5-year period, there were a total of 1270 patient encounters in the ED that had a discharge diagnosis of epistaxis. Of those 1270 patients, 443 were excluded because they were under the age of 18 years old. Of the remaining 827 adult patient encounters, 131 patients had trauma as a cause of epistaxis and therefore were excluded. There were 120 encounters excluded because the patients either left without being seen or they were seen multiple times within 72 h of the original visit for

Discussion

Prophylactic antibiotics for anterior nasal packing in spontaneous epistaxis were prescribed in 53% of patients in our ED. This percentage reflects the controversy and perhaps the lack of compelling evidence that exists to support prophylactic antibiotic use in this clinical scenario. The current use of prophylactic systemic antibiotics in the management of patients with anterior nasal packing for epistaxis assumes that such patients are at greater risk of developing TSS, recurrent epistaxis,

Conclusions

Approximately half of the physicians in our ED continue to prescribe prophylactic antibiotics for anterior packing in patients with spontaneous epistaxis. This is likely due to the fact that there is a paucity of adequately powered studies to demonstrate the lack of benefit of this practice. Implementation of treatment algorithms may be helpful in standardizing the prescribing practices and risk stratifying those patients who would benefit most from prophylactic antibiotics. The current study

Declaration of interest

None.

References (20)

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    In 2017, a systematic review by Lange et al. found no statistically significant benefit to prophylactic antibiotics use in patients with nasal packing across six studies (6). In 2019, Murano et al. evaluated the antibiotic prescribing practices of emergency physicians treating anterior epistaxis, finding 53.7% (57 of 106) of patients with packing were prescribed prophylactic systemic antibiotics (7). They found no significant difference with respect to rate of infection between the two groups.

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    There is also one case report of toxic shock syndrome in a patient who had bone marrow transplant for acute myeloid leukemia and received anterior nasal packing.[5] We were unable to examine the effect of immunosuppression on risk of infection after nasal packing, as only one study within our meta-analysis examined patients' immunocompetency [14]. Due to lack of clear consensus or guidelines, the practice of prescribing antibiotics for patients with anterior nasal packing varies.

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