We have all taken care of patients with stubborn nosebleeds. The patient holds pressure, we hold pressure, we attempt cautery, and just as the patient is about to be discharged, the bleeding recurs. Often, these patients end up with nasal packs and are sent home on antibiotics to follow up with an ENT. But is that antibiotic prescription necessary? We know that antibiotics have a number of known nasty side effects, including diarrhea (up to 12.5% of patients), allergic reactions, and severe anaphylaxis (up to 0.024%).
Epistaxis is a common emergency department complaint leading to more than 450,000 visits per year and a lifetime incidence of 60 percent. (Otolaryngol Clin North Am 2008;41:525; Ann Emerg Med 2005;46:77.) Posterior epistaxis is considerably less common than anterior epistaxis, and represents about five to 10 percent of all presentations.
Prophylactic antibiotics are prescribed with packing because we worry that patients with packs are at high risk for infectious complications, including acute otitis media, sinusitis, and toxic shock syndrome. A deep dive into the literature finds little to guide our management. The available evidence is poor quality, and there is an overwhelming absence of high-quality, randomized, double-blind, placebo-controlled trials. Only four relevant studies exist when it comes to the dogma or routine prescription of antibiotics for nasal packing.
Posterior Nasal Packing. Are Intravenous Antibiotics Really Necessary?
Derkay CS, Hirsch BE, et al.
Arch Otolaryngol Head Neck Surg
Derkay and colleagues randomized 20 patients (I know, I know; I was floored by this huge study as well) who required posterior packs for spontaneous epistaxis to receive IV Cefazolin or placebo. All of the packs were impregnated with antibiotics, and all of the packs stayed in for at least 72 hours. (The study did not specify the exact length of time for packing.) Not a single patient developed an infectious complication. The authors noted that the study sample is too small to make any significant conclusions, that the results did not change their practice, and they recognize the need for a larger, multi-institutional trial to answer the question. Sadly, no one has undertaken such a trial.
Prospective Study of the Risk of Not Using Prophylactic Antibiotics in Nasal Packing for Epistaxis
Pepper C, Lo S, Toma A
J Laryngol Otol
This study is the largest of the group, enrolling 149 patients with spontaneous epistaxis in a before-and-after design. Essentially, protocol was changed at the author's tertiary otorhinolaryngology referral hospital toward using antibiotic prophylaxis in patients discharged with packing in place. The researchers enrolled 78 patients during the empiric prophylactic antibiotics phase (in this case — amoxicillin/clavulanic acid), and 71 patients were enrolled prior to mandatory antibiotic use. The placement of packing (anterior or posterior) was not specified, and most patients had packing in for 24 to 36 hours. No randomization or blinding was employed as a result of this design. The authors found no infectious complications in any of the patients examined even with these risks of bias, which intrinsically favored the intervention arm.
Based on these limited data, perhaps all patients receiving nasal packing don't require prophylactic antibiotics, and maybe they should be prescribed just for those with prolonged packing time. The following two studies used this strategy.
Should Prophylactic Antibiotics be Used Routinely in Epistaxis Patients with Nasal Packs?
Biggs TC, Nightingale K, et al.
Ann R Coll Surg Engl
These authors also employed a before-and-after study design during a period of institutional policy change. The protocol called for antibiotics to be given only in patients who had packing in place for more than 48 hours. The authors examined patients presenting with spontaneous epistaxis requiring anterior packing for hemorrhage control. Researchers enrolled 38 patients prior to policy change, and 70 percent of them were given antibiotics, the majority receiving amoxicillin/clavulanic acid). Researchers gave 15 percent of patients antibiotics in the after arm of the study. Once again, authors found no difference in infectious complications between the two groups.
Are Systemic Prophylactic Antibiotics Indicated with Anterior Nasal Packing for Spontaneous Epistaxis?
Biswas D, Mal RK.
The authors examined delayed use of prophylactic antibiotics if the packing duration was more than 24 hours. Researchers gave antibiotics to 11 of the 28 patients in whom the packing was left in place for more than 24 hours. The researchers found no infectious complications in either group.
Summary: A detailed look at the vast array of limitations and study weaknesses would take a small book. All four of these studies suffered from varying degrees of methodological issues, but many of these shortcomings would favor antibiotic treatment. Given the available data, it does not appear that routine prophylactic antibiotics are necessary for patients with spontaneous epistaxis requiring anterior or posterior packing. It appears more reasonable to arrange close ENT (or ED if outpatient ENT unavailable) follow-up in 24 to 36 hours for reassessment and possible packing removal. Prescribing prophylactic antibiotics may be reasonable if the packing remains in place at this point, although we have no data to support even this approach.
A correction from my last column back in February on the role of loop diuretics in acute pulmonary edema. I mistakenly said the backup of blood into the pulmonary vasculature leads to increased osmotic pressure, but I meant increased hydrostatic pressure. Thanks to Bruce Stevenson in Seattle for the post-publication review.
Other Studies on Epistaxis
1. Gifford TO, Orlandi RR. Epistaxis. Otolaryngol Clin North Am 2008;41(3):525.
2. Pallin DJ, Chng YM, et al. Epidemiology of Epistaxis in US Emergency Departments, 1992 to 2001. Ann Emerg Med 2005;46(1):77.