EM Controversies: Antibiotics for nasal packing? County EM

Author: Robby Allen, MD

Edited by: Eden Kim MD, Roshanak Benabbas MD

Acknowledgments: Michael Lucchesi MD, Aleksandr Gleyzer MD

Our “EM controversies” lecture series continued with a faculty showdown: Dr. Lucchesi versus Dr. Gleyzer. Watch the debate here. Their Challenge? Antibiotics for nasal packing. What does the evidence say?

Case:

A 62-year-old female with a history of deep venous thrombosis on apixaban comes to the emergency department (ED) with epistaxis for two hours. Vitals are normal. Exam is notable for mild oozing of blood from the left naris. Laboratory workup demonstrates the absence of anemia, thrombocytopenia, or coagulopathy. Epistaxis continues despite conservative measures, and the decision is made to insert anterior nasal packing. Fortunately, the epistaxis stops and you schedule a follow-up appointment with ENT in two days. Your astute intern who just finished the ENT chapter in Tintinalli perks up, “Don’t we need to prescribe antibiotics?”

Antibiotics for nasal packing: Why do we care?

Classic teaching recommends prophylactic antibiotics (e.g. amoxicillin-clavulanate x 5 days) to avoid the theoretical risk of toxic shock syndrome (TSS). Why is it theoretical? Well, because there has not been a single documented case of TSS from the insertion of nasal packing for anterior nasal packing.[1]

“If there are no cases reported, why all the hoopla?”

There have been case reports of TSS reported after extended tampon use and nasal packing following rhinoplasty surgery.[2,3] From these cases alone, it became tradition to prescribe antibiotics after nasal packing for epistaxis. A 2005 survey of UK ENT physicians found 78% of physicians believed prophylactic antibiotics reduced the incidence of infection.[4]

What does the evidence say?

1) A 2013 retrospective, observational study reviewed patients admitted to the ENT service for spontaneous epistaxis requiring anterior nasal packing.[5] They analyzed 59 patients before and after the implementation of an algorithm (Figure). After discharge, patients received a telephone survey at six weeks to monitor for infective nasal symptoms (crusting, discharge, pain, sinusitis). Unfortunately, the authors only reported rates of complications before and after implementation of the algorithm but did not report rates of complications based on whether or not they received antibiotics. So, there is not much we can take away from this study aside from the 0 cases of reported TSS. However, this study does suggest the effectiveness of the algorithm in reducing unnecessary antibiotic use (74% vs 15.8%).

Figure: Proposed algorithm for prophylactic antibiotic in spontaneous epistaxis[5]

2) How about a more recent study in an ED setting? This 2019 study retrospectively reviewed 106 patients (57 with antibiotics, 49 without) with anterior packing placed in the ED.[6] No one with anterior packing, with or without antibiotics, developed signs of infection at follow-up. This study is limited in its retrospective design, small sample size, and high loss to follow-up rate (35%). No meaningful conclusions may be drawn.

3) Any large, systematic reviews? A 2017 systematic review included six total studies (n=990) with nasal packing for epistaxis (n=254) or septoplasty (n=736).[7] Unfortunately, only three of the studies were randomized control trials (RCT): two evaluating packing after septoplasty, one for posterior packing for epistaxis. Therefore, except for an absence of any documented cases of TSS, we cannot draw any meaningful conclusions from this data.

4) Our last study is a 2019 systematic review and meta-analysis of patients with packing placed for epistaxis.[8] Of the five identified studies, four were included in the meta-analysis, including one ED setting and three inpatient ENT. None of the included studies were randomized trials. The authors calculate a number-needed-to-treat (NNT) of 571 to prevent one CSI with antibiotics. It is not statistically sound to calculate a NNT for a non-statistically significant finding. But, a bigger issue is that this data is highly prone to bias given the analysis of non-randomized data. (To paraphrase the founder of thennt.com and SUNY Downstate professor of EM, Dr. Zehtabchi, you can basically throw out any meta-analyses of treatment studies that include non-randomized data.) In conclusion, this is yet another underpowered, flawed meta-analysis that still found no cases of TSS.

Summary of the evidence:

So, we looked at two non-randomized studies and two systematic reviews – most poorly designed, some inappropriately pooled, and all underpowered to detect differences in complications with the use of prophylactic antibiotics. But, the available literature is noteworthy for zero reported cases of TSS which is the reason why we typically give antibiotics in the first place.

So what to do when the evidence is inconclusive?

What do the experts say?

This clinical guideline acknowledges the available evidence that suggests no difference in risk of infections such as TSS with or without antibiotics.[9] Despite this, the authors hedge, “given the lack of convincing data, the risks and benefits of antibiotics use in patients with packing in place should be evaluated in each patient.”

Risks and Benefits

What does it mean to evaluate “the risks and benefits of antibiotic use in each patient?” Well, for now, we can say that there is no available evidence to suggest a benefit of routine antibiotic prophylaxis in anterior packing for epistaxis. Are there higher-risk populations such as the elderly, immunocompromised, diabetic that may benefit more than others? Possibly. And possibly not. To definitively answer that question given the rarity of these complications, we would need a much larger population (probably too large to do a well-done RCT, so data would likely be limited to a retrospective review).

What about the risks? The risks of antibiotic use are well documented, with complications including but not limited to anaphylaxis, Steven-Johnson Syndrome, rash, gastrointestinal, and Clostridium difficile.[1] A study of pediatric patients found the incidence of antibiotic-associated diarrhea to be nearly 20% with amoxicillin/clavulanate.[10] And that’s not to mention the growing threat of antibiotic resistance, which could become the reason for the next great pandemic…

Further areas of research

The optimal duration of packing is unknown. In the aforementioned studies, the duration of packing was variable and not always clearly documented, however, as noted in the figure, there is a theoretical increased risk of complications with prolonged duration. Therefore, a shorter duration of packing may reduce the theoretical risk of infectious complications and obviate the need for antibiotics along with reducing the discomfort associated with packing.

Additionally, while we discuss the risks and benefits of oral antibiotics, do topical antibiotics (often impregnated in packing) provide any benefit or harms compared to traditional lubricants?

What about the type of nasal packing? As we discuss packing, we typically refer to anterior, non-resorbable packing. But, resorbable packing options are also emerging which may be associated with decreased pain and reduced risk of rebleeding associated with the removal and insertion of packing.[9] However, with any novel medical product, we should also consider costs, availability, while awaiting well-conducted RCTs studying patient-oriented outcomes that compare the different packing options.

What do you do when you disagree with your consultant?

Ultimately, your sleep-deprived, not-necessarily-evidence-based PGY-2 ENT consultant who is just trying to make it through the night, may reasonably fall back to their epistaxis template and traditional guidelines and recommend prophylactic antibiotics. What to do then? After reading this blog post you may get on your righteous EBM horse and rattle off the above evidence. However, you are unlikely to effect any meaningful change of practice at 2 am.

Instead, a more fruitful approach may be to host interdepartmental meetings and come up with agreed-upon hospital guidelines that may reduce unnecessary antibiotics.

At the end of the day, the responsibility of an ED patient belongs to the ED physician. You consult specialists for their input, but ultimately the decision comes down to you and the patient.

Case summary:

Having reviewed the evidence and guidelines, you share your knowledge with the patient and recommend against antibiotics. You instruct her to return to the ED in 48 hours for packing removal if they cannot be seen by an ENT physician within that time frame. You discharge your patient without antibiotics.