What is the recommended antibiotic prophylaxis for epistaxis?

From the Guidelines

Antibiotic prophylaxis is generally not routinely recommended for uncomplicated epistaxis (nosebleeds). Most cases of epistaxis can be managed with direct pressure, topical vasoconstrictors, and other local measures without antibiotics. However, in specific situations such as nasal packing placement that will remain for more than 24-48 hours, prophylactic antibiotics may be considered to prevent toxic shock syndrome and other infectious complications. In these cases, the recommended regimen is typically amoxicillin-clavulanate 875/125 mg orally twice daily, or in penicillin-allergic patients, clindamycin 300 mg orally four times daily. The duration of prophylaxis should match the duration of packing, usually 3-5 days. For patients with significant comorbidities like diabetes, immunosuppression, or valvular heart disease, antibiotic prophylaxis may be more strongly considered. The rationale for selective antibiotic use is to balance prevention of serious infections while avoiding unnecessary antibiotic exposure that contributes to resistance and adverse effects. Nasal saline irrigation after packing removal can help cleanse the nasal cavity and reduce infection risk without antibiotics.

Some key points to consider:

• The use of antibiotic prophylaxis in epistaxis is not universally recommended and should be considered on a case-by-case basis 1.
• Patients with significant comorbidities may benefit from antibiotic prophylaxis, but the decision should be made based on individual risk factors 1.
• The recommended antibiotic regimens are amoxicillin-clavulanate or clindamycin, with the duration of prophylaxis matching the duration of packing 1.
• Nasal saline irrigation can help reduce infection risk without antibiotics, and should be considered as part of the treatment plan 1.

It's worth noting that the evidence for antibiotic prophylaxis in epistaxis is not strong, and the decision to use antibiotics should be made based on individual patient factors and clinical judgment. The most recent and highest quality study on this topic is from 2021, which recommends against routine use of antibiotic prophylaxis in uncomplicated epistaxis 1. However, this study also notes that antibiotic prophylaxis may be considered in specific situations, such as nasal packing placement or in patients with significant comorbidities.

From the Research

Recommended Antibiotic Prophylaxis for Epistaxis

• The use of prophylactic antibiotics in patients with epistaxis who have nasal packing is a topic of debate, with some studies suggesting that it may not be necessary 2, 3, 4, 5, 6.
• A study published in 2019 found that there was no significant difference in the rate of infection between patients who were prescribed prophylactic systemic antibiotics and those who were not 2.
• A systematic review and meta-analysis published in 2020 found that the proportion of clinically significant infections in patients with anterior nasal packing was low, and that prescribing prophylactic antibiotics may not be necessary 5.
• Another study published in 2025 found that the rates of clinically significant infections and adverse drug events among patients with anterior nasal packing for spontaneous epistaxis were low, and that prophylactic antibiotics provided little benefit while posing a potential risk to the population 4.
• A study published in 2013 found that the use of topical antibiotics may be more appropriate, cheaper, and as effective as systemic prophylactic antibiotics in epistaxis patients with nasal packs 6.
• The current evidence suggests that prophylactic antibiotics may not be necessary for patients with epistaxis who have nasal packing, and that further high-quality randomized trials are needed to support this finding 2, 3, 4, 5, 6.

Key Findings

• Low rates of clinically significant infections in patients with anterior nasal packing 4, 5.
• No significant difference in the rate of infection between patients who were prescribed prophylactic systemic antibiotics and those who were not 2.
• Prophylactic antibiotics may not be necessary for patients with epistaxis who have nasal packing 2, 3, 4, 5, 6.
• Topical antibiotics may be a suitable alternative to systemic prophylactic antibiotics in epistaxis patients with nasal packs 6.