From the Guidelines
Nasal packing typically does not require prophylactic antibiotics in most cases. For routine nasal packing after procedures like septoplasty or to control epistaxis, antibiotics are generally unnecessary unless specific risk factors are present, as noted in the clinical practice guideline by 1. When antibiotics are indicated, common choices include amoxicillin-clavulanate (875/125 mg twice daily), cefuroxime (500 mg twice daily), or clindamycin (300 mg four times daily) for 5-7 days while packing remains in place, as suggested by 2.
Key Considerations
- For patients with higher infection risk (immunocompromised, diabetic, or with prolonged packing >48 hours), antibiotic prophylaxis becomes more important, as highlighted in the study by 1.
- Topical antibiotics like bacitracin or mupirocin ointment can be applied directly to packing material as an alternative to systemic treatment.
- The rationale for selective antibiotic use balances infection prevention against antimicrobial stewardship concerns, as routine prophylaxis contributes to bacterial resistance without clear benefit in low-risk cases, as discussed in 2.
Monitoring for Infection
- Patients with nasal packing should be monitored for signs of infection including increasing pain, fever, purulent discharge, or worsening swelling, which would warrant prompt evaluation and potential antibiotic therapy, as advised in 1.
- It is essential to weigh the risks and benefits of antibiotic use in each patient, considering the lack of convincing data on the mandatory use of antibiotics with nasal packing, as noted in 2.
From the Research
Nasal Packing Antibiotic Use
- The use of antimicrobial prophylaxis in the presence of posterior nasal packing for the treatment of posterior epistaxis remains controversial 3.
- A study found that antibiotic-impregnated posterior gauze packing employed in all patients, with no infectious complications noted in either group, suggesting the usefulness of antimicrobial prophylaxis for preventing complications from posterior nasal packing 3.
- However, a meta-analysis of 5 articles with 383 patients receiving anterior nasal packing found that the proportion of clinically significant infections was low (0.8%), resulting in a number needed to treat to prevent one infection of 571, suggesting that prescribing prophylactic antibiotics for anterior nasal packing may not be necessary 4.
Systemic Antibiotic Prescribing
- A study introduced a new treatment algorithm resulting in significant reduction of use in systemic antibiotics, with emphasis instead on the use of topical antibiotics, and found no statistically significant associated increase in infective nasal symptoms, rebleeding, or readmission rates six weeks following hospital discharge 5.
- Systemic prophylactic antibiotics are unnecessary in the majority of epistaxis patients with nasal packs, and the use of topical antibiotics such as Naseptin may be more appropriate, cheaper, and as effective 5.
- A retrospective review of 275 cases of anterior nasal packing found no instances of toxic shock syndrome, and no statistically significant difference in the development of acute sinusitis between patients given prophylactic antibiotics and those without 6.
Prophylactic Antibiotic Use
- A systematic review of 6 studies with a total of 990 patients found no reports of toxic shock syndrome, and no statistical difference in purulent drainage in patients who had septoplasty treated with or without antibiotics, suggesting that the available literature does not show a significant benefit to the use of antibiotics with nasal packing 7.
- The use of prophylactic systemic antibiotics with nasal packing has been a controversial topic, with few evidence-based studies to determine the need for prophylactic systemic antibiotics 7.
- Patients who receive nonabsorbable nasal packing were more likely to receive antibiotic prophylaxis, but there was no observed advantage or disadvantage to using prophylactic antibiotics in anterior nasal packing in the emergency department, regardless of whether patients received absorbable or nonabsorbable packing 6.