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Prophylactic Antibiotics for Nasal Packing
Where’s the Evidence?
“ Articles review”
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Introduction :
Epistaxis is a common problem, with a lifetime incidence
of about 60% (Gifford 2008).
While the majority of cases do not require medical
attention, epistaxis remains a common presenting
complaint in the Emergency Department .
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The management of epistaxis can be highly variable, with
different techniques being used in nasal packing with
either coagulant impregnated balloons, nasal tampons,
or petroleum gauze.
Introduction :
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Anterior nasal packing is the commonest type of
packing used for the management of epistaxis, when
initial treatment by pressure and cautery are failed.
Introduction :
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Concern for the development of infectious complications
(sinusitis, otitis, toxic shock syndrome) after nasal
packing seems to have motivated the clinical
recommendations. American College of Emergency Physicians 2009
Introduction :
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Toxic Shock Syndrome : It’s a toxin-mediated acute life-
threatening rare complication.
Characterized by High fever rash, hypotension, multiorgan
failure .
Usually precipitated by infection with either Staphylococcus
aureus or group A Streptococcus (GAS)
Introduction :
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The incidence of TSS with nasal packing following nasal
surgery is approximately 16.5 in 100,000, or 1 in
approximately 6000 cases (Jacobson 1986).
Introduction :
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Controversy exists regarding the use of systemic
prophylactic antibiotics with anterior nasal packing.
Introduction :
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Articles review :
One important note, the literature base is scant on all
topics regarding Prophylactic antibiotics after nasal
packing for epistaxis.
Randomized Double-Blind Control Trials (RDCT) are rare
and study quality is overall very poor.
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Article 1
In this study : a large randomized trial evaluating the use
of prophylactic antibiotics with nasal packing following
septoplasty.
Result : They found no difference in post-operative pain,
infectious symptoms, or the amount of purulent nasal
discharge with or without prophylactic antibiotics.
Ricci G, D'Ascanio L. Antibiotics in septoplasty: evidence or habit?
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Pepper C et al. Prospective study of the risk of not using
prophylactic antibiotics in nasal packing for epistaxis. J Laryng
Otology 2012: 257-9. PMID: 22214602
In this study : They examined 149 consecutive patients
who underwent nasal packing, over a six-month period.
78 patients were routinely prescribed prophylactic
antibiotics (Amoxicillin/Clavulanic Acid) and 71 patients
were not routinely prescribed antibiotics.
Article 2
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Exclusion criteria included antibiotics prescribed for
unrelated pathology and post-operative epistaxis. Signs
and symptoms of acute otitis media, sinusitis and toxic
shock syndrome were assessed .
Result : They found neither group had infectious
complications .
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Biswas D, Mal RK. Are systemic prophylactic antibiotics indicated with anterior packing for spontaneous epistaxis?ActaOto-Laryngologica 2009; 129: 179-81. PMID: 18607977
In this study : Over a period of 6 months, 21 patients
had anterior packing of which 9 received antibiotics.
Result : after removal of pack ,the investigators sent
swabs from the packed and unpacked nares and found
no difference in bacterial growth in the antibiotic and no
antibiotic group.
Article 3
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Derkay CS et al. Posterior nasal packing. Are Intravenous antibiotics really necessary?Arch Otolaryngol 1989; 115: 439-41. PMID: 2923686
In this study : Twenty patients were prospectively
randomized into this placebo-controlled, double-
masked pilot study to receive either placebo or
cefazolin sodium.
Article 4
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Result : They found that no infectious complications
were noted in either group. The packings from the
patients in the placebo group were foul smelling and
heavily colonized with gram-negative bacteria while the
packings from the antibiotic group were odor-free and
lightly colonized with only one gram-positive organism.
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Conclusion :
The available evidence does not defend the routine use
of prophylactic antibiotics in patients who require nasal
packing for epistaxis.
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While site of packing (anterior vs. posterior), sterility of
the environment (operative room vs. ED), and entry into
nasal cavity (post-surgical vs. non-instrumented) may
have some effect on the incidence of infectious
outcomes.
Conclusion :
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Conclusion :
However , the applicability of these results to patients
with anterior nasal packing for epistaxis is unclear.
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Based on a survey of physicians in the United Kingdom
conducted in 2005.
78% of physicians believe that the use of prophylactic
antibiotics with anterior nasal packing reduce the
incidence of infection (toxic shock syndrome, sinonasal
infection and middle ear infection) .
Conclusion :
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(6%) of physicians suggested prophylactic antibiotics
may help to reduce the incidence of re-bleeding .
(16%) of physicians were unsure of the benefit of
antibiotic use.
Conclusion :
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