Written by Kathryn Sulkowski and Ketan Patel
Patients with anterior nasal packing experience an exceptionally low risk of clinically significant infection (CSI), making the use of prophylactic antibiotics largely unnecessary.
Antibiotics for epistaxis? Let’s not make a mountain out of a nosehill
Epistaxis is a common issue encountered in the ED, and conservative measures often prove insufficient in controlling the bleeding, necessitating the use of anterior packing. The question of whether to prescribe prophylactic antibiotics to these patients remains inadequately studied, which may contribute to the inappropriate overuse of antibiotics.
This retrospective cohort study used the TriNetX database to assess whether prophylactic antibiotics reduce CSI after anterior nasal packing for epistaxis. Among 5,487 matched adults, 2,737 received antibiotics and 2,750 did not. CSI occurred in 0.5% vs. 0.4% respectively (risk difference 0.2%, 95%CI -0.005 to 0.002; p=0.31). Adverse drug events were 1% in both groups (p=0.94). Routine antibiotic prophylaxis showed no significant benefit, raising questions about its use in anterior epistaxis management.
This study has several limitations. Some of the studies included in the database were conducted by organizations outside of the United States, where practices regarding antibiotic use and packing methods (absorbable versus non-absorbable) may differ considerably. Furthermore, issues related to patient compliance, as well as cases of individuals seeking care for a CSI outside of their original healthcare system, may not have been accurately captured.
How does this change my practice?
I do not routinely use prophylactic antibiotics if I have already placed anterior packing in the patient. This database driven study reinforces this practice. I will continue to reserve antibiotics for the severely immunocompromised and those with posterior packing. By avoiding unnecessary medication, we can prioritize patient safety and reduce antibiotic resistance.
Source
Is antibiotic prophylaxis necessary for anterior epistaxis with packing? Insights from a large database. Am J Emerg Med. 2025 Mar 19;93:64-72. doi: 10.1016/j.ajem.2025.03.040. Epub ahead of print. PMID: 40147155
