Antibiotics for Nasal Packing?

[GeneralVeers]

I routinely do not give antibiotics for anterior nasal packing (Rapid Rhino) that I've instructed to return to the ER in 24 hours for packing removal.

I had a colleague see one of my patients back, and questioned why I didn't give them.

I did a literature search, and most sources recommend antibiotics for packing that will be in place longer than 3 days. Even then the literature said there was no good evidence that antibiotics had any benefit in reducing infection or toxic shock.

There was no data for 24 hour packing.

So do you guys give antibiotics? (please support with evidence).

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[southerndoc]

Yes, and sorry, I don't have evidence to support it.

 

[Apollyon]

Nasal fractures always (and you get the epistaxis from that). Routine epistaxes, no. I've thought about it, and I don't know why I don't do it.

 

[BADMD]

So do you guys give antibiotics?

Yes.

(please support with evidence).

Because I still remember the lecture I got at 3 am as a resident when I didn't want to. Maybe some day I'll put evidence to my practice.

 

[Seville]

I was told by an attending this week to always give antibiotics due to potential toxic shock risks and worries that the pt wouldn't come back expeditiously to remove the packing.

I'm just a student though...

 

[Jeff698]

I give them and, like many things I give ABX for, have little evidence other than tradition to go by.

Take care,
Jeff <- heathen who still gives ABX for strep throat.

 

[Hercules]

I give them and have no evidence. Like several of my practices it's based on the unscientific discussions I've had with ENTs and other specialists.

 

[Seaglass]

What they said. I always heard it was for toxic shock too.

 

[kungfufishing]

I do it. Both the toxic shock/will they really come back on time? and the plain old likelihood of infection - foreign body in a spot loaded with bacteria. Having said that, I would like to see if the abx make any difference.

 

[quinsy]

I have done it both ways based on attending preference (since I am a resident), but I think it's unnecessary.

After all ladies leave tampons in for a day and don't take antibiotics... I've seen too many superbugs floating around to feel like giving antibiotics for every little thing.

I have doubts about the concern that anyone would avoid coming back to get nasal packing removed expeditiously. I find it more likely that they go home and take it out themselves before 24 hours has even elapsed.

 

[Apollyon]

I have done it both ways based on attending preference (since I am a resident), but I think it's unnecessary.

After all ladies leave tampons in for a day and don't take antibiotics... I've seen too many superbugs floating around to feel like giving antibiotics for every little thing.

I have doubts about the concern that anyone would avoid coming back to get nasal packing removed expeditiously. I find it more likely that they go home and take it out themselves before 24 hours has even elapsed.

Look up the history of the tampon and toxic shock syndrome. There's a reason why "super absorbent" isn't available any more. I think the rhino rocket is more absorbent than a vaginal tampon.

 

[quinsy]

Look up the history of the tampon and toxic shock syndrome. There's a reason why "super absorbent" isn't available any more. I think the rhino rocket is more absorbent than a vaginal tampon.

I don't know where you shop, my friend, but as a woman I can assure you that not only is super available, SUPER PLUS and ULTRA are readily apparent on any supermarket shelf.
http://www.amazon.com/Kotex-Securit...ie=UTF8&s=miscellaneous&qid=1251725154&sr=8-7
(I'd take you to the supermarket, but Amazon is easier).

FYI from PubMed: "in 1999 the Food and Drug Administration proposed an amendment to tampon labeling regulation 21CFR 801.430(e)(1) which provided an absorbency term for tampons that absorb 15 to 18 g of fluid, namely, ultra. Soon thereafter tampons with this increase in absorbency became widely available on the marketplace, thereby making five categories of extant tampons, namely, light (<6 g), regular (6 to 9 g), super (9 to 12 g), super-plus (12 to 15 g), and ultra (15 to 18 g). "

I tried searching the internet because yes, I am really that bored... can't find how much a Rhino Rocket absorbs. I also looked to see what a gram is in fluid ounces... it looks like 15 grams is only 0.5 fluid ounce.

Anyway, myself, and surely many other female physicians, often must utilize such feminine products for time periods longer than the recommended "8 hours". I must have done it a thousand times just personally. Maybe I'm just totally biased by my case study of 1, but I have doubts about the danger of this practice.

 

[Apollyon]

Being a guy, I can't say I'm up on my vaginal tampons (as the "Rapid Rhino" is a nasal same). What I recall is the most absorbent tampons drying out the vaginal wall, causing cracking, which allowed bacteria to enter, and leading to TSS. Whatever they're called, I cannot say.

Now, mind you, this was ~30 years ago now.

edit: This link, although from the crap Wikipedia, outlines the story. It was the Rely tampon. Now, Rely could absorb 20x its dry volume, but I REALLY don't know how much blood there is in a period.

 

[GeneralVeers]

Now, mind you, this was ~30 years ago now.

edit: This link, although from the crap Wikipedia, outlines the story. It was the Rely tampon. Now, Rely could absorb 20x its dry volume, but I REALLY don't know how much blood there is in a period.

We have better materials now than the tree bark and twigs they made things out of when you were young......

 

[roja]

I don't give them, because I like to have some form of evidence, I hate doing things 'just because' (ie see no epi in hand lacs, abx in adult pharyngitis, etc) and I absolutely HATE giving abx for no reason. They dont' have a negative side effect profile, we give them like water and have resistance issues nonstop.

Also, if you worry a patient won't come and take a nasal tampon out, I have serious doubts about thier compliance with antibiotics.

So, people are adults. I advice them to return to the ED in 24 hours for removal. And I explain that if it is left in longer there is a chance thier nose could rot off or they could get a systemic life threatening infection. And then I document the discussion.

 

[MGG1848]

Was speaking with an ENT about this topic regarding a patient I had to admit for horrible epistaxis on coumadin with a mechanical heart valve. Finally under control with bilateral packing and topical thrombin.

Anyway, he mentioned he only usually does it for bilateral packing or "high-risk" patients (not sure what that means). Anyway, he didnt really know of particular evidence either.

 

[EM OR BUST]

Yes, and sorry, I don't have evidence to support it

 

[Frogger0108]

I am not a medical student..but a patient....I went to the emergancy room due to a nose bleed that did not want to stop for hours...the doctor told me they were going to use a new item...the rapid rhino...I had it inserted and inflated...it did stop the bleeding..but a few hours later, I was in in agony. My face felt like it was on fire and I had alot of pressure all the way to my ear and even my teeth were hurting...I started to run a fever....and then my nose started bleeding again...so I went back to the emergancy room, and the doctor stated to me that the rhino can cause sinus infections, which I had one now, and the rhino had deflated. So I just had it removed. He stated that I should have been given antibiotics from the start....now it has been a week...and I am still sick...my opinion my not count for much...but let me tell you...giving someone antibiotics when inserting the rapid rhino for any reason, for any duration, would be a good idea. Don't put another person through what I have been going through...Now my doctor is sending me to a ear nose and throat doctor to check for polyps and to see how far the infection had gone. I am still running a fever and still in pain...give the antibiotics...all this for a nose bleed?

 

[southerndoc]

It would take more than a few hours for you to develop an infection and start running a fever. I suspect you probably had a bad sinusitis which caused your nose bleeding and you would've developed a fever and problems whether your nose was packed or not.

 

[GeneralVeers]

It would take more than a few hours for you to develop an infection and start running a fever. I suspect you probably had a bad sinusitis which caused your nose bleeding and you would've developed a fever and problems whether your nose was packed or not.

Agreed. I would think greater than 12 hours would be at risk, probably more likely 24 hours to develop a fever.

Unlikely that the Rhino Rocket in the above case caused an infection.

 

[diphenyl]

I was told by an attending this week to always give antibiotics due to potential toxic shock risks and worries that the pt wouldn't come back expeditiously to remove the packing.

I'm just a student though...

PT noncompliance would be my biggest incentive. I have never seen a better reason to do so than the one stated above.

 

[roja]

My only thought on this regarding patient compliance is this:

Are they more likely to remove (either by an MD or simply pull it out) a wad of nasal packing or take a full course of antibiotics?

 

[Zanegray]

ACP Pier recommends systemic antibiotics:
"Staphylococcus-appropriate systemic antibiotics will not prevent colonization of S. aureus in the nasal tampons but can reduce the incidence of toxic shock syndrome"

They reference:
Topazian RG, Goldberg MH, Hupp JR, eds. Oral and Maxillofacial Infections. 4th ed. Philadelphia: WB Saunders; 2002.

 

[Zanegray]

But... the following is a pilot study which indicates maybe not so important. the discussion section includes a nice summary of data to date on infection and states that no instance of TSS is reported in the literature except one in Thailand... so, maybe for "low risk" patients it is not so important. Looks like we'll have to use (GASP) clinical judgement, on this one.


Acta Otolaryngol. 2009 Feb;129(2):179-81. Are systemic prophylactic antibiotics indicated with anterior nasal packing for spontaneous epistaxis? Biswas d and Mal RK.

 

[deleted6669]

I always give them and have the pt f/u with ent.
I have heard a few of my colleagues chewed out by ent for not giving abx in this setting so I always do.

 

[GeneralVeers]

But... the following is a pilot study which indicates maybe not so important. the discussion section includes a nice summary of data to date on infection and states that no instance of TSS is reported in the literature except one in Thailand... so, maybe for "low risk" patients it is not so important. Looks like we'll have to use (GASP) clinical judgement, on this one.

Naww, it's easier just to practice old-fashioned medicine whereby we put people on antibiotics with no specific evidence or clinical reasoning.

 

[dmitrinyr]

I always give them and have the pt f/u with ent.
I have heard a few of my colleagues chewed out by ent for not giving abx in this setting so I always do.

I can understand if you are a resident and you give ABx with no evidence of them helping just because your attending tells you to do so or you got chewed out by ENT for not doing so. But why would you do this if you're an attending? Or would ENT not say anything once you're an attending, or say it in a nicer way?

 

[deleted6669]

I can understand if you are a resident and you give ABx with no evidence of them helping just because your attending tells you to do so or you got chewed out by ENT for not doing so. But why would you do this if you're an attending? Or would ENT not say anything once you're an attending, or say it in a nicer way?

if a specialist gets a bee in their bonnet they don't care who you are, they abuse on an equal opportunity basis....because they all know this one pt who got treated some other way(than the way they like) who suffered spontaneous human combustion or some equally terrible fate....

 

[roja]

Yeah, I had an ob-gyn throw a hissy fit because I wouldn't do a culdocentesis in a young nonpregnant patient with RLQ pain and a positive FAST, fever and elevated WBC's. He was shocked I wanted a CT vs admit for obs, and was not going to do a culdocentesis.

 

[Apollyon]

You know how many culdos I've done? Zero. Not credentialed, and never plan to be.

 

[southerndoc]

You know how many culdos I've done? Zero. Not credentialed, and never plan to be.

Neither am I. I never received training on it other than reading a book about it.

Regarding antibiotics, it's probably best to ask your ENT consultants what they prefer since you'll be sending patients to them for follow-up. If they want antibiotics, then prescribe them. If they don't, then you can mention whatever latest research shows, tell them you'll forward it to them, and tell them to get back to you if they still want it (but in the mean time I would still prescribe them).

Our ENT's want antibiotics so I prescribe them. It's either prescribe them and avoid conflict, or don't prescribe them and hear about it repeatedly.

 

[diphenyl]

Yeah, I had an ob-gyn throw a hissy fit because I wouldn't do a culdocentesis in a young nonpregnant patient with RLQ pain and a positive FAST, fever and elevated WBC's. He was shocked I wanted a CT vs admit for obs, and was not going to do a culdocentesis.

Did this person even do a surgical rotation in medical school? Was he going to wait for peritonitis and sepsis to set in before he got some imaging?

 

[docB]

if a specialist gets a bee in their bonnet they don't care who you are, they abuse on an equal opportunity basis....because they all know this one pt who got treated some other way(than the way they like) who suffered spontaneous human combustion or some equally terrible fate....

The majority of the older guys in my group all treat uncomplicated kidney stones with antibiotics despite the evidence to the contrary. It all goes back to this one really horrible case in the 90s where someone wound up septic with a stone.

Did this person even do a surgical rotation in medical school?

I'm sure he did but if his go, no go was going to be based on a culdo then I suspect it was back in the 80s or earlier.

 

[GeneralVeers]

The majority of the older guys in my group all treat uncomplicated kidney stones with antibiotics despite the evidence to the contrary. It all goes back to this one really horrible case in the 90s where someone wound up septic with a stone.
.

That's exactly my point. I don't like practicing medicine "just because that's how we do it" with no evidence. Antibiotics cost money, have side effects/interactions, and lead to bacterial resistance.

We give antibiotics far too often and with little evidence. We're slitting our own throats, because more and more antibiotics are becoming ineffective every year.

 

[roja]

We give antibiotics far too often and with little evidence. We're slitting our own throats, because more and more antibiotics are becoming ineffective every year.

I continually shock my residents because I only give abx when they are actually indicated.