Key messages

• It is not clear whether antibiotic prophylaxis decreases the risk of rhinosinusitis and/or other infectious complications in patients with nasal packing for anterior epistaxis because the certainty of the evidence is very low
• The baseline risk of infectious complications was very low in the studies.
• According to the available evidence, the potential benefits of antibiotics do not seem to outweigh the risks

What is the evidence.
See evidence matrix  in Epistemonikos later

We found only one systematic review [1] including three non-randomized studies, two of them retrospective and one prospective [2],[3],[4].

What types of patients were included

All of the studies included patients treated in emergency rooms for spontaneous anterior epistaxis requiring nasal packing and/or other intervention.

What types of interventions were included

All studies compared use of prophylactic antibiotics against no antibiotics. Amoxicillin-clavulanic acid was used in all of the studies, although others as clarithromycin and piperacillin/tazobactam were also used [3],[4].

What types of outcomes
were measured

The outcome measured by the studies was "infectious complications". This term refers to bacterial sinusitis, acute otitis media and staphylococcal toxic shock. It was measured through questionnaires and/or laboratory or radiological examinations when needed.

To whom this evidence does and does not apply

• This evidence applies to patients visiting emergency rooms for spontaneous anterior epistaxis.
• It does not apply to patients with epistaxis produced by trauma or after surgery.

• The outcomes presented in the summary of findings table correspond to those critical for decision making according to the opinion of the authors.
• In the hypothetical case of no effect on the main outcomes and minimal or no adverse effects, other outcomes such as 'bad smell' noticed by some patients could become relevant

• The evidence about the benefits and risks has very low certainty, so it is not possible to estimate an adequate balance.
• Both outcomes presented (rhinosinusitis and staphylococcal toxic shock) had a very low incidence (only two cases of rhinosinusitis and none of staphylococcal toxic shock), so any potential benefit would be of low absolute magnitude. 

• Some doctors may decide not to prescribe antibiotics due to the known adverse effects of its administration as well as the possibility of increasing population resistance to antibiotics.
• It is also possible that some doctors decide to keep the use of antibiotics due to the high risk of changing the usual behavior based on very low certainty evidence. In this case, it is particularly important to inform patients about the uncertainty associated with this measure.

• It is not possible to provide an adequate estimation of the cost-benefit because the certainty of the evidence is very low.
•  Since antibiotics used have a relatively low cost, and adverse effects seem to be rare, it is likely that resources considerations would not be the main drivers of this decision.

Differences between this summary and other sources

• The conclusions of this summary are consistent with the only systematic review identified.
• The findings are discordant with the main identified guideline, which recommends the use of antibiotics if the packing is in situ for more than 24 hours [6].

• The probability of new evidence changing what we know about is very high, given the very low certainty of the evidence.
•  We did not identify ongoing studies assessing this question.