Prophylactic antibiotics for anterior nasal packing in emergency department: A systematic review and meta-analysis of clinically-significant infections

Antibacterial polyurethane foams with quaternized-chitosan as a chain extender for nasal packing and hemostasis

Endoscopic surgery is an effective and common clinical practice for chronic sinusitis. Nasal packing materials are applied in nasal surgery to prevent hemorrhage and promote wound healing. In this study, a degradable polyurethane foam dressing is successfully developed as a promising nasal packing material with good biocompatibility and antibacterial capability. Specifically, quaternized chitosan (QCS) serves as the crosslinker instead of polyols to offer polyurethane foam (PUF-QCS) antibacterial capability. The PUF-QCS2.0 % (with 2.0 wt% QCS) exhibits satisfactory liquid absorption capacity (19.4 g/g), high compressive strengths at both wet (14.5 kPa) and dry states (7.7 kPa), and a good degradation rate (8.3 %) within 7 days. Meanwhile, PUF-QCS2.0 % retains long-term antibacterial activity for 7 days and kills 97.3 % of S. aureus and 91.8 % of E. coli within 6 hours in antibacterial testing. Furthermore, PUF-QCS2.0 % demonstrates a positive hemostatic response in the rabbit nasal septum mucosa trauma model by reducing hemostatic time over 50.0 % and decreasing blood loss up to 76.1 % compared to the commercial PVA nasal packing sponge. Importantly, PUF-QCS also exhibits a significant antibacterial activity in nasal cavity. This nasal packing material has advantages in post-surgery bleeding control and infection prevention. STATEMENT OF SIGNIFICANCE: The performance of a nasal packing sponge requires good mechanical properties, fast and high liquid absorption rate, effective degradability and strong antibacterial activity. These features are helpful for improving the postoperative recovery and patient healing. However, integrating these into a single polyurethane foam is a challenge. In this study, quaternized chitosan (QCS) is synthesized and used as a chain extender and antibacterial agent in preparing a degradable polyurethane foam (PUF-QCS) dressing. PUF-QCS undergoes partial degradation and exhibits effective broad-spectrum antibacterial activity in 7 days. The reduction of postoperative bleeding and infection observed in the animal experiment further demonstrates that the PUF-QCS developed here outperforms the existing commercial nasal packing materials.

[Fundamentals and practice of the application of nasal packing in sinonasal surgery]

BACKGROUND AND OBJECTIVES

This paper presents an overview on nasal packing materials which are available in Germany. The current literature is analyzed whether there are robust criteria regarding use nasal packing after sinonasal surgery, whether there are fundamental and proven advantages or disadvantages of products, and what this means in clinical practice.

MATERIALS AND METHODS

Selective literature analysis using the PubMed database (key words "nasal packing", "nasal tamponade", "nasal surgery", "sinonasal surgery", or "sinus surgery"), corresponding text books and resulting secondary literature.

RESULTS AND CONCLUSIONS

Because of systematic methodological shortcomings, the literature does not help in the decision-making about which nasal packing should be used after which kind of sinonasal surgery. In fact, individual approaches for the many different clinical scenarios are recommended. In principle, nasal packing aims in hemostasis, should promote wound healing, and should not result in secondary morbidity. Nasal packing materials should be smooth (non-absorbable materials), inert (absorbable materials), and should not exert excessive pressure. Using non-absorbable packing entails the risk of potentially lethal aspiration and ingestion. For safety reasons inpatient control is recommended as long as this packing is in situ. With other, uncritical packing materials and in patients with special conditions, outpatient control could be justified.

Nasal Packing in Septal Surgery: A Narrative Review

Recently, alternatives to intranasal packing following septoplasty and rhinoseptoplasty have been widely used and promoted. Here, we aimed to systemically review and compare the different types of nasal packing used in these two surgeries. To assess patient comfort and surgical outcomes, we conducted a comprehensive search of multiple databases such as PubMed, MEDLINE, Web of Science, and Google Scholar to identify and evaluate relevant articles. A detailed and extensive search was performed with the help of the keywords "nasal packing," "septoplasty," "rhinoseptoplasty," "nasal splints," and "intranasal packing." Overall, our review findings indicate that alternative methods (e.g., trans-septal suturing and insertion of intranasal splints) are better options than intranasal packing.

Antibiotic use in nasal bone fracture: a single-center retrospective study

Background

Prophylactic antibiotics are used to prevent surgical wound infection; however, proper indications must be followed with careful consideration of the risks and benefits, especially in clean or clean-contaminated wounds. Nasal bone fractures are the most common type of facial bone fracture. The most common method for treating nasal bone fracture is closed reduction, which is performed inside the nasal cavity without an incision. The purpose of this study was to determine the need for antibiotic use in the closed reduction of nasal bone fractures.

Methods

A retrospective study was conducted using data from the National Insurance Service Ilsan Hospital of the Republic of Korea between 2016 and 2018. The records of patients who underwent closed reduction of nasal bone fracture were reviewed and classified according to sex, age, comorbidities, perioperative antibiotic usage, postoperative complications, nasal packing, anesthesia type, surgeon’s specialty, and operation time.

Results

Among the 373 patients studied, the antibiotic prescription rate was 67.3%. Just 0.8% of patients were prescribed preoperative antibiotics only, 44.0% were prescribed postoperative antibiotics only, and 22.5% were prescribed both preoperative and postoperative antibiotics. There were no cases that satisfied the definition of “surgical site infection.” Furthermore, 2.1% of infection-related complications (e.g., mucosal swelling, synechia, and anosmia) occurred only in the antibiotic usage group. The use of nasal packing, anesthesia type, and surgeon’s specialty did not show any difference in infection-related complication rates.

Conclusion

According to the study findings, the routine use of perioperative antibiotics is not recommended in uncomplicated nasal bone fracture surgery.

Nasal Packing in the Emergency Department: A Practical Review for Emergency Providers

We performed a narrative review of epistaxis management in the emergency department. First, we examined the pathophysiology, the current types of treatment that are available to emergency clinicians. When nasal packing is indicated, we examined the efficacy of nasal packing in addition to other topical treatment such as tranexamic acid and the evidence of prophylactic antibiotics. We detailed current studies involving tranexamic acid and prophylactic antibiotics for nasal packing. Finally, we introduced an epistaxis clinical care pathway, based on current evidence, to aid emergency clinicians with their clinical decision-making processes.

[Epistaxis-overview and current aspects]

Nosebleeds (epistaxis) are usually minor. Medical intervention is only necessary in about 6% of cases. The source of bleeding is frequently located in the anterior region of the nose (Kiesselbach's plexus). The estimated lifetime prevalence of epistaxis is 60%. Diffuse epistaxis is often a manifestation of systemic disease. Epistaxis is the leading symptom of Rendu-Osler-Weber disease (hereditary hemorrhagic telangiectasia, HHT). If intervention is required, the first-choice of treatment is bidigital compression for several minutes. Common therapeutic measures include local hemostasis using electrocoagulation or chemical agents, e.g., silver nitrate. Resorbable anterior nasal tampons or tampons with a smooth surface are also frequently employed. In case of failed surgical closure of the sphenopalatine artery, angiographic embolization is the method of choice.

Role of Anterior Nasal Packing in Endoscopic Skull Base Surgery: Italian Survey

BACKGROUND

Nowadays, the endoscopic endonasal approach to sellar and parasellar region tumors is a common technique in neurosurgery, and surgical nuances, complications, and management strategies are shared in a multidisciplinary setting between neurosurgeons and ear, nose, and throat surgeons. Due to the heterogeneity of its variations, the role of the anterior nasal packing in endoscopic endonasal approach to the skull base surgery (EESBS) has not yet been unanimously accepted and no consensus or guidelines on its use exist.

MATERIALS AND METHODS

A survey containing 10 questions about indications, management advantages, and pitfalls of the use of anterior nasal packing in EESBS was created by using an online open-source tool (SurveyMonkey). The questionnaire was sent to 39 Italian neurosurgical departments, which routinely adopt the endoscopic endonasal approach.

RESULTS

Almost half of 39 selected centers (19; 48.7%) answered our survey. The main results can be summarized as 1) anterior nasal packing after EESBS is considered useful by 84% of participants, 2) prevention of epistaxis is the principal indication for anterior nasal packing, 3) the type of approach and skull base reconstruction influence the use of anterior nasal packing, and 4) nasal discomfort is considered the principal negative aspect of nasal packing.

CONCLUSIONS

Our study identified that anterior nasal packing is commonly adopted in certain conditions, namely when extensive nasal dissection is performed. Furthermore, the choice to adopt or not the anterior nasal packing should be tailored taking in account specific conditions, such as acromegaly and Cushing disease. It represents an important factor in reducing postoperative sinonasal complications of EESB.

A Clinical Decision Analysis for Use of Antibiotic Prophylaxis for Nonabsorbable Nasal Packing

OBJECTIVE

Nonabsorbable nasal packing is often placed for the treatment of epistaxis or after sinonasal or skull base surgery. Antibiotics are often prescribed to prevent toxic shock syndrome (TSS), a rare, potentially fatal occurrence. However, the risk of TSS must be balanced against the major risk of antibiotic use, specifically Clostridium difficile colitis (CDC). The purpose of this study is to evaluate in terms of cost-effectiveness whether antibiotics should be prescribed when nasal packing is placed.

STUDY DESIGN

A clinical decision analysis was performed using a Markov model to evaluate whether antibiotics should be given.

SETTING

Patients with nonabsorbable nasal packing placed.

METHODS

Utility scores, probabilities, and costs were obtained from the literature. We assess the cost-effectiveness of antibiotic use when the risk of community-acquired CDC is balanced against the risk of TSS from nasal packing. Sensitivity analysis was performed for assumptions used in the model.

RESULTS

The incremental cost-effectiveness ratio for antibiotic use was 334,493 US dollars (USD)/quality-adjusted life year (QALY). Probabilistic sensitivity analysis showed that not prescribing antibiotics was cost-effective in 98.0% of iterations at a willingness to pay of 50,000 USD/QALY. Sensitivity analysis showed that when the risk of CDC from antibiotics was greater than 910/100,000 or when the incidence of TSS after nasal packing was less than 49/100,000 cases, the decision to withhold antibiotics was cost-effective.

CONCLUSIONS

Routine antibiotic prophylaxis in the setting of nasal packing is not cost-effective and should be reconsidered. Even if antibiotics are assumed to prevent TSS, the risk of complications from antibiotic use is of greater consequence.

LEVEL OF EVIDENCE

3a.

Utilization of Prophylactic Antibiotics After Nasal Packing for Epistaxis

BACKGROUND

There have been few investigations examining the benefits, consequences, and patterns of use for prophylactic antibiotics for nasal packing in the emergency department setting. Given the frequency of epistaxis in the emergency department, it is an ideal setting to study the efficacy and utilization patterns of prophylactic antibiotics in nasal packing.

OBJECTIVE

Our aim was to assess both rates of utilization and evidence of benefit for prophylactic antibiotics in patients with nasal packing for epistaxis.

METHODS

A single-institution retrospective review of 275 cases of anterior nasal packing in an urban emergency department between September 2013 and April 2017 was performed. Chi-square statistical analysis was used to evaluate results.

RESULTS

Among 275 cases studied, there were no instances of toxic shock syndrome. Roughly 73% of patients with nonabsorbable packing received prophylactic antibiotics. Only one (1.1%) case of sinusitis was noted among the nonabsorbable packing with prophylaxis group, with no such complication in the nonprophylaxis group. In contrast, 95% of patients with absorbable nasal packing were not given prophylactic antibiotics. Analysis of all cases given prophylactic antibiotics vs. no prophylaxis, regardless of packing type, revealed no statistically significant difference in the development of acute sinusitis (1% vs. 0.56%; p = 0.6793).

CONCLUSIONS

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. However, patients who receive nonabsorbable nasal packing were more likely to receive antibiotic prophylaxis.