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

Abstract

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

Retrospective Review of Surgical Site Infections after Endoscopic Endonasal Sellar and Parasellar Surgery: Multicenter Quality Data from the North American Skull Base Society

“…21 Moreover, several studies have not shown clear benefits to using antibiotics in the setting of nasal packing use after sinonasal surgery. 21,22 The unclear need for antimicrobials with nasal packing use may introduce a level of confounding into this study.…”

“…Recent reports have decreased in frequency, and the development of newer packing materials may have contributed to this decline. 21 Moreover, several studies have not shown clear benefits to using antibiotics in the setting of nasal packing use after sinonasal surgery. 21,22 The unclear need for antimicrobials with nasal packing use may introduce a level of confounding into this study.…”

When is Antibiotic Prophylaxis for Nasal Packing Indicated?

“…The literature evaluated includes one prospective cohort study 1 (level 2), one systematic review 2 (level 2), one systematic review with meta‐analysis 3 (level 2), one retrospective cohort study 4 (level 3), and one cost‐effectiveness study 5 (level 1).…”

“…Maul et al's 2021 study included both epistaxis and post-operative sinonasal surgery patients in their retrospective analysis of the cost-effectiveness of antibiotic prophylaxis with nonabsorbable nasal packing. 5 Specifically, they compared the risk of nasal packing causing TSS with the risk of antibiotics causing CDC using a costeffectiveness approach. Maul et al chose CDC due to its significant financial burden on the healthcare system relative to other potential antibiotic complications.…”

Rhinologist Use of Antibiotics With Nasal Packing for Epistaxis

“…7 This recommendation was largely based on a recent study that concluded that antibiotic prophylaxis was not cost-effective when considering the infrequency of infectious complications with nasal packing. 8 To date, no studies have characterized the specific practice patterns of otolaryngologists treating epistaxis patients with packing. The present study had 3 objectives.…”