Mammalian bites
(Redirected from Bite)
Background
- 5% of untreated dog bites will become infected (similar to rate of non-bite wounds)
- 80% of untreated cat bites will become infected
- Human Bite - (Also see Closed fist infection)
High-Risk Wounds
- Cat, human, livestock, or monkey bites
- Deep puncture wounds
- Hand or foot wounds
- Bites in immunosuppressed patients
Clinical Features
- Depends on source of bite - bite marks or puncture wounds.
Differential Diagnosis
Envenomations, bites and stings
- Hymenoptera stings (bees, wasps, ants)
- Mammalian bites
- Closed fist infection (Fight bite)
- Dog bite
- Marine toxins and envenomations
- Toxins (ciguatera, neurotoxic shellfish poisoning, paralytic shellfish poisoning, scombroid, tetrodotoxin
- Stingers (stingray injury)
- Venomous fish (catfish, zebrafish, scorpion fish, stonefish, cone shells, lionfish, sea urchins)
- Nematocysts (coral reef, fire coral, box jellyfish, sea wasp, portuguese man-of-war, sea anemones)
- Phylum porifera (sponges)
- Bites (alligator/crocodile, octopus, shark)
- Scorpion envenomation
- Reptile envenomation
- Spider bites
Evaluation
- Clinical diagnosis, based on history and physical exam
- Consider X-ray
- If concern for retained foreign body (e.g. tooth)
- To rule out fracture (adult dogs may exert >200 lbs force bite)
- Consider Ultrasound
- If concern for abscess or foreign body
- CT Angio if concern for vascular injury
- Wounds overlying a joint should be examined through complete range of motion to assess for tendon injury
Management
- A mnemonic to remember management: HELICOPTER
- History, Examination, Liberal cleansing, Irrigation, Closure & Culture consideration, Operative cleansing & closure, Prophylactic antibiotics, Tetanus immunization, Elevation, Rabies risk
Indications for Primary Closure of Mammalian Bites
- Consider primary closure in face bites [1] [2] if all of the following are true:
- Repair can occur within 6hr of injury (time dependent upon individual judgment)
- Repair only requires single-layer closure; no devitalized tissue
- No underlying fracture
- No systemic immunocompromising conditions
- Large gaping wounds outside the face may also require closure with loose approximation
- Consider antibiotics in patients who are primarily closed
Antibiotics
Cat and Dog Bites
Coverage for Pasteurella, Strep, and Staph
- Consider for high-risk wounds
- wounds reaching the level of the muscle/tendon, wounds to the hand[3], violation of bone or joint capsule, immunocompromised hosts, wounds associated with significant local edema
- Amoxicilin-clavulanate 875mg PO BID x 5-7 days OR[4]
- Doxycycline 100mg PO BID x 14 days if penicillin allergic [5]
- Clindamycin 450mg (5mg/kg) PO q8hrs daily x7 days PLUS
- Ciprofloxacin 500mg PO q12hrs x 7 days OR
- TMP/SMX 2DS tabs (5mg/kg) PO q12hrs
Human Bites
All human bites should be strongly considered for antibiotic therapy.[6]
Requires polymicrobial coverage for: S. aureus, Strep Viridans, Bacteroides, Coagulase-neg Staph, Eikenella, Fusobacterium, Cornebacterium, peptostreptococus
- Amoxicilin-clavulanate 875mg PO BID x 5-7days OR
- Clindamycin 450mg (5mg/kg) PO q8hrs daily x7 days PLUS
- Ciprofloxacin 500mg PO q12hrs x 7 days OR
- TMP/SMX 2DS tabs (5mg/kg) PO q12hrs
Mammalian Bites Severe Infections
- Ampicillin/Sulbactam 3g IV (50mg/kg IV) q 6hrs daily OR
- Cefoxitin 1g IV q8hrs (25mg/kg q6hrs) OR
- Pipericillin/Tazobactam 4.5g IV (80mg/kg IV) q8hrs OR
- Ceftriaxone 1g (50mg/kg IV) once + Metronidazole 500mg IV q8hrs OR
- Clindamycin 600mg IV q8hrs PLUS
- TMP/SMX 5mg/kg IV q12hrs OR
- Ciprofloxacin 400mg IV q12hrs OR
Antivirals
- Monkey Bites: Acyclovir or Valacyclovir
- Monkeys are carriers of Cercopithecine herpesvirus 1 aka Herpesvirus simiae aka B virus.
- Valacylovir — 1g PO q8hrs for 14 days or Acyclovir —800mg PO 5 times daily for 14 days
Rabies prophylaxis
- Rabies immune globulin should be inidividualized[7]
- Indicated for bites from bats, monkeys, skunks, raccoons, foxes. In the U.S. rare for dog and cat bites to contain rabies (however different rules apply for stray animal in areas with higher rabies incidence)
- CDC recommends that if possible, the animal be tested, or quarantined for 10 days monitoring to help with the decision to provide rabies prophylaxis
Tetanus Prophylaxis
IDSA suggests considering Tetanus Vaccination in patients whose last Vx was 10 years or more [8]
Hand Bites
- Consider hand surgeon consultation early for hand bite infections (see closed fist infection)
Extremity Wounds
Keep involved extremity elevated. Educate patient to avoid soaking the wound and avoid wrapping bandages too tightly.
Disposition
- Discharge if mild or no apparent infection
- Admit for IV antibiotics as indicated in other skin and soft tissue infections
See Also
- Laceration Repair
- Closed fist infection
- Herpes B virus
- EBQ:Antibiotic prophylaxis for mammalian bites
External Links
References
- ↑ Rui-feng C, Li-song Huang, Ji-bo Z, Li-qiu Wang. Emergency treatment on facial laceration of dog bite wounds with immediate primary closure: a prospective randomized trial study. BMC Emergency Medicine. 2013;13(Suppl 1):S2. doi:10.1186/1471-227X-13-S1-S2.
- ↑ Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america. Clin Infect Dis. 2014 Jul 15;59(2):e10-52, executive summary can be found in Clin Infect Dis 2014 Jul 15;59(2):147
- ↑ EBQ:Antibiotic prophylaxis for mammalian bites
- ↑ Griego RD, Rosen T, Orengo IF, Wolf JE. Dog, cat, and human bites: a review. J Am Acad Dermatol. 1995;33:1019–29.
- ↑ Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EJ. Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med. 1999;340:85–92.
- ↑ EBQ:Antibiotic prophylaxis for mammalian bites
- ↑ Human rabies—Washington, D.C., 1995. MMWR Morb Mortal Wkly Rep. 1995;44:625–7.
- ↑ Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america. Clin Infect Dis. 2014 Jul 15;59(2):e10-52, executive summary can be found in Clin Infect Dis 2014 Jul 15;59(2):147