Diseases » Insect sting allergies

Mammalian Bites

Mammalian Bites: Excerpt from The 5-Minute Pediatric Consult

Jill C. Posner, MD, MSCE

Mammalian Bites - BASICS

Mammalian Bites - description

Injury to the human skin and/or subcutaneous tissues caused by bite, causing usually local, and in some cases systemic, effects.

Mammalian Bites - general prevention

Ensure that children are routinely immunized against tetanus and hepatitis and that family pets are immunized against rabies.

Mammalian Bites - epidemiology

• Animal bites:
  • Dogs are responsible for 90–95%, cats, 3–8%; rodents or rabbits, 1%; and raccoons and other animals, 1%.
  • 90% of the offending animals are well known to the victim.
  • Children are the most common victims.
  • Boys are twice as likely as girls to be bitten by dogs; girls are more likely to be bitten by cats.
• Human bites:
  • Incidence is unknown, due to lack of reporting.
  • Most common in children ages 2–5 years.
  • In older children, bites may occur accidentally during sports activities or intentionally during altercations or abusive situations.

Mammalian Bites - incidence

There are an estimated 4.5 million dog bites, 400,000 cat bites, and 250,000 human bites annually in the US.

Mammalian Bites - pathophysiology

Animal bites:

• Crush-and-tear injuries can result from dog maulings, sometimes involving bone.
• Cat bites are generally puncture-type wounds, penetrating deeper and carrying a higher risk of infection.
• Human bites generally only violate skin, although penetration into joint and tendon sheath spaces can occur (especially bites overlying the metacarpal-phalangeal areas).
• Reports of rates of infectious complications have yielded varying results. Early studies report that infection occurs in 3–18% of dog bites, 28–80% of cat bites, and 15–20% of human bites. Studies that are more recent have suggested an incidence of infection after dog and cat bites to be closer to 2–3%.
• Bacteriologic analysis of infected animal and human wounds demonstrate polymicrobial cause, most commonly mixed aerobic and anaerobic species. Pasteurella species are the most frequent isolates from both dog bites (Pasteurella canis) and cat bites (Pasteurella multocida and Pasteurella septica).
• Common anaerobes include Fusobacterium, bacterioids, Porphyromonas, and Prevotella.
• For infected human bites, bacterial isolates include Streptococcus anginosus, Staphylococcus aureus, Eikenella corrodens, and Fusobacterium and Prevotella species.

Mammalian Bites - etiology

• Animal bites:
  • Dogs
  • Cats
  • Rodents
  • Wild animals
• Human bites

Mammalian Bites - DIAGNOSIS

Mammalian Bites - signs & symptoms

Mammalian Bites - history

Animal bites:

• Type of animal
• Apparent health of the animal
• Provocation for the attack
• Location of the bite or bites
• Availability of animal for undergoing observation (i.e., it is a known animal as opposed to a stray or wild animal?)
• Rabies immunization status of the animal
• Tetanus immunization status of the child

Mammalian Bites - physical exam

• Carefully assess neurovascular integrity
• Location of bite:
  • If bite is located over a joint, assess for violation of joint capsule.
• Examine entire patient to ensure that all wounds are identified and treated.
• Older wounds:
  • Assess for signs of infection such as erythema, induration, purulence, regional adenopathy, and elevated temperature.

Mammalian Bites - tests

No tests routinely done

Mammalian Bites - lab

Blood culture if fever or systemic toxicity

Mammalian Bites - imaging

In significant dog bites, consider radiography to evaluate for presence of fracture, foreign body (e.g., tooth), and air within joint.

Mammalian Bites - TREATMENT

Mammalian Bites - general measures

• Wound care:
  • Copious irrigation to remove visible debris
  • Cleanse but do not irrigate puncture wounds.
• Human bites over metacarpals (clenched-fist injuries) require orthopedic evaluation for possible surgical exploration and irrigation.
• Débride devitalized tissue.
• The increased risk of infection associated with suturing a potentially contaminated wound must be weighed against the cosmetic effect due to nonclosure.
  • Primary closure of larger wounds or significant facial wounds may be indicated unless wound is old or has evidence of infection.
  • Hand wounds may be an exception, due to high propensity for infection.

Mammalian Bites - medication

• Antibiotics: Data are often contradictory. In general:
  • All cat bites should be treated with prophylactic antibiotics, due to high risk of infection with P. multocida. Amoxicillin–clavulanic acid is drug of choice (50 mg/kg/d divided b.i.d. or t.i.d. for 5 days).
  • All human bites should be treated with antibiotic prophylaxis. Amoxicillin–clavulanic acid is drug of choice (50 mg/kg/d divided b.i.d. or t.i.d. for 5 days).
  • An alternative antibiotic regimen for penicillin-allergic patients is trimethoprim-sulfamethoxazole plus clindamycin.
  • Bites to the hand, deep puncture wounds, and wounds in immunocompromised hosts may be treated empirically.
  • Skin and soft-tissue infections requiring hospitalization: Ampicillin/sulbactam 150 mg/kg/d in 4 divided doses. For penicillin-allergic patients, 3rd-generation cephalosporin. Antibiotics with poor activity against Pasteurella include penicillinase-resistant penicillins, clindamycin, and aminoglycosides.
• Tetanus prophylaxis if indicated
• Rabies prophylaxis if indicated:
  • Unknown dog or cat; dogs or cats with unknown immunization status that cannot be observed for 10 days
  • Bites from wild animals, including raccoons, bats, skunks, foxes, coyotes
  • Because bat bites may go undetected, especially by a sleeping child, rabies prophylaxis is now recommended after exposure to bats in a confined setting.
  • Rabies is unlikely if the child was bitten by an immunized dog, cat, other pet (e.g., hamsters, guinea pigs, gerbils, rabbits), squirrels, mice, or rats.
  • The regimen for patients who have not been vaccinated previously should include both human rabies vaccine (a series of 5 doses administered IM) and rabies immune globulin (20 IU/kg) administered as much as possible into the wound, the remainder given IM at a site distant from the site used for vaccine administration.
• HIV postexposure prophylaxis (PEP):
  • There are case reports describing transmission of HIV by human bites; however, the risk of transmission due to biting is unknown. It is estimated to be extremely small. Bites with saliva containing no visible blood have no associated risk for transmission and, therefore, are not considered exposures.
  • A bite with a break in the skin is considered low risk and a bite with intact skin is felt to pose no risk.
  • HIV PEP requires a multidrug regimen administered over 28 days that can be associated with significant toxicity.
  • Hepatitis B has been transmitted from nonbloody saliva. Check the vaccination status of the bitten (or biter if necessary) to consider PEP. Unvaccinated children should begin the hepatitis B vaccine series.
  • The transmission rate of hepatitis C via human bites is unknown and no regimen for PEP currently exists.
  • Decisions to initiate PEP might best be made in consultation with local experts or by contacting the National Clinicians Post-Exposure Prophylaxis Hotline at 888-448-4911.

Mammalian Bites - FOLLOW UP

Mammalian Bites - disposition

Mammalian Bites - issues for referral

Local regulations dictate the reporting of animal bites to health departments.

Mammalian Bites - prognosis

Animal bites:

• Most injury from animal bites is trivial, but infections, and rarely deaths, do occur.

Mammalian Bites - complications

Human bites over metacarpals (clenched fist) can penetrate tendon sheaths, become infected, and result in a tenosynovitis.

Mammalian Bites - patient monitoring

Signs and symptoms of infection

Mammalian Bites - bibliography

American Academy of Pediatrics. Bite Wounds. Red Book: Report of the Committee on Infectious Diseases. 27th ed. Washington, DC: American Academy of Pediatrics; 2006.
1. Goldstein EJC. Current concepts on animal bites: Bacteriology and therapy. Curr Clin Top Infect Dis. 1999;19:99–111.
2. Griego RD, Rosen T, Orengo IF, et al. Dog, cat, and human bites: A review. J Amer Acad Dermatol. 1995;33:1019–1029.
3. Havens PL and the Committee on Pediatric AIDS. Postexposure prophylaxis in children and adolescents for nonoccupational exposure to human immunodeficiency virus. Pediatrics. 2003;111:1475–1489.
4. Moran GJ, Talan DA, Mower W, et al. Appropriateness of rabies postexposure prophylaxis treatment for animal exposures. JAMA. 2000;284:1001–1007.
5. Talan DA, Abrahamian FM, Moran GJ, et al. Clinical presentation and bacteriologic analysis of infected human bites in patients presenting to the emergency departments. Clin Infect Dis. 2003;37:1481–1489.
6. Talan DA, Citron DM, Abrahamian FM, et al. Bacteriologic analysis of infected dog and cat bites. N Engl J Med. 1999;340:85–92.

Mammalian Bites - CODES

Mammalian Bites - icd9

• E906.0 Dog bite
• E906.3 Bite of other animal
• E906.5 Bite by unknown animal

Mammalian Bites - PATIENT TEACHING-MED

Mammalian Bites - prevent

Educate children about the safe handling of animals.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

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More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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