Bite Wound Infections: Mark A. Ward, MD
Bite Wound Infections: Mark A. Ward, MD
Bite Wound Infections: Mark A. Ward, MD
A
management, and prevention of ani- 5 year-old boy presents with complaints of a swollen, red
mal bite infections, including those and painful right hand 1 day after being bit on the hand
from humans, dogs, cats, and other by his neighbor's Chihuahua. The parents report that
vertebrates. the initial bite didn't seem that bad. It was a small bite
from a tiny dog. They washed it with soap and water, applied an
Keywords: antibiotic ointment and a Band-Aid. They were shocked to see
bite injury; animal bites; human that it had become so nasty looking after only one day. On exam,
bites; children; rabies; tetanus the boy's right hand was very tender and markedly swollen. The
prophylaxis palmar aspect was erythematous with purulent drainage easily
expressed from a small open wound.
Hand surgery was consulted and the child was taken to the
operating room for debridement. Gram stain of the wound revealed
gram-negative coccobacillus, gram- positive cocci and gram-
positive rods. Cultures were positive for Pasteurella multicida,
Streptococcus mitis, and Corynebacterium canis. The child's
infection gradually improved after several days of IV ampicillin-
sulbactam and he was discharge home on oral Augmentin.
The boy is now afraid of small dogs, but is making friends with
his cousin's chow-mixed breed...
Animal bites are a frequent reason for emergency department
visits, accounting for approximately 1% of all encounters. 1 They
are particularly important in pediatrics as more than half of
victims are children. 2 Although most bite wounds heal unevent-
fully, infectious complications are common. Therefore, emergen-
cy physicians should be familiar with the approach to the
assessment of bite wounds and the management of infections
Section of Infectious Disease, Department that may result from them. This article will review the
of Pediatrics, Baylor College of Medicine,
epidemiology, management, and prevention of animal bite
Houston, TX.
infections, including humans, dogs, cats, and other vertebrates.
Reprint requests and correspondence:
Mark A. Ward, MD, Texas Children's
Infections associated with insect bites and other nonvertebrates
Hospital, 6621 Fannin St, Suite A-170, will not be considered.
Houston, TX 77030.
[email protected]
EPIDEMIOLOGY
1522-8401/$ - see front matter Pet ownership in the United States is widespread, with an
© 2013 Published by Elsevier Inc. estimated 36.5% of households owning at least 1 dog and 30.4%
owning at least 1 cat. Specialty and exotic pets, including fish,
reptiles, ferrets, hamsters and other rodents, birds, and a variety
of other exotic animals are owned by an estimated and males were more likely to be victims of dog
10.6% of US households. As opposed to ownership bites. 14 As with dog bites, it is difficult to estimate
of cats and dogs, which has been very stable at the true prevalence of cat bites as most are minor
current levels over the past decade, overall and go unreported. Despite the usual benign nature
ownership of specialty and exotic animals has of cat bites, the resultant puncture wounds that they
decreased from levels in 2006 (16.5%). 3 Regard- often create increase the likelihood of infection
less, pet ownership is widespread in the United compared with canine bites.
States, and therefore, the potential for bite injuries
is substantial.
Exotic Pets, Wild Animals, and Livestock
Wild and exotic animal bites are much less
Dogs frequent than dog and cat bites but do account for
Recent data on the frequency of dog bite injuries a substantial number of bite injuries. Data from
are lacking. However, almost 2 decades ago, it was Indiana indicate that they account for approxi-
estimated that approximately 4.5 million of such mately 5% of bites in that state. 15 Squirrels were
injuries occurred each year in the United States. 4 the most common wild animal identified in that
As dog ownership has increased since that time, it series. Among exotic animals, reptiles are among
is almost certain that the incidence of bites has the most commonly owned. In 2011, there were
increased as well. Multiple studies have found that more than 4 000 000 turtles, snakes, and lizards
these injuries are more common in children, most kept as pets in the United States. 3 Likewise, it has
frequently involve the extremities, and usually been estimated that more than 15 000 monkeys are
result from the victim's pet. 5,6 Although rare in kept as pets. 16 Data for the frequency of ownership
comparison with the overall frequency of bites, and bite prevalence due to other exotic pets are
approximately 20 to 30 fatal dog attacks occur each lacking. Finally, livestock may inflict bite wounds
year. 4,7 Certain breeds of dogs have been implicat- but are not subject to mandatory reporting, and
ed more frequently in dog bites, particularly for therefore, data in regard to these injuries are
severe and fatal attacks. These include pit bulls, largely anecdotal.
German shepherds, and other large breeds. 6,8
However, denominator data are lacking, making
an estimate of the risk by breed impossible to
Human
Human bites are thought to be the third most
estimate accurately. In addition, the concept of
high-risk breeds has not been confirmed in all common type of mammalian bite. 17 Once again,
studies examining the issue. 9,10 Furthermore, accurate descriptive statistics are not available. In
addition, much of the available data relating to
several studies have demonstrated that breed
human bites involve adults. Human bites have a
identification is frequently inaccurate, making
long-standing reputation as being particularly se-
reported studies of attack rates by breed further
vere and prone to infection. This fearsome reputa-
suspect. 11,12
tion has been called into question in more recent
Regardless, it is clear that large dogs are capable of
studies. As with reports of other bite injuries, those
inflicting very significant injury. Resulting wounds
are characterized by laceration, avulsion, and crush involving human bites often have selection bias,
injuries. The jaws of large breeds can exert an with more severe injuries resulting in patients
seeking medical attention being studied, whereas
estimated force of up to 450 lb/in 2, sufficient to
more minor injuries in which no physician visit
penetrate sheet metal. 13
occurred being excluded. 18 More recent studies of
human bites, including studies of children, suggest
Cats that the overall rate of infection is much lower than
National data for cat bite injuries are lacking. previously suggested. 19,20
However, it is estimated that they are much less
frequent than dog bites, accounting for only 5% to
10% of animal bites in the United States each year. ASSESSMENT AND MANAGEMENT
In a study reported from El Paso, Texas, there were
2177 dog bite investigations in a single year History
compared with 343 cat bites. Cat bites were more Management of bite wounds begins with a careful
likely to be provoked (89.4%) than dog bites (57.5%). history. Emphasis should be on identification of the
Interestingly, in this study, adults and females were biting animal as well as the circumstances under
more likely to be cat bite victims, whereas children which the bite occurred. In particular, an attempt to
90 VOL. 14, NO. 2 • BITE WOUND INFECTIONS / WARD
the normal canine oral flora. 36 The most frequently associated with a range of organisms similar to that
isolated aerobes included Pasteurella spp (most found with human bites, including streptococci,
commonly Pasteurella canis), streptococci, Neisseria staphylococci, E corrodens, and anaerobes. 44 The
spp, and Corynebacterium spp. Among anaerobes, oral flora of reptiles, including snakes, lizards, and
Fusobacterium, Porphyromonas, Prevotella, Propionibac- alligators, includes a variety of gram-negative
terium, Bacteroides, and Peptostreptococcus were the organisms, including Aeromonas hydrophila, and bite
most common isolates. Most wounds yielded multi- infections due to this organism have been
ple organisms, with a median of 5 isolates per reported. 45,46
wound. 36 In addition to these more commonly
isolated organisms, dog bites may be associated
Surgical Management
with infections with less well-known species, such as
The surgical approach to infected animal bites is
Capnocytophaga canimorsus. 21,37 Despite the infre-
similar to that for any other infected wound. The
quency of infections due to this organism, it remains
wound should be debrided and any abscesses
an important consideration because it may result in
drained. The possibility of retained foreign mate-
severe infection, leading to sepsis and death.
rial should be considered, and careful exploration
Although this is primarily a consideration in
of the wound undertaken if this possibility cannot
patients with immunocompromising conditions
be ruled out.
such as splenic dysfunction and alcoholism, fatal
In addition, the possibility of injury to underlying
infection from the organism has been described in
structures should be considered. This is especially
otherwise healthy individuals. 38
true for bites involving the hand, where involvement
of the flexor tendons, bones, and joint space may
Cats
occur. 47 Another high-risk situation involves dog
In the same multicenter study cited above, cat
bites to the head, especially when the victim is an
bite infections had a distribution of infecting
infant. Despite apparently innocuous scalp injuries,
organisms similar to dog bites. Once again Pasteur-
penetration of the skull may occur, and studies to
ella spp were the most frequent isolates. However,
investigate this possibility should be considered. 48
Pasteurella multocida was the most common species
isolated in contrast to the P canis most commonly
found in dog bites. 36 Antibiotic Management
Controlled trials of antibiotics in the management
Humans of established bite wound infections are lacking.
As for infections from other mammalian bites, Therefore, selection of antibiotics should be guided
most human bite wound infections are polymicro- by the antibiotic susceptibility patterns of the most
bial, including aerobic and anaerobic species. 39 likely infecting organism. For more minor infec-
Frequently isolated aerobes include a variety of tions, amoxicillin/clavulanate orally provides excel-
streptococcal and staphylococcal species. In addi- lent coverage for the organisms most commonly
tion, E corrodens is a frequent cause of infections encountered in bite infections due to dogs, cats, and
after human bites. 40 In addition, the anaerobes humans and is recommended by both the Red Book
reported in human bite infections are more likely to Committee of the American Academy of Pediatrics
be β-lactamase producers than those obtained from as well as the Infectious Diseases Society of
nonhuman bite infections. 41 America. For children allergic to β-lactam agents,
reasonable alternatives include an extended-spec-
Other Animals trum cephalosporin or trimethoprim-sulfamethoxa-
The relative frequency of infecting organisms with zole plus clindamycin. More serious wound
other types of animal bites is difficult to estimate infections necessitating intravenous therapy may
due to the infrequency of such injuries and the lack be treated with ampicillin-sulbactam. 49,50 In com-
of systematically collected data. Nevertheless, a munities with high rates of methicillin-resistant
number of case reports and case series have Staphylococcus aureus, the regimen should include an
reported a large variety of organisms that cause agent active against that organism, especially if
infections in this setting. For example, tularemia Gram stain of material from the wound suggests the
secondary to a squirrel bite has been reported. 42 Pig possibility of a staphylococcal infection. Depending
bites have been associated with a number of on local susceptibility patterns, the severity of the
infecting agents, most commonly streptococcal infection, and the age of the patient, clindamycin,
and staphylococcal organisms, but also Pasteurella vancomycin, trimethoprim-sulfamethoxazole, and a
spp. 43 Infected nonhuman primate bites have been tetracycline are reasonable choices.
BITE WOUND INFECTIONS / WARD • VOL. 14, NO. 2 93
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