Bites, Animal Multimedia Presentation (Catastrophic Pit Bull Injury) - Massachusetts General...

8/14/2019 Bites, Animal Multimedia Presentation (Catastrophic Pit Bull Injury) - Massachusetts General Hospital (Bites, Animal)

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emedicine.medscape.com

eMedicine Specialties > Emergency Medicine > Environmental

Bites, Animal

Alisha Perkins Garth, MD, Staff Physician, Harvard Affiliated Emergency Medicine Residency, Brigham and Women's Hospital, Massachusetts General

Hospital

N Stuart Harris, MD, FACEP, Assistant Professor in Surgery, Harvard Medical School, Massachusetts General Hospital; Attending Physician,Massachusetts General Hospital

Updated: Jun 25, 2009

Introduction

Background

Because many animal bites are never reported, determining the exact incidence of animal bite wounds in the United States, let alone the world, is

difficult. An estimated 74.8 million dogs lived in the United States in 2007; these account for an estimated 5 million dog bites per year, of which 800,000

require medical attention[1 ]

. Substantially more dog bites occur than cat bites. These two species account for the majority of (nonhuman) animal bite

wounds encountered in the emergency department (ED).

Pathophysiology

Dog bites typically cause a crushing-type wound because of their rounded teeth and strong jaws. An adult dog can exert 200 pounds per square inch

(psi) of pressure, with some large dogs able to exert 450 psi.[2 ]

Such extreme pressure may damage deeper structures such as bones, vessels, tendons,

muscle, and nerves.

ites, Animal: [Print] - eMedicine Emergency Med... http://emedicine.medscape.com/article/768875-

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Wounds to the left arm inflicted during a pit bull attack. This young patient was also bitten once on the left side

of his face.

The sharp pointed teeth of cats usually cause puncture wounds and lacerations that may inoculate bacteria into deep tissues. Infections caused by cat

bites generally develop faster than those of dogs.[3,4 ]

Limited literature is available on other animal bites. Monkey bites have a notorious reputation based largely on anecdotal reports. Several cases of

unprovoked attacks on young children and infants by domesticated ferrets have been documented. The bites of foxes, raccoons, skunks, bats, dogs, and

cats have been clearly linked to rabies exposure. Bites from large herbivores generally have a significant crush element because of the force involved.

Bites of the hand generally have a high risk for infection because of the relatively poor blood supply of many structures in the hand and anatomic

considerations that make adequate cleansing of the wound difficult. In general, the better the vascular supply and the easier the wound is to clean (ie,

laceration vs puncture), the lower the risk of infection.

A major concern in all bite wounds is subsequent infection. Infections can be caused by nearly any group of pathogens (bacteria, viruses, rickettsia,


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spirochetes, fungi). At least 64 species of bacteria are found in the canine mouth, causing nearly all infections to be mixed.[5,6,7 ]

Common bacteria

involved in bite wound infections include the following:

Dog bites

Staphylococcus species

Streptococcus species

Eikenella species

Pasteurella species

Proteus species

Klebsiella species

Haemophilus species

Enterobacterspecies

DF-2 orCapnocytophaga canimorsus

Bacteroides species

Moraxella species

Corynebacterium species

Neisseria species

Fusobacterium species

Prevotella species

Porphyromonas species

Cat bites

Pasteurella species

Actinomyces species

Propionibacterium species

Bacteroides species


Clostridium species

Wolinella species

Peptostreptococcus species



Herbivore bites

Actinobacillus lignieresii

Actinobacillus suis

Pasteurella multocida

Pasteurella caballi

Staphylococcus hyicus subsp hyicus

Swine bites

Pasteurella aerogenes

Pasteurella multocida

Bacteroides species

Proteus species

Actinobacillus suis


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Flavobacterium species

Mycoplasma species

Rodent bites - Rat-bite fever

Streptobacillus moniliformis

Spirillum minus

Primates

Bacteroides species


Eikenella corrodens


Enterococcus species


Enterobacteriaceae

Simian herpes virus

Large reptiles (crocodiles, alligators)

Aeromonas hydrophila

Pseudomonas pseudomallei

Pseudomonas aeruginosa

Proteus species

Enterococcus species

Clostridium species

Frequency

United States

Of an estimated 3-6 million animal bites per year in the United States,[8 ]approximately 80-90% are from dogs, 5-15% are from cats, and 2-5% are from

rodents, with the balance from other small animals (eg, rabbits, ferrets), farm animals, monkeys, reptiles, and others. Some estimate that 1% of

emergency visits are for dog bite wounds. Approximately 1% of dog bite wounds and 6% of cat bite wounds require hospitalization.[1,9 ]

International

The lack of standard reporting in many countries makes accurate estimates of animal bite incidence difficult to determine. Depending on locale, the

range of animals inflicting bites is wide and includes large cats (tigers, lions, leopards), wild dogs, hyenas, wolves (Eurasia), crocodiles, and other

reptiles. As in the United States, most bites, however, are from domestic dogs. In developing countries, animal bites (especially bites by dogs, cats,

foxes, skunks, and raccoons) carry a high risk of rabies infection.

Mortality/Morbidity

Dog attacks kill approximately 10-20 people annually in the United States.

[8,10 ]

Most of these fatalities, unfortunately, are young children. While localinfection and cellulitis are the leading causes of morbidity, sepsis is a potential complication of bite wounds, particularly C canimorsus (DF-2) sepsis in

immunocompromised individuals. Pasteurella multocida infection (the most common pathogen contracted from cat bites) also may be complicated by

sepsis. Meningitis, osteomyelitis, tenosynovitis, abscesses, pneumonia, endocarditis, and septic arthritis are additional concerns in bite wounds. When

rabies occurs, it is almost uniformly fatal.

Sex

Women are more frequently bitten by cats, whereas men are more often bitten by dogs (despite being man's best friend).[11 ]


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Age

Peak incidence of animal bites occurs among children aged 5-9 years.[9,8,10 ]

Clinical

History

History for animal bites should include the following:

Time and location of event

Type of animal and its status (ie, health, rabies vaccination history, behavior, whereabouts)

Circumstances surrounding the bite (ie, provoked or defensive bite versus unprovoked bite)

Location of bites (most commonly on the upper extremities and face)

Prehospital treatment

Patients medical history (immunocompromise, peripheral vascular disease, diabetes, tetanus and rabies vaccination history)

Physical

Major resuscitation rarely is required. Because patients typically are children, reassurance and parental presence may facilitate examination. Where

applicable, consider the following:

Distal neurovascular status

Tendon or tendon sheath involvement

Bone injury, particularly of the skull in infants and young children

Joint space violation

Visceral injury

Foreign bodies (eg, teeth) in the wound


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The devastating damage sustained by a preadolescent male during a pit bull attack. Almost lost in this

photograph is the soft tissue damage to this victim's thigh. This patient required 2 units of O- blood and

several liters of isotonic crystalloid. Repair of these wounds required a pediatric surgeon, an experienced

orthopedic surgeon, and a plastic surgeon. Attacks such as these have caused a movement in some areas of the

country to ban pit bulls.


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Massive soft tissue damage of the right leg caused by a pit bull attack. This patient was transferred to a level

one pediatric trauma center for care. At times, staff members may need counseling after caring for savagely

mauled patients.

Causes

Bite wounds from cats and dogs can occur without provocation, but provoked bites, such as disturbing animals while they are eating, are more common.

Older animals often are less tolerant of disturbances, especially by children. Most dog bites involve a dog that belongs to the family or friend of the victim

and approximately half occur on the pet owner's property.[10 ]

Certainly, unprovoked bites by wild or sick-appearing animals (most notably by dogs, cats, raccoons, foxes, skunks, and bats) further raise

underlying concerns about likelihood of rabies exposure.

Differential Diagnoses


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Bites, Human Neck Trauma

Cellulitis Osteomyelitis

Fractures, Cervical Spine Rabies

Hand Infections Tetanus

Workup

Laboratory Studies

Fresh bite wounds without signs of infection do not need to be cultured. Infected bite wounds should be cultured to help guide future antibiotic

therapy.

Other laboratory tests are indicated as the patient's condition dictates (eg, CBC and blood cultures for patients with sepsis).

IfC canimorsus sepsis is suspected, examine the peripheral smear for the organism, a bacillus.

Imaging Studies

Radiography is indicated if any concerns exist that deep structures are at risk (eg, hand wounds; deep punctures; crushing bites, especially over

joints).

Occult fractures or osteomyelitis may be discovered.

Radiographs may find foreign bodies in the wound (eg, teeth).

Children who have been bitten in the head should be examined for bony penetration with plain films or CT scan. If the child was shaken,

consider cervical spine evaluation.

Other Tests

Treatment

Prehospital Care

Obtaining the history of the bite event is of major importance, including home treatment of wounds, body parts involved, and other symptoms

(see History).

Rinse bite wounds, if possible, and cover with a sterile dressing. Tap water has been shown to be as effective for irrigation as sterile saline.[12 ]

Encourage patients to seek prompt care.

Emergency Department Care

Most bite wounds can be treated in the ED. Essentials of treatment are necessary inspection, debridement, irrigation, and closure, if indicated.

Complete trauma evaluation occasionally is indicated.

Carefully inspect bite wounds to identify deep injury and devitalized tissue. Obtaining an adequate inspection of a bite wound without it

first being anesthetized is nearly impossible. Care should be taken to visualize the bottom of the wound and, if applicable, to examine the

wound through a range of motion.

Debridement is an effective means of preventing infection. Removing devitalized tissue, particulate matter, and clots prevents these from

becoming a source of infection, much like any foreign body. Clean surgical wound edges result in smaller scars and promote fasterhealing.

Irrigation is another important means of infection prevention. A 19-gauge blunt needle and a 35-mL syringe provide adequate pressure (7

psi) and volume to clean most bite wounds. In general, 100-200 mL of irrigation solution per inch of wound is required.[12 ]

Heavily

contaminated bite wounds require more irrigation. Large dirty wounds may require irrigation in the operating room. Isotonic sodium

chloride solution is a safe, available, effective, and inexpensive irrigating solution. Few of the numerous other solutions and mixtures of

saline and antibiotics have any advantages over saline. If a shieldlike device is used, take care to prevent the irrigating solution from

returning to the wound, which decreases the effectiveness of the irrigation.

Primary closure may be considered in limited bite wounds that can be cleansed effectively (this excludes puncture wounds, ie, cat

bites). Other wounds are best treated by delayed primary closure. Facial wounds, because of the excellent blood supply, are at low risk


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for infection, even if closed primarily, but the risk of superinfection must be discussed with the patient prior to closure. Bite wounds to the

hands and lower extremities, with a delay in presentation, or in immunocompromised hosts, generally should be left open.[7 ]

If a bite wound involves the hand, consider immobilizing in a bulky dressing or splint to limit use and promote elevation.

Consider tetanus and rabies prophylaxis for all wounds. Antirabies treatment may be indicated for bites by dogs and cats whose rabies status

can not be obtained, or in foxes, bats, raccoons, or skunks in the Americas (see Rabies for treatment and dosing information).

Oehler et al have established a wound management strategy following animal bites to prevent severe complications that include the following

steps:[13 ]

Culture for aerobes and anaerobes if abscess, severe cellulitis, devitalized tissue, or sepsis is present.

Use saline solution for wound irrigation.

Debride necrotic tissue and remove any foreign bodies.

If fracture or bone penetration, radiography is indicated (MRI or CT may also be indicated).

Initiate prophylactic antibiotics in selected cases (based on type and specific animal involved).

If methicillin-resistant Staphylococcus aureus (MRSA) is suspected, first-line antibiotics include trimethoprim-sulfamethoxazole,

doxycycline, minocycline, and clindamycin.

Hospitalization is indicated if fever, sepsis, spreading cellulitis, severe edema, crush injury, or loss of function is present. Also consider

hospitalization for patients who are immunocompromised or are likely to be noncompliant.

Administer tetanus booster (if none given in past year) or initiate primary series in nonvaccinated individuals.

Assess the need for rabies vaccine and immunoglobulin.

For additional information, see Medscapes Wound Management Resource Center.

Consultations

Extensive wounds, those involving tissue loss, or those involving complex structures may require plastic surgery consultation.

If the skull is penetrated, neurosurgery consultation is indicated.

Local public health authorities should be notified of all bites and may help with recommendations for rabies prophylaxis.

Medication

This is one of most controversial subjects in wound care. Remember that proper wound care (inspection, debridement, irrigation, closure, if indicated)

reduces infection more than antibiotics. In general, low-risk wounds do not require prophylactic antibiotics. However, therapy is recommended for

high-risk wounds (eg, cat bites that are a true puncture, bites to the hand, massive crush injury, late presentation, poor general health).[14 ]

The goal of initial therapy is to cover staphylococci, streptococci, anaerobes, and Pasteurella species. Prophylactic antibiotics may be given for a 3- to

5-day course. The first-line oral therapy is amoxicillin-clavulanate. For higher risk infections, a first dose of intravenous antibiotic may by given (ie,

ampicillin-sulbactam, cefuroxime, ticarcillin-clavulanate, piperacillin-tazobactam, or a carbapenem). Other combinations of oral therapy include amoxicillin

plus cephalexin (possible poor compliance due to complicated regimen), clindamycin plus a fluoroquinolone (adults), clindamycin plus sulfamethoxazole

and trimethoprim (Bactrim) (children), and less effective azithromycin or doxycycline.[15,6,7 ]

If the wound is infected on presentation, a course of 10 days

or longer is recommended.

For monkey bites, postexposure prophylaxis valacyclovir or acyclovir should be given for 14 days.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Ampicillin and sulbactam (Unasyn)

Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal

activity against susceptible organisms.


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Dosing

Adult

1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin

Pediatric

12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin

Interactions

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease

effects of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Imipenem and cilastatin (Primaxin)

For treatment of multiple organism infections in which other agents do not have wide-spectrum coverage or are contraindicated due to potential for

toxicity.

Dosing

Adult

Base initial dose on severity of infection, and administer in equally divided doses; dose may range from 250-500 mg q6h IV for a maximum of 3-4 g/d

Alternatively, 500-750 mg q12h IM or intra-abdominally

Pediatric

Infants >3 months and children

12 years: Administer as in adults

Interactions

Coadministration with cyclosporine may increase CNS side effects of both agents; coadministration with ganciclovir may result in generalized seizures

ContraindicationsDocumented hypersensitivity; known hypersensitivity to amide local anesthetics; children with CNS infections (increased seizure risk); children


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CrCl (mL/min) 80-50: 0.5 g q6-8h

CrCl 50-10: 0.5 g q8-12h

Hemodialysis (HD): 0.25-0.5 g after HD, then q12h

Adjust dose in renal insufficiency; avoid use in children


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penicillins may result in increased risk of bleeding

Contraindications

Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated

with an oral penicillin during the acute stage

Precautions

Pregnancy


Precautions

Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT levels

during therapy; exercise caution in patients with hepatic insufficiencies; perform urinalysis, and BUN and creatinine determinations during therapy and

adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions

Meropenem (Merrem IV)

Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria.

Has slightly increased activity against gram-negatives and slightly decreased activity against staphylococci and streptococci compared to imipenem.

Dosing

Adult

1 g IV q8h

Pediatric

40 mg/kg IV q8h

Interactions

Probenecid may inhibit renal excretion of meropenem, increasing meropenem levels

Contraindications


Precautions

Pregnancy


Precautions

Dosage adjustments (adult adjustments)

CrCl (mL/min) 10-50: 0.5-1 g q12h

CrCl


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Pediatric

10-15 mg/kg PO tid (based on amoxicillin component)

Interactions

Coadministration with warfarin or heparin increases risk of bleeding

Contraindications


Precautions

Pregnancy


Precautions

Give for a minimum of 10 d to eliminate organism and prevent sequelae (endocarditis, rheumatic fever); following treatment, perform cultures to confirm

eradication of streptococci

Amoxicillin (Trimox, Biomox, Amoxil)

Alone, this drug is effective against Pasteurella species. However, not indicated for skin and skin structure infections caused by beta-lactamase

producing strains ofStaphylococcus aureus. A second antibiotic such as cephalexin is needed forStaphylococcus infections.

Dosing

Adult

250-500 mg PO tid

Pediatric

30-50 mg/kg/d PO divided tid; not to exceed 500 mg/dose

Interactions

Reduces the efficacy of oral contraceptives

Contraindications


Precautions

Pregnancy


Precautions

Adjust dose in renal impairment; may enhance chance of candidiasis

Ticarcillin and clavulanate potassium (Timentin)

Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth. Antipseudomonal penicillin plus beta-lactamase inhibitor that

provides coverage against most gram-positive organisms, most gram-negative organisms, and most anaerobes.

Dosing

Adult

3.1 g IV q4-6h

Pediatric


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3 months

60 kg: 3.1 g IV q4-6h

Interactions

Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV

line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels

Contraindications

Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated

with oral penicillin during acute stage

Precautions

Pregnancy


Precautions

Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT levels

during therapy; exercise caution in patients with hepatic insufficiencies; perform urinalysis, and BUN and creatinine determinations during therapy and

adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions

Cephalexin (Keflex, Biocef, Keftab)

First-generation cephalosporin that arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing

organisms. Primary activity against skin flora.

Dosing

Adult

250-500 mg PO qid

Pediatric

25-50 mg/kg/d PO divided qid; not to exceed 500 mg/dose

Interactions

Coadministration with aminoglycosides increases nephrotoxic potential

Contraindications


Precautions

Pregnancy


Precautions

Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur

with prolonged use or repeated therapy

Sulfamethoxazole/trimethoprim (Bactrim, Bactrim DS, Septra, Septra DS)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.

Dosing


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Adult

400-800 mg SMX PO bid

Pediatric

30-60 mg/kg/d SMX PO divided bid; not to exceed 800 mg/dose

Interactions

May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood

levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase

with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with

coadministration; may increase levels of zidovudine

Contraindications

Documented hypersensitivity; megaloblastic anemia due to folate deficiency

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes

occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if

signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholism, advanced age, anticonvulsant therapy, malabsorption

syndrome); hemolysis may occur in G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic

impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation

Clindamycin (Cleocin)

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except

enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to

arrest.

Dosing

Adult

300 mg PO qid

Pediatric

10-25 mg/kg/d PO divided qid; not to exceed 600 mg/dose

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin;

antidiarrheals may delay absorption of clindamycin

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy


Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing

overgrowth ofClostridium difficile


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Ciprofloxacin (Cipro)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S epidermidis, and most gram-negative organisms, but no activity against

anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.

Dosing

Adult

500 mg PO bid

Pediatric

Not recommended

Interactions

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere

with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations;

may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Contraindications


Precautions

Pregnancy


Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function

impairment; superinfections may occur with prolonged or repeated antibiotic therapy

Azithromycin (Zithromax)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Treats

mild-to-moderate microbial infections

Dosing

Adult

500 mg PO on day 1, then 250 mg PO qd for 4 d

Pediatric

10 mg/kg PO d 1; not to exceed 500 mg/dose, then 5 mg/kg PO qd for 4 d; not to exceed 250 mg/dose

Interactions

May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids;

nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine

Contraindications

Documented hypersensitivity; hepatic impairment; do not administer with pimozide

Precautions

Pregnancy


Precautions


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Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and

cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or

debilitated patients

Doxycycline (Doryx, Vibramycin, Bio-Tab)

Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Dosing

Adult

100 mg PO bid

Pediatric

8 years: 2-5 mg/kg/d PO in 1-2 divided doses; not to exceed 200 mg/d

Interactions

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase

hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased

risk of pregnancy

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level

determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent

discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Cefuroxime (Ceftin, Kefurox, Zinacef)

Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have; adds activity against P mirabilis, H

influenzae, E coli, K pneumoniae, and M catarrhalis. Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose

and route of administration.

Dosing

Adult

500 mg PO bid

Pediatric

15-30 mg/kg/d PO divided bid; not to exceed 500 mg/dose

Interactions

Disulfiramlike reactions may occur when alcohol is consumed within 72 h after taking cefuroxime; may increase hypoprothrombinemic effects of

anticoagulants; may increase nephrotoxicity in patients receiving potent diuretics such as loop diuretics; coadministration with aminoglycosides increases

nephrotoxic potential

Contraindications



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Precautions

Pregnancy


Precautions

Reduce dosage by half if creatinine clearance is 10-30 mL/min, and by 3/4 if


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Probenecid, zidovudine, or cimetidine coadministration prolongs half-life and increases CNS toxicity of valacyclovir

Contraindications


Precautions

Pregnancy


Precautions

Caution in renal failure (decrease dose) and coadministration of nephrotoxic drugs; associated with onset of hemolytic uremic syndrome

Follow-up

Further Inpatient Care

Patients with infected animal bites may need inpatient care. This depends on the general health of the patient, the extent and nature of the

infection, and the patient's compliance.

Consider admitting patients with hand bites that become infected (generally involving deep structures). Consider consultation with hand surgery

service if deep infection, such as involving the tendon sheath or other structures, is suspected as surgical irrigation may be indicated.

Further Outpatient Care

Close follow-up care is essential in animal bite wounds. Reevaluate a low-risk bite for signs of infection within 48 hours and a high-risk bite within

24 hours.

In some centers that have an observation unit, admission to that area for direct clinical observation and repeat doses of parenteral antibiotics can

be considered on a case-by-case basis.

Transfer

Patients who require extensive repair or prolonged inpatient care may need transfer to a tertiary care facility.

ComplicationsComplications of animal bite wounds may include the following:

Wound infection

Sepsis

Cosmetic deformity

Loss of limb

Loss of function

Prognosis

The prognosis of animal bite wounds is generally excellent.

Patient Education

Educating patients about the risk of infection despite proper wound care, antibiotics (if indicated), and close follow-up care is very important.

Even bite wounds that have received the best care may become infected. Teach patients the signs of infection and the need for prompt attention

if the wound should become infected.

For excellent patient education resources, visit eMedicine's Bites and Stings Center and Bacterial and Viral Infections Center. Also, see

eMedicine's patient education articles Animal Bites and Rabies.


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Miscellaneous

Medicolegal Pitfalls

Meticulous documentation of both the history of the bite and of treatment is important to prevent questions about the appropriateness of care.

Documentation should include a thorough assessment of neurovascular and functional status, evidence that retained foreign bodies were

carefully ruled out, decisions about antibiotic use, decisions of primary versus delayed closure, rabies risk assessment, and other aspects of

care.

In many locations, animal bites must be reported to local authorities.

Special Concerns

Pediatric patients

Previously bitten patients remain at risk if the dog, cat, or other animal that bit them continues to be aggressive or is located where

another bite could occur.

Move the animal to another location.

Multimedia


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Media file 1: The devastating damage sustained by a preadolescent male during a pit bull attack. Almost lost in

this photograph is the soft tissue damage to this victim's thigh. This patient required 2 units of O- blood and

several liters of isotonic crystalloid. Repair of these wounds required a pediatric surgeon, an experienced

orthopedic surgeon, and a plastic surgeon. Attacks such as these have caused a movement in some areas of the

country to ban pit bulls.


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Media file 2: Massive soft tissue damage of the right leg caused by a pit bull attack. This patient was

transferred to a level one pediatric trauma center for care. At times, staff members may need counseling after

caring for savagely mauled patients.


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Media file 3: Massive soft tissue damage of the lower left leg caused by a pit bull attack. Most of the fatalities

from dog bites are children. Rottweilers and pit bulls are responsible for about 60% of fatalities.


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Media file 4: A different angle of the patient in Image 3 showing the massive soft tissue damage to this child's

left lower leg. Pit bull attacks are not rare.


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Media file 5: Wounds to the left arm inflicted during a pit bull attack. This young patient was also bitten once

on the left side of his face.

References

Centers for Disease Control and Prevention. Nonfatal dog bite-related injuries treated in hospital emergency departments--United States,

2001. MMWR Morb Mortal Wkly Rep. Jul 4 2003;52(26):605-10. [Medline].

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Chambers GH, Payne JF. Treatment of dog bite wounds. Minn Med. 1969;52:427-430. [Medline].2.

Freer L. Bites and injuries inflicted by wild and domestic animals. In: Auerbach PS, ed.Wilderness Medicine. 5th

ed. Mosby; 2007:1133-55.3.

Dire DJ. Cat bite wounds: risk factors for infection.Ann Emerg Med. Sep 1991;20(9):973-9. [Medline].4.

Talan DA, Citron DM, Abrahamian FM, et al. Bacteriologic analysis of infected dog and cat bites. N Engl J Med. Jan

14 1999;340(2):85-92. [Medline].

5.

Abrahamian FM. Dog B ites: Bacteriology, Management, and Prevention. Curr Infect Dis Rep. Oct 2000;2(5):446-453. [Medline].6.


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Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect

Dis. Nov 15 2005;41(10):1373-406. [Medline].

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Gilchrist J, Sacks JJ, White D, Kresnow MJ. Dog bites: still a problem?. Inj Prev. Oct 2008;14(5):296-301. [Medline].8.

Weiss HB, Friedman DI, Coben JH. Incidence of dog bite injuries treated in emergency departments.JAMA. Jan

7 1998;279(1):51-3. [Medline]. [Full Text].

9.

Sacks JJ, Lockwood R, Hornreich J, Sattin RW. Fatal dog attacks, 1989-1994.Pediatrics. Jun 1996;97(6 Pt 1):891-895. [Medline].10.

Palacio J, Leon-Artozqui M, Pastor-Villalba E, Carrera-Martin F, Garcia-Belenguer S. Incidence of and risk factors for cat bites: a first step in

prevention and treatment of feline aggression. J Feline Med Surg. Jun 2007;9(3):188-95. [Medline].

11.

Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound

irrigation.Academic Emergency Medicine. May 2007;14 (5):404-9. [Medline].

12.

Oehler RL, Velez AP, Mizrachi M, Lamarche J, Gompf S. B ite-related and septic syndromes caused by cats and dogs. Lancet Infect

Dis. Jul 2009;9(7):439-47.

13.

Cummings P. Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials.Ann Emerg

Med. Mar 1994;23(3):535-40. [Medline].

14.

Gilbert DN, Moellering RC, Eliopoulos FM, Sande MA, eds. Bites. In: The Sanford Guide to Antimicrobial Therapy. 37

th

ed. 2007:46,47,140.15.

Guy RJ, Zook EG. Successful treatment of acute head and neck dog bite wounds without antibiotics.Ann Plast

Surg. Jul 1986;17(1):45-8. [Medline].

16.

Trott A. Bite wounds. In: Wounds and Lacerations Emergency Care and Closure. 2nd

ed. St Louis, Mo: Mosby-Year Book Inc; 1997:265-84.17.

Weber EJ. Mammalian bites. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th

ed. Mosby; 2006:906-21.

18.

Keywords

animal bites, animal bite management, wound management, animal bite treatment, animal bite infection, bite wound, animal bite wound, dog bite, cat

bite, pet bite, wild animal bite, bite wound infection, bite-related infection, mammal bites, rodent bites, ferret bites, rabbit bites, pit bull bite, cellulitis,

rabies, septic arthritis, Staphylococcus, Streptococcus, Pasteurella, Bacteroides, Capnocytophaga canimorsus, Eikenella, Enterobacter, Proteus,Haemophilus, Klebsiella, Actinomyces, Fusobacterium, Peptostreptococcus, Clostridium, Wolinella, Propionibacterium, osteomyelitis

Contributor Information and Disclosures

Author

Alisha Perkins Garth, MD, Staff Physician, Harvard A ffiliated Emergency Medicine Residency, Brigham and Women's Hospital, Massachusetts General

Hospital

Alisha Perkins Garth, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Emergency

Medicine Residents Association, Phi Beta Kappa, Sigma Xi, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

N Stuart Harris, MD, FACEP, Assistant Professor in Surgery, Harvard Medical School, Massachusetts General Hospital; Attending Physician,

Massachusetts General Hospital

N Stuart Harris, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of

Emergency Physicians, International Society for Mountain Medicine, and Massachusetts Medical Society


Medical Editor

Robert M McNamara, MD, FAAEM, Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine

Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical

Association, Pennsylvania Medical Society, and Society for Academic Emergency Medicine


6 of 27 1/1/10 8:05


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Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Managing Editor

James Steven Walker, DO, MS, Clinical Professor of Surgery, Department of Surgery, University of Oklahoma Health Sciences CenterJames Steven Walker, DO, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of

Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association


CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer,

CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical

Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics

Association, Phi Beta Kappa, and Society for Academic Emergency Medicine


Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine,

Harvard Medical School

Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency

Medicine


Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Jack L Stump, MD, to the development and writing of this article.

Further Reading

1994-2010 by Medscape.

All Rights Reserved

(http://www.medscape.com/public/copyright)


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Contributor Information and Disclosures

AuthorAlisha Perkins Garth, MD,Staff Physician, Harvard Affiliated Emergency Medicine Residency, Brigham and

Women's Hospital, Massachusetts General Hospital

Alisha Perkins Garth, MD is a member of the following medical societies: Alpha Omega Alpha, American College

of Emergency Physicians, Emergency Medicine Residents Association, Phi Beta Kappa, Sigma Xi, and Society for

Academic Emergency MedicineDisclosure: Nothing to disclose.

Coauthor(s)N Stuart Harris, MD, FACEP,Assistant Professor in Surgery, Harvard Medical School, Massachusetts General

Hospital; Attending Physician, Massachusetts General Hospital

N Stuart Harris, MD, FACEP is a member of the following medical societies: American Academy of Emergency

Medicine, American College of Emergency Physicians, International Society for Mountain Medicine, and

Massachusetts Medical Society


Medical Editor

Robert M McNamara, MD, FAAEM,Chair and Professor, Department of Emergency Medicine, TempleUniversity School of Medicine

Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of

Emergency Medicine, American Medical Association, Pennsylvania Medical Society, and Society for Academic

Emergency Medicine


Pharmacy EditorFrancisco Talavera, PharmD, PhD,Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Managing EditorJames Steven Walker, DO, MS,Clinical Professor of Surgery, Department of Surgery, University of Oklahoma

Health Sciences Center

James Steven Walker, DO, MS is a member of the following medical societies: American Academy of Emergency

Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians,

and American Osteopathic Association


CME EditorJohn D Halamka, MD, MS,Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess

Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending

Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency

Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency

MedicineDisclosure: Nothing to disclose.

Chief EditorJonathan Adler, MD,Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital;

Division of Emergency Medicine, Harvard Medical School

Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine

and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.!

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