Bites

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Bites

• Michael A. Renzi, DO, FACP
• Advocare
• Heights Primary Care

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Epidemiology

• 1 of ED visits
• 80-90 are from dogs
• 5-15 are from cats

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Human Deaths from Animal Attacks

• Humans 200,000(US-3,400)
• Snake 60,000
• Crocodile 1000
• Tiger 800-1600
• Lion 60-200
• Leopard30-125
• Hippopotamus 200-300

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Human Bites
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Microbiology

• 80 S. aureus
• Mouth Anaerobes
• Group A ß-hemolytic Strep
• Eikenella

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Dog/Cat Bites
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Dogs, Mans BFF?

• 4.7 million bits annually
• 750,000 visits
• 66 of bites are not reported
• 59 per 10,000 incidence
• 250 per 10,000 in India
• 96 percent of rabies cases

Chhabra M. Humna rabies in Delhi, Indian Journal
of Peds, 2004 71217-220 CDC, US, 2001. MMWR
200352605-610
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Cat Bites

• 400,000 bits annually
• Mostly female cats
• Mostly female victims

Smith Treating Mammalian bite wounds, J Clinical
Pharm , 2000 2585-99
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Microbiology

• Pasteurella multocida 60
• S. aureus
• Cynocatophagia
• Anaerobes
• The average dog has 64 different bacterial
  isolates in mouth

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Marine Bites

• Shark, fish, eel
• Vibrio(cirrhotics)
• Aeromonas(GNR)

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Evaluation

• Provoked or unprovoked?
• Penicillin allergy
• Tetanus status
• Evaluate for injury below the skin

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Treatment

• Aggressive debridement and wound lavage
• Closure of lacerations within 24 hours
• May avoid antibiotics in superficial dermis
  non-extremity wounds(scalp)
• All hand bites get prophylactic antibiotics
• ABX may be warranted in immuno-compromised hosts

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Antibiotic Selection

• Amoxicillin/Clavulanate
• Azithromycin
• Cipro

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Rabies Prophylaxis

• Live captured animal is best
• Need the head
• Keep it in the frig until it can be analyzed
• Unprovoked aggression
• Lack of fear of humans
• Daylight attacks

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Which Animals?

• Racoons
• Skunks
• Bats
• Foxes
• Cats
• Dogs
• Cattle
• Horses

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Bees/Wasps
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Bee Stings

• Local edema
• Prednisonefor local edema
• H1 blockade for urticaria
• Epinephrine-laryngeal edema

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Flea Bites
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Chiggers
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Tick Line Up
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Eyrthema Chronica Migrans
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Evidence for the Evidence

• Grade AGood evidence to support use
• Grade BModerate Evidence
• Grade CPoor Evidence
• Grade DModerate Evidence Against use
• Grade EGood Evidence Against use

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Quality of the Evidence

• IOne positive randomized controlled trial
• IIOne well designed trial
• Without randomization
• Cohort
• Case controlled
• IIIEvidence and opinions from
  authorities based on clinical experience or
  expert committes

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Prophylaxis

• Routine use of antibiotics or serologic testing
  after tic bite(E-1, D-III)
• Remove attached tic ASAP(A-III)
• Treatment with ticks attached longer than 48
  hours (C-III)

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Who to Treat

• All Patients with ECM(A-I)
• All patients who develop a rash or high fever
  (gt100F) within 30 days of bite (A-II)
• Erlichiciosis or Babesiosis
• All patients with positive ELISA(A-1)

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Spiders
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Some Basics

• Offending critter rarely recovered
• Bite thin-skinned areas
• Areas where clothing presses tightly
• Appearance of the wound does not help with
  diagnosis

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Spiders-Brown Recluse
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Brown Recluse Bite
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Harmless
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Black widow

• Found in every state in US
• Usually warmer climates
• Highly venomous
• Have them bring in the spider

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Yellow Sac

• Bites feel like bee sting
• Serum Sickness
• Eschar not always present

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Scabies
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Nice People Get Scabies

• Without treatment, infection may last
  indefinitely
• Nocturnal itching is hallmark of scabies
• 4-6 weeks between infestation and symptoms

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Treatment

• Permethrin (A)
• Launder clothing and sheets
• Launder the kids, spouse
• Zoloft may be necessary