JRH is a 47 yo wm w underlying chronic HCV, htn

1

• JRH is a 47 yo wm w/ underlying chronic HCV, htn
• Sustained cat bite to L hand (L 3rd finger,
  lateral aspect of dorsum of hand) 5 d pta
• Cats vaccines UTD
• Pt. managed wound himself w/ local tx (H2O2,
  alcohol) but developed progressive
  swelling/erythema of hand

2

• Worsened pain but no purulence
• No f/c/lymphangitis at home
• Presented to ED, temp of 101.6, ESR 36, CRP 8.3 ?
  to OR for I D
• Extension of bite into joint space
• Cxs sent
• Begun on Amp/Sulbactam got tetanus booster in ED

3
From old chart

• 2/9/70 - (14 yo) lacerated L index finger with a
  saw
• 11/2/76 (21 yo) stepped on a nail at work which
  punctured his boot entered the bottom of his
  foot had numbness in 1st 3rd toes
• 1/4/82 (26 yo) smashed his R ring finger while
  putting the battery in his car (subungual
  hematoma noted)

4
From old chart

• 12/22/83 (28 yo) intoxicated, passed out,
  injured L shoulder Gr I AC joint separation
• 1/28/89 (33 yo) walked into a tree branch,
  scratching the L eye L corneal abrasion by slit
  lamp

5

• PE BP 160/92, T 97.7 L hand dressed in
  elevator sling, no evidence of lymphangitis or
  regional LAD
• Labs WBC 16.6, Hgb 14.6, Cr 0.5, ESR 36, CRP
  8.3
• Gram stain no organisms, no WBC cultures pending

6
Assessment / Suggestions

• L hand cat bite with associated cellulitis
  questionable septic arthritis
• Continue Unasyn 3.0 g IV q 6h
• Defer final decision re total duration of tx
• Await culture results

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Outcome

• Cultures remained negative
• Discharged three days later on Amp/Sulbactam
• Has not followed up

8
Animal Bite Trivia

• Each year, animal bites result in ______ visits
  to Emergency Departments
• A) 5,000
• B) 300,000
• C) 1,000,000

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Animal Bite Trivia

• Each year, animal bites result in ______ visits
  to Emergency Departments
• A) 5,000
• B) 300,000
• C) 1,000,000

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Animal Bite Trivia

• True or False?
• Dog bites are more likely to become infected when
  compared to cat bites.

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Animal Bite Trivia

• True or False?
• Dog bites are more likely to become infected when
  compared to cat bites.
• False. 3-18 of dog bites and 28-80 of cat
  bites become infected, with occasional sequelae
  of meningitis, endocarditis, septic arthritis,
  septic shock. (Talan et al N Engl J Med
  199934085)

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Animal Bite Trivia

• True or False?
• The most common bacterial isolates from animal
  bite wounds are Staphylococci and Streptococci.

13
Animal Bite Trivia

• True or False?
• The most common bacterial isolates from animal
  bite wounds are Staphylococci and Streptococci.
• False. Pasteurella species were the most common
  isolates from both dog bites and cat bites in a
  recent study. (Talan et al N Engl J Med
  199934085)

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Animal Bite Facts

• There are gt 110 million pet cats dogs in the US
• These pets are found in approximately 70 of
  households and have been directly or indirectly
  associated w/ the transmission of at least 30
  infectious agents to humans
• Tan, JS Arch Intern Med 1997 1571933

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Animal Bite Facts

• Each year, several million Americans are bitten
  by animals
• 300,000 visits to EDs (accounts for 1 of all ED
  visits)
• 10,000 hospitalizations
• 20 deaths
• 90 of bites are from dogs cats
• Cat bites much more likely to become infected and
  have sequelae

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Microbiology of Infected Bites

• Talan et al multicenter case series which
  included 18 EDs in the US to define the bacteria
  of cat dog bites
• 107 pts met enrollment criteria
• Ages 1-82
• 57 were cat bites 50 were dog bites
• The majority of dog cat bites were punture
  wounds

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Microbiology of Infected Bites

• Pasteurella species were the most common isolates
  from both dog bites (50) cat bites (75).
• Past. canis predominated among dog bites Past.
  multocida subspecies multocida septica were the
  most common isolates from cat bites
• Staph, strep, moraxella, neisseria were common
  aerobic isolates

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Microbiology of Infected Bites

• Fusobacterium, bacteroides, porphyromonas,
  prevotella were common anaerobic isolates
• Majority of infections were mixed infections

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Management of Bite Wounds

• Even apparently minor wounds require careful
  exploration
• May overlie fxs involve tendons, vessels, or
  nerves penetrate into a joint space
• To close or not to close?
• Do not close punctures, if not potentially
  disfiguring, if inflicted by humans, wounds
  involving the legs arms, if gt24 h old
• Close fresh, noninfected lacerations, /- facial
  wounds (consult plastics)

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Management of Bite Wounds

• Antimicrobials or not?
• Controversial, because incidence of documented
  infection has varied greatly among different
  studies (Fleisher N Engl J Med 1999340139)
• Almost always recommended for hi-risk wounds,
  e.g. deep punctures (especially if inflicted by
  cats), those requiring surgical repair, those
  involving the hands

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Antimicrobials for Bite Wounds

• Emperical tx for dog cat bites should be
  directed against pasteurella, streptococci,
  staphylococci, and anaerobes.

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Antimicrobials for Bite Wounds

• Emperical tx for dog cat bites should be
  directed against pasteurella, streptococci,
  staphylococci, and anaerobes.
• AUGMENTIN (or UNASYN if IV therapy needed)

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Antimicrobials for Bite Wounds

• What considerations are required for the
  penicillin-allergic patient?
• Pasteurella species usually are susceptible to
  amp, pcn, 2nd/3rd gen. cephalosporins, doxy,
  TMP/SMX, quinolones, clarithromycin, azithromycin
• Agents used for routine skin infections such as
  1st gen. cephalosporins, clinda,
  antistaphylococcal pcns, erythro are less
  active against pasteurella in vitro

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Antimicrobials for Bite Wounds

• A monotherapeutic alternative for satisfactory
  empiric treatment is not available.
• Alternatives
• 1) TMP/SMX Clindamycin (PO or IV)
• 2) Cefuroxime Metronidazole
• 3) Fluroquinolone Clindamycin
• 4) ?Azithromycin

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Final Thoughts

• Tetanus
• Given risk of tetanus after bites of all kinds,
  tetanus IG AND toxoid should be administered to
  pts who have had two or fewer primary
  immunizations. Toxoid alone can be given if the
  pt has completed a primary immunization series
  but has not received a booster in more than 5
  years.

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Final Thoughts

• Rabies
• Rabies associated w/ domestic animal bites is
  exceedingly uncommon
• Rabies prophylaxis is indicated primarily for
  bites caused by nondomestic animals, especially
  raccoons, skunks, foxes, or bats
• Quarantine the animal if possible observe for
  erratic behavior for 10 days sacrifice animal to
  examine brain if necessary

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Animal Bite Pneumonic

• History
• Examination
• Liberal cleansing and
• Irrigation
• Closure, cultures
• Operative cleansing and closure
• Prophylactic or therapeutic antimicrobial
• Tetanus immunization status
• Elevation
• Rabies risk