Which Of The Following Is Included In The Care Of An Animal Bite?
Dog and Cat Bites
Am Fam Medico. 2014 Aug xv;90(4):239-243.
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Article Sections
- Abstract
- Wound Treatment
- Wound Closure
- Antibiotic Prophylaxis
- Rabies
- Preventing Brute Bites
- Laws and Regulations
- References
Dog bites account for 1% of all injury-related emergency section visits in the United States and more $l 1000000 in inpatient costs per twelvemonth. [ corrected] Nearly animal bites are from a canis familiaris, usually one known to the victim. Nigh domestic dog seize with teeth victims are children. Bite wounds should be cleaned, copiously irrigated with normal saline using a twenty-mL or larger syringe or a 20-gauge catheter attached to the syringe. The wound should exist explored for tendon or bone involvement and possible foreign bodies. Wounds may be closed if cosmetically favorable, such as wounds on the face or gaping wounds. Antibiotic prophylaxis should be considered, especially if in that location is a high risk of infection, such as with cat bites, with puncture wounds, with wounds to the hand, and in persons who are immunosuppressed. Amoxicillin/clavulanate is the beginning-line prophylactic antibiotic. The need for rabies prophylaxis should be addressed with any animal bite because even domestic animals are often unvaccinated. Postexposure rabies prophylaxis consists of immune globulin at presentation and vaccination on days 0, iii, vii, and fourteen. Counseling patients and families about animal safety may assist decrease animal bites. In well-nigh states, physicians are required by police to report beast bites.
Dog bites account for 1% of injury-related emergency section visits in the The states and an estimated $53.9 million in inpatient costs per year.1 Of the approximately 4.5 1000000 persons who are bitten by dogs each twelvemonth, approximately 316,000 are treated in the emergency department, and 9,500 are hospitalized.i [ corrected] In that location are 10 to 20 animal bite–related deaths, mostly from dogs, annually.1–4
Canis familiaris bites account for 85% to 90% of animal bites in the United States at a rate of 103 to 118 per 100,000 population1,five; no one dog breed is most oft responsible.half dozen Pit balderdash and Rottweiler breeds business relationship for most of the homo fatalities related to dog bites over the past two decades.vi,vii Virtually canis familiaris bite victims are children, and these bites ordinarily involve the head and neck. Adolescents and adults tend to have more bite wounds to the extremities.2,3,7 More than 70% of bites are from a dog that is known to the victim, and about 50% are self-reported as unprovoked.ii
SORT: Cardinal RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Bear witness rating | References | Comments |
|---|---|---|---|
| Bite wounds may exist airtight if cosmetically desirable. However, wounds at high risk of infection should be left open. | B | xiii, 14, 16 | Randomized controlled trials |
| Antibody prophylaxis should be used for high-risk bite wounds and considered for average-risk wounds. | B | 10, 16, eighteen, xix | Meta-analysis |
| Postexposure rabies prophylaxis should exist given to all persons mayhap exposed to rabies. | C | 24, 26, 28 | Show-based guidelines |
| Preexposure rabies prophylaxis should be considered for persons at higher risk of rabies exposure, and for international travelers to at-adventure areas who are unlikely to get postexposure prophylaxis within 24 hours of a possible rabies exposure. | C | 24, 26, 28 | Prove-based guidelines |
Cat bites account for 5% to 10% of fauna bite wounds.1 Cat bites occur most often in adult women, usually on the extremities. Virtually all of these bites are self-reported as provoked.2
Wound Treatment
- Abstract
- Wound Handling
- Wound Closure
- Antibiotic Prophylaxis
- Rabies
- Preventing Beast Bites
- Laws and Regulations
- References
Beast bite wounds are considered grossly contaminated; therefore, proper wound treatment is essential to forestall secondary infection. The afflicted pare surface should exist cleansed, and the wound should be copiously irrigated with water, normal saline, or dilute povidone-iodine solution, especially if the creature may exist rabid.8–ten To gargle the wound, a 20-mL or larger syringe should exist used to generate the loftier force per unit area required for adequate cleaning.10 If a 20-mL or larger syringe is unavailable, a xx-estimate catheter tin can exist connected to the syringe to increase the pressure.9–11 Cautious debridement of devitalized tissue further decreases the potential for infection.9,10,12
The wound should be carefully explored for tendon or os involvement and foreign bodies, such equally teeth fragments.nine,10 Older dogs and cats often have significant periodontal disease, increasing the hazard that a tooth will intermission off during a bite. Radiography is indicated if a foreign body or bone involvement is suspected.9 Tendon ruptures should be evident on test, but identifying a partial tendon rupture requires conscientious exploration of the wound. Observing the tendon throughout the joint'southward full extension and full flexion tin reveal minor or partially torn tendons, which warrant referral for repair.
Wound Closure
- Abstruse
- Wound Treatment
- Wound Closure
- Antibody Prophylaxis
- Rabies
- Preventing Animal Bites
- Laws and Regulations
- References
There are few studies addressing whether an animal seize with teeth wound should be primarily closed. Traditionally, beast bite wounds were left open up to prevent secondary infections. In one written report of 169 dog bite wounds in 96 patients, the infection rate was statistically equivalent for wounds that were primarily closed (7.half dozen%) and those that were left to heal by secondary intention (7.eight%).13 In a second study of 145 bite wounds that were primarily closed, only v.5% became infected, including bites from dogs (61%), cats (31%), and humans (eight%).14 Both of these studies are small and have pattern limitations; therefore, wounds may exist primarily closed if desired for cosmetic reasons.9,ten,xiii–fifteen However, allowing a wound to shut past secondary intention should exist considered if there is a college run a risk of infection (Table 110,eleven,16), such as wounds to the hand.9,10 The safety and effectiveness of pare adhesives have non been studied in creature bite wounds.17
Tabular array i.
Factors That Increase the Take chances of Infection from an Animal Bite
| Bite in extremities with underlying venous and/or lymphatic compromise | |
| Seize with teeth involving the mitt | |
| Bite well-nigh or in a prosthetic joint | |
| Cat bites | |
| Crush injuries | |
| Delayed presentation | |
| Greater than 6 to 12 hours for bites to the arm or leg | |
| Greater than 12 to 24 hours for bites to the face | |
| Puncture wounds | |
| Victim with diabetes mellitus or immunosuppression | |
Antibiotic Prophylaxis
- Abstract
- Wound Handling
- Wound Closure
- Antibiotic Prophylaxis
- Rabies
- Preventing Brute Bites
- Laws and Regulations
- References
There are conflicting data regarding antibiotic prophylaxis in the handling of domestic dog bite wounds and very limited information in other animate being bite wounds. A meta-analysis of eight randomized trials showed a benefit with antibiotic prophylaxis in beast bites (relative risk = 0.56; number needed to treat = 14); the infection rate was 16% in untreated patients.18 However, a Cochrane review of nine trials showed no statistical difference in infection rate between prophylaxis and no handling, except in seize with teeth wounds to the hand.xix In hand wounds, antibiotic prophylaxis reduced the rate of infection from 28% to two% (odds ratio = 0.10; number needed to care for = 4). Still, studies were heterogeneous and used different antibiotics. Antibiotic prophylaxis should exist used for high-gamble bite wounds (Table onex,eleven,16) and considered in boilerplate-risk wounds.9,18,19
Cultures of bite wounds are generally not helpful initially, unless the wound is abscessed or already infected.9,ten Mutual pathogens associated with animate being bites include Staphylococcus, Streptococcus, Pasteurella, Capnocytophaga, Moraxella, Corynebacterium, Neisseria, and anaerobic bacteria.20 Pasteurella multocida is a common bacterium in the mouths of cats, but it can as well exist nowadays in dogs. This bacterium can cause a fast-growing infection in humans and is one of the reasons to consider antibiotic prophylaxis for seize with teeth wounds. Wounds that go infected within 24 hours of the bite are oftentimes caused by Pasteurella.10–12 Capnocytophaga canimorsus is an emerging man pathogen that has been isolated from the mouths of 24% of dogs and 17% of cats.ten,12,21 This fastidious gram-negative bacterium tin can cause septicemia, meningitis, and endocarditis. Patients who take had splenectomy or who corruption booze are at highest take a chance of C. canimorsus infection. A beta-lactam/beta-lactamase inhibitor combination is the initial treatment of selection for this bacterium.
Antibiotic prophylaxis should exist considered for all bites requiring closure and for high-risk bites.nine,10 All true cat bites are considered high risk for infection because they tend to cause deep puncture wounds.nine,10
Amoxicillin/clavulanate (Augmentin) is by and large considered the first-line prophylactic treatment for animal bites.10,sixteen Table 2 summarizes the handling options.10,16,22 A 3-mean solar day to seven-day course of safe antibiotics is probable acceptable and was typical in most studies.9
Table ii.
Prophylactic Antibiotic Dosages for Animal Bites
| Adults | |
| Outset-line | |
| Amoxicillin/clavulanate (Augmentin), 875/125 mg every 12 hours | |
| Alternatives | |
| Clindamycin, 300 mg 3 times per day plus ciprofloxacin (Cipro), 500 mg twice per twenty-four hour period | |
| Doxycycline, 100 mg twice per day | |
| Penicillin VK, 500 mg 4 times per twenty-four hours plus dicloxacillin, 500 mg 4 times per day | |
| A fluoroquinolone; trimethoprim/sulfamethoxazole, 160/800 mg twice per day; or cefuroxime axetil (Ceftin), 500 mg twice per day plus metronidazole (Flagyl), 250 to 500 mg 4 times per twenty-four hour period, or clindamycin, 300 mg three times per twenty-four hours | |
| Children | |
| First-line | |
| Amoxicillin/clavulanate, 25 to 45 mg per kg divided every 12 hours | |
| Alternative | |
| Clindamycin, 10 to 25 mg per kg divided every 6 to 8 hours plus trimethoprim/sulfamethoxazole, 8 to 10 mg per kg (trimethoprim component) divided every 12 hours | |
| Pregnant women who are allergic to penicillin | |
| Azithromycin (Zithromax), 250 to 500 mg per twenty-four hour period | |
| Close monitoring is needed because of high failure rate | |
Tetanus vaccination is recommended afterward an animal seize with teeth if it has been more than five years since the patient has been immunized.eleven Table 3 summarizes the indications for tetanus prophylaxis in patients with wounds.23
Tabular array 3.
Indications for Tetanus Prophylaxis
| History of tetanus immunization | Clean, minor wounds | All other wounds | ||
|---|---|---|---|---|
| Vaccine | Immune globulin | Vaccine | Immune globulin | |
| Uncertain or < 3 doses | Yep | No | Yeah | Yes |
| ≥ 3 doses | No, unless > 10 years since last dose | No | No, unless > 5 years since last dose | No |
Rabies
- Abstract
- Wound Treatment
- Wound Closure
- Antibiotic Prophylaxis
- Rabies
- Preventing Animal Bites
- Laws and Regulations
- References
Rabies is a virus that tin infect any mammal. In the by decade, there have been up to eight man cases in the U.s. each year.24 Once symptomatic, it is almost universally fatal. Postexposure prophylaxis, which costs almost $1,000, is 100% constructive if used properly.24 There have been 6,000 to 7,000 documented cases per yr of rabies in animals in the United States and Puerto Rico over the past 10 years.25 In the United States, cats are the most usually infected domesticated beast, whereas raccoons, bats, and skunks are the most commonly infected wildlife. In 2012, in that location were 257 cases of rabies in cats and 84 cases in dogs.25 In well-nigh areas of the United states, information technology is required by law that dogs and cats be vaccinated. Despite this, data show that only 45% of dogs and 8% of cats that cause bites requiring an emergency department visit are vaccinated for rabies.2
Postexposure prophylaxis is indicated in all persons who were perhaps exposed to a rabid animal and is given to almost xvi,000 to 39,000 persons in the United States each yr.26 Prophylaxis consists of immune globulin at presentation and rabies vaccination on days 0, 3, 7, and fourteen. The immune globulin is infiltrated around the bite wound, and any additional book is administered at a site distant to the vaccination site, usually the opposite arm every bit the rabies vaccine. In the past, a fifth dose of the vaccine was given on twenty-four hour period 28; however, in 2009, the Advisory Committee on Immunization Practices recommended dropping this step.24,27 If the patient had already received preexposure prophylaxis before the creature seize with teeth, no immune globulin is needed, and the rabies vaccine is administered only on days 0 and 3.24
Postexposure prophylaxis is by and large non needed in patients with a canis familiaris or cat seize with teeth as long as the fauna is non showing signs of rabies, such as inappetence, dysphagia, abnormal behavior, ataxia, paralysis, altered vocalization, or seizures; however, the animal should be monitored for at to the lowest degree 10 days.8,24,26,27 If the fauna shows signs of rabies, becomes ill, or dies, firsthand postexposure prophylaxis is recommended. No animal should exist euthanized within 10 days of biting someone so that it can exist properly observed. If there is a question nigh whether postexposure prophylaxis should be given, physicians can contact their local health department or go to http://www.cdc.gov/rabies/resources/contacts.html for a list of state and local rabies consultation contacts.
Preexposure prophylaxis should be considered in persons with higher risk of rabies exposure, such as certain laboratory workers, veterinarians, spelunkers, and certain international travelers. The Centers for Affliction Control and Prevention recommends that travelers to at-take chances areas receive preexposure prophylaxis if they are unlikely to receive handling within 24 hours of a possible exposure. Preexposure prophylaxis consists of three vaccines given on days 0, seven, and 21 to 28.26,28
Saliva, brain tissue, and nervous system tissue are considered infective. Blood, urine, and carrion are not infective, and contact does not warrant postexposure prophylaxis. Table 4 includes postexposure rabies prophylaxis recommendations for specific animal bites.26 Postexposure prophylaxis should be strongly considered in persons mayhap exposed to a bat, such every bit if awakening from sleep and finding a bat in the room or finding a bat in the room with an unattended kid.
Table 4.
Recommendations for Postexposure Rabies Prophylaxis
| Blazon of animal bite | Evaluation and disposition of fauna | Recommendations |
|---|---|---|
| Dog, cat, ferret | Healthy; detect beast for 10 days | Vaccination should non exist initiated unless the beast develops clinical signs of rabies |
| Rabid (or suspected) | Vaccination should begin immediately | |
| Unknown (due east.one thousand., escaped) | Public health officials should be consulted; immediate vaccination should be considered | |
| Raccoon, skunk, fox, other carnivore, bats | Regarded every bit rabid unless the animal tests negative | Consider immediate vaccination; if the animal is being tested, delay vaccination until results are available |
| Livestock, horses | Consider individually | Public health officials should exist consulted; most livestock in the United states of america are vaccinated for rabies |
| Rodent, rabbit, hare, other mammal | Consider individually | Public health officials should exist consulted; bites of rabbits, hares, and small rodents (e.g., squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice) almost never require postexposure rabies prophylaxis |
Preventing Animate being Bites
- Abstruse
- Wound Treatment
- Wound Closure
- Antibiotic Prophylaxis
- Rabies
- Preventing Animal Bites
- Laws and Regulations
- References
Studies have shown that although well-nigh primary care physicians hold that counseling patients virtually pet-related wellness hazards is important, less than 20% counsel their own patients and family unit members.29 At that place are a few studies that demonstrate a benefit of counseling children and families about preventing dog bites.thirty Most dogs that bite are known to the victim.2–4,half dozen,vii Dogs should be socialized to children from the fourth dimension they are puppies. Training makes a dog more confident and less likely to seize with teeth out of fearfulness. Pets should have regular veterinary visits to stay updated on vaccines and to improve health. Pets that are in hurting or ill are more than likely to bite. Neutering dogs has been shown to subtract bites. Immature children should never be left alone with pets.31 A brochure on domestic dog bite prevention from the American Veterinarian Medical Association is available at https://www.avma.org/public/Pages/Dog-Bite-Prevention.aspx.
Laws and Regulations
- Abstract
- Wound Treatment
- Wound Closure
- Antibody Prophylaxis
- Rabies
- Preventing Animal Bites
- Laws and Regulations
- References
Most areas in the Usa crave health care professionals to report dog bites and many other creature bites, including bites in patients who present to an ambulatory office. Physicians should be familiar with their state and local laws. Because rabies in animals is a national reportable illness, suspected animals should exist sent for testing. Local or country health departments tin can provide information virtually submitting and storing specimens.
Data Sources: We searched the Cochrane database using the fundamental words animal bite, bite wound, and rabies; the U.S. Preventive Services Task Forcefulness and Institute for Clinical Systems Improvement using the cardinal words animal bite, rabies, and bite wound; the Centers for Disease Command and Prevention using the central words animal seize with teeth and rabies; and the Agency for Healthcare Enquiry and Quality, National Guideline Clearinghouse, Essential Bear witness Plus, and UpToDate using the central word animal seize with teeth. Medline was searched when the other sources did non yield answers to our questions. We too searched the Journal of the American Veterinary Medical Clan. Search dates: June 2011, January 2012, June 2013, and June 2014.
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REFERENCES
show all references
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2. Centers for Disease Command and Prevention. Nonfatal dog bite-related injuries treated in infirmary emergency departments—U.s., 2001. MMWR Morb Mortal Wkly Rep. 2003;52(26):605–610.
3. Gandhi RR, Liebman MA, Stafford BL, Stafford PW. Dog bite injuries in children: a preliminary survey. Am Surg. 1999;65(ix):863–864.
4. Patrick GR, O'Rourke KM. Dog and cat bites: epidemiologic analyses suggest different prevention strategies. Public Health Rep. 1998;113(iii):252–257.
5. Centers for Affliction Control and Prevention. Web-based Injury Statistics Query and Reporting System. Nonfatal injury reports, 2001–2012. http://webappa.cdc.gov/sasweb/ncipc/nfirates2001.html. Accessed June 24, 2014.
vi. Sacks JJ, Sinclair L, Gilchrist J, Golab GC, Lockwood R. Breeds of dogs involved in fatal homo attacks in the United States between 1979 and 1998. J Am Vet Med Assoc. 2000;217(6):836–840.
vii. Kaye AE, Belz JM, Kirschner RE. Pediatric canis familiaris bite injuries: a 5-year review of the experience at the Children's Hospital of Philadelphia. Plast Reconstr Surg. 2009;124(2):551–558.
8. Centers for Illness Control and Prevention. Rabies. http://www.cdc.gov/rabies/medical_care/index.html. Accessed June nineteen, 2013.
ix. Oehler RL, Velez AP, Mizrachi M, Lamarche J, Gompf S. Bite-related and septic syndromes caused by cats and dogs [published correction appears in Lancet Infect Dis. 2009;ix(ix):536]. Lancet Infect Dis. 2009;9(7):439–447.
10. Morgan M, Palmer J. Dog bites. BMJ. 2007;334(7590):413–417.
11. Fleisher GR. The direction of seize with teeth wounds. N Engl J Med. 1999;340(two):138–140.
12. Beck I. Management of human and animal bite wound infection: an overview. Curr Infect Dis Rep. 2009;11(five):389–395.
xiii. Maimaris C, Quinton DN. Dog-bite lacerations: a controlled trial of primary wound closure. Arch Emerg Med. 1988;five(iii):156–161.
14. Chen E, Hornig South, Shepherd SM, Hollander JE. Chief closure of mammalian bites. Acad Emerg Med. 2000;vii(two):157–161.
xv. Paschos NK, Makris EA, Gantsos A, Georgoulis Advert. Principal closure versus non-closure of dog bite wounds. a randomised controlled trial. Injury. 2014;45(1):237–240.
16. Stevens DL, Bisno AL, Chambers HF, et al.; Infectious Diseases Guild of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections [published corrections appear in Clin Infect Dis. 2006;42(8):1219, and Clin Infect Dis. 2005;41(12):1830]. Clin Infect Dis. 2005;41(10):1373–1406.
17. Dermabond [package insert]. Somerville, N.J.: Ethicon, Inc.; 2003. http://www.ethicon360emea.com/sites/default/files/products/DERMABOND_Labeling.pdf. Accessed June 19, 2013.
18. Cummings P. Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials. Ann Emerg Med. 1994;23(3):535–540.
nineteen. Medeiros I, Saconato H. Antibody prophylaxis for mammalian bites. Cochrane Database Syst Rev. 2001;(ii):CD001738.
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21. Tierney DM, Strauss LP, Sanchez JL. Capnocytophaga canimorsus mycotic abdominal aortic aneurysm: why the mailman is afraid of dogs. J Clin Microbiol. 2006;44(two):649–651.
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30. Duperrex O, Blackhall M, Burri M, Jeannot East. Education of children and adolescents for the prevention of dog bite injuries. Cochrane Database Syst Rev. 2009;(2):CD004726.
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