A 25-year-old woman presents with complaints of redness of her right hand and arm. She reports that 1 day prior to presentation she was playing with a stray cat that she had been feeding and it “lovingly” bit her hand.
A 45-year-old man is brought to the ED after being bitten by a police dog. The arresting officer reports that the man was running away from a crime scene when the dog bit him several times. The patient has multiple gaping lacerations to his leg that range in length from 4 cm to 14 cm.
An 8-year-old boy is brought in by his mother because he was bitten by his guinea pig last week. The child denies any complaints, but the mother is worried that the child has “caught a disease” from the bite.
Which of these patients require antibiotic treatment? Which require rabies prophylaxis? Do any require admission to the hospital?
The incidence of mammalian bites is difficult to determine because a large number of these bites are never reported. Analysis of results from a telephone survey estimated that some 4.5 million dog bites occurred annually in the United States, with approximately 20% of those patients seeking medical treatment.1 The cost of healthcare associated with these injuries has risen dramatically over the years, with one report estimating that it exceeds $160 million annually.2 It is estimated that animal bites account for 1% of all emergency department (ED) visits each year.
The majority of bite wounds can be attributed to dogs, cats, and humans, with dog bites constituting about 80% of reported wounds. A small percentage of wounds are inflicted by other mammals, and these wounds are often a larger concern to the general public due to unfamiliarity with their treatment. In this issue of Emergency Medicine Practice, we take an in-depth look at the management of mammalian-bite wounds, including the timing of wound closure, the use of prophylactic antibiotics, and the latest recommendations for rabies postexposure prophylaxis (PEP).
A PubMed literature search was conducted using the terms mammalian bites and human bites and excluding the terms reptile, fishes, amphibians, chordata nonvertebrate, invertebrates, insect bites, tick bites, tick toxicoses, and tick paralysis, and limiting the search to articles dating since 2000. This search resulted in 1114 articles for abstract review. From this, 95 articles were identified for complete review. Additionally, the references from these articles were searched, revealing approximately 200 additional articles for review. The Cochrane Database of Systematic Reviews was searched for systematic reviews of mammalian bites and wound infection, and 2 pertinent reviews were identified. Additional resources included guidelines from the Advisory Committee on Immunization Practices (United States Centers for Disease Control and Prevention [CDC]) from 2008 and 2010 regarding rabies prophylaxis; the Public Health Service guidelines from 1991 and 2006 regarding tetanus prophylaxis; and the 2001 guidelines on PEP for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus (HIV). These guidelines are consensus statements, not systematic, evidence-based guidelines.
The majority of the literature regarding mammalian bites is weak and consists of reviews and case reports. Most studies regarding mammalian bites are relatively small and lack the power to obtain statistical significance. A few meta-analyses have shown statistical significance, but they are rare in the literature.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study are included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
Mary Ann Edens, MD; Jose A. Michel, MD; Nathaniel Jones, MD
April 1, 2016
May 1, 2019
Upon completion of this article, you should be able to:
Physician CME Information
Date of Original Release: April 1, 2016. Date of most recent review: March 10, 2016. Termination date: April 1, 2019.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: This Medical Journal activity, Emergency Medicine Practice, has been reviewed and is acceptable for up to 48 Prescribed credits by the American Academy of Family Physicians per year. AAFP accreditation begins July 1, 2015. Term of approval is for one year from this date. Each issue is approved for 4 Prescribed credits. Credit may be claimed for one year from the date of each issue. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 1 Infectious Disease CME credits, 0.5 Pharmacology CME credits, and 4 Trauma CME credits, subject to your state and institutional approval.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Edens, Dr. Michel, Dr. Jones, Dr. Galjour, Dr. Koyfman, Dr. Jagoda, Dr. Shah, Dr. Damilini, Dr. Toscano, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.
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