Mammalian Bites in the Emergency Department: Recommendations for Wound Closure, Antibiotics, and Postexposure Prophylaxis (Trauma CME and Pharmacology CME)

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Epidemiology And Pathophysiology
   1. Dog Bites
   2. Cat Bites
   3. Human Bites
   4. Other Mammalian Bites
6. Prehospital Care
7. Emergency Department Evaluation
   1. History
   2. Physical Examination
8. Diagnostic Studies
   1. Imaging
   2. Cultures
9. Treatment
   1. Wound Care And Repair
      1. General Concepts
      2. Dog-Bite Repair
      3. Cat-Bite Repair
      4. Human-Bite Repair
   2. Antimicrobial Prophylaxis
      1. Dog And Cat Bites
      2. Human Bites
   3. Tetanus Prophylaxis
   4. Rabies
      1. Observation Versus Rabies Postexposure Prophylaxis
      2. Rabies In Rodents And Lagomorphs
      3. Rabies Postexposure Prophylaxis And Bats
      4. Rabies In Ferrets
10. Special Considerations
    1. Capnocytophaga canimorsus Infection
    2. Cat Scratch Disease
    3. Disease Transmission Via Human Bites
    4. Monkey Bites
    5. Large Cats
11. Clinical Pathway For Repair And Antibiotic Treatment Of Mammalian-Bite Wounds In The Emergency Department (Trauma CME)
12. Clinical Pathway For Rabies Prophylaxis For Mammalian-Bite Wounds In The Emergency Department
13. Disposition
    1. Outpatient Treatment
    2. Inpatient Treatment
14. Summary
15. Risk Management Pitfalls For Management Of Mammalian Bites
16. Time- And Cost-Effective Strategies
17. Case Conclusions
18. Tables and Figures
    1. Table 1. Most Common Organisms Isolated From Bite Wounds
    2. Table 2. Types Of Wounds In Which Antibiotic Prophylaxis Should Be Considered
    3. Table 3. Centers For Disease Control And Prevention Rabies Postexposure Prophylaxis Recommendations
    4. Figure 1. Dog Bite
    5. Figure 2. Cat Bite
    6. Figure 3. Bat Bite
19. References

Abstract

Half of all Americans will experience a mammalian bite at some time in their life, and the cost of caring for these injuries has reached $160 million annually. Emergency clinicians must consider many factors when making decisions regarding care of these injuries: risk of infection, cost of antibiotics, time of wound healing, cosmetic and functional result, and risk of other injuries or diseases. Knowledge of the current literature and practice guidelines facilitates care for these injuries in the most cost-effective and clinically sound manner. This systematic review provides best-practice recommendations based on the best available evidence.

Case Presentations

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?

Introduction

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).

Critical Appraisal Of The Literature

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.

Risk Management Pitfalls For Management Of Mammalian Bites

1. “It’s just a small bite wound from a cat. It’s not going to get infected.”
   All animal-bite wounds have a risk of infection. Cat bites are particularly worrisome because they are puncture wounds that can go deep into tissue, allowing bacteria to be trapped deep under the skin and causing infection.


2. “He said he just scraped his hand on a wall during a fight.”
   Be very suspicious of any wounds to the hand that occurred during a fight. Patients commonly do not tell the full truth about how they obtained an injury, and a wound to the hand (particularly if overlying the metacarpal-phalangeal joint) may have occurred by striking a person’s mouth/tooth. This type of injury is concerning for bacteria being seeded deep into the joint capsule, causing osteomyelitis or septic arthritis.


3. “The patient says he has a primary care physician, so as an EMT, is it okay for me to tell the patient to follow up with the doctor in the morning, even though the dog bite looks deep?”
   One of the primary risk factors for infection of bite wounds is time to antibiotics. For this reason, all patients experiencing bite wounds should be advised to seek immediate treatment.


4. “The patient said he felt something on his arm and then saw a bat fly out of his window. There is no visible wound, so no treatment is necessary.”
   Bat bites can be very small, often requiring magnification to visualize. Bats most often prefer to avoid contact with humans, so any bite or scratch should be taken seriously and the patient should receive rabies prophylaxis.


5. “It’s just a dog bite, so x-rays aren’t needed.”
   Dogs' jaws exert very high pressure when they bite. The possibility of underlying orthopedic damage is high, and x-rays are generally warranted.


6. “It’s just a small human bite on the back. The only treatment needed is prophylactic antibiotics.”
   Prophylactic antibiotics are not warranted for most human-bite wounds, unless they are on the hands or feet. However, transmission of other diseases must remain a concern. HIV transmission, while extremely rare, can occur if the biter had blood in his saliva at the time of the bite. Additionally, hepatitis B and C can be transmitted even through nonbloody saliva contact. Discussion must occur regarding PEP for these viral diseases.


7. “This patient’s dog-bite wound is clean and he is being discharged with antibiotic prophylaxis, so he can follow up with his primary care physician in a week.”
   Even with antibiotic prophylaxis, bite wounds can become infected. It is important to follow up all bite wounds in 24 to 48 hours to evaluate for signs of infection that require admission for more aggressive treatment.


8. “This patient reports he has been bitten by a stray dog before and received the rabies vaccine at that time. Since he was previously immunized, he does not require any rabies treatment with the bite wound he received today.”
   All patients with bite wounds at high risk for rabies need PEP. If the patient has been previously immunized, then a 2-dose regimen of vaccine at days 0 and 3 can be given rather than the standard 4-dose regimen. Additionally, the patient does not need rabies immune globulin if he has been previously immunized.


9. “Even though the edges are red, I need to close this 3-day-old dog-bite wound to the face to prevent scarring.”
   Erythematous edges could be a sign of infection. Any dog bite with evidence of infection should not be closed primarily. A better cosmetic result will occur with secondary closure after the infection is treated.


10. “This patient with a dog bite reports his last tetanus shot was 7 years ago, so he doesn’t need one today.”
    Bite wounds are considered high-risk for tetanus, and prophylaxis should be given if the patient has not received prophylaxis within the past 5 years.

Tables and Figures

References

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.

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