Take the Latest AccessPharmacy Quick Test - Treatment of Bite Wounds

AccessPharmacy Quick Test AccessPharmacy's Quick Test, sent twice a month, lets you test your pharmacologic knowledge and anonymously compare your results to those of your peers. Quick Test is developed by Terry L. Schwinghammer, PharmD, AccessPharmacy's Editor-in-Chief, from the site's online resources. Your results will be ranked against those of your peers. Quick Test posted on 3.1.11: Treatment of Bite Wounds Bite Wounds   Approximately half the population in the United States will be bitten by either an animal or another human sometime during their lifetimes. Bite wounds have a substantial potential for infectious complications. If left untreated, complications such as soft tissue infection and osteomyelitis may occur, possibly requiring extensive débridement or amputation. Animal Bites   Epidemiology   Dog bites account for approximately 80% of all animal bite wounds requiring medical attention. Data from U.S. emergency departments reported 368,245 visits for new dog bite-related injuries in 2001. Based on the data gathered in this study, approximately 1,000 new dog bite injuries are seen in emergency departments every day. Approximately one-half of dog bites occur in individuals younger than 20 years of age, usually males (55%). More than 70% of bites are to the extremities. Facial bites are also seen, particularly in children younger than 5 years of age. Up to 65% of bite wounds in young children involve the head and neck, and can be a lethal event because of blood loss. From 1979 through 1994, 279 deaths were the result of attacks by dogs. Patients at greatest risk of acquiring an infection after a bite have had a puncture wound (usually the hand), have not sought medical attention within 12 hours of the injury, and are older than 50 years of age. Cat bites, with an estimated incidence of 5% to 15% of all animal bites, are the second most common cause of animal bite wounds in the United States. Bites and scratches occur most commonly on the upper extremities, with most injuries reported in women. Infection rates, estimated at 30% to 50%, are more than double those seen with dog bites. Etiology   Infections from dog bite wounds are caused predominantly by mouth flora from the animal. Most infections are polymicrobial, with approximately five bacterial isolates per culture. Pasteurellamultocida is the most frequent isolate. Other common aerobes include streptococci, staphylococci, Moraxella, and Neisseria. The most common anaerobes are Fusobacterium, Bacteroides, Porphyromonas, and Prevotella. Wound-site cultures in both infected and noninfected patients have similar bacteria present, with aerobic organisms isolated from 74% to 90% and anaerobic organisms isolated from 41% to 49% of patients. Infections arising from cat bites or scratches are frequently (75%) caused by P. multocida, which has been isolated in the oropharynx of 50% to 70% of healthy cats. Mixed aerobic and anaerobic infections have been reported in 63% of cat bite wounds, whereas approximately one-third of cultures grow aerobes only. Both tularemia (Pasteurella tularensis) and rabies also have been transmitted by cat bites. Pathophysiology   The potential for infection from an animal bite is great owing to the pressure that can be exerted during the bite and the vast number of potential pathogens that make up the normal oral flora. Cats' teeth are slender and extremely sharp. Their teeth easily penetrate into bones and joints, resulting in a higher incidence of septic arthritis and osteomyelitis. Although a dog's teeth may not be as sharp, they can exert a pressure of 200 to 450 lb/in2 and therefore result in a serious crush injury with much devitalized tissue. Known human pathogens such as S. aureus, P. multocida, and anaerobes are among the more than 64 species of bacteria that are harbored in the average dog mouth. In addition, the polymicrobic (aerobic and anaerobic) nature of animal bites provides a synergistic relationship, thus making an infection harder to eradicate. Sidebar: Clinical Presentation   General Health care providers see two distinct groups of patients seeking medical attention for dog bites. The first group presents within 12 hours of the injury; these patients require general wound care, repair of tear wounds, or rabies and/or tetanus treatment. The second group of patients presents more than 12 hours after the injury has occurred; these patients usually have clinical signs of infection and seek medical attention for infection-related complaints. Symptoms Patients seek medical care for infection-related complaints (i.e., pain, purulent discharge, and swelling). Signs Patients with infected dog bite wounds generally present with a localized cellulitis and pain at the site of injury. Cellulitis usually spreads proximally from the initial site of injury, and a gray malodorous discharge may be encountered. If P. multocida is present, a rapidly progressing cellulitis is observed, with pain and swelling developing within 24 (70%) to 48 (90%) hours of initial injury. Fever is uncommon. Fewer than 20% of patients have a concomitant adenopathy or lymphangitis. Laboratory Tests Samples for bacterial cultures (aerobic and anaerobic) should be obtained. Wounds seen less than 8 hours or more than 24 hours after injury that show no signs of infection may not need to be cultured. Other Diagnostic Tests A roentgenogram of the affected part should be considered when infection is documented in proximity to a bone or joint. Treatment: Dog and Cat Bites   Table 114-4 lists the recommended drugs and dosing regimens for animal bite wounds. Cultures obtained from early, noninfected bite wounds are not of great value in predicting the subsequent development of infection. Documentation of the mechanism of injury is important; if possible, an immunization history of the animal should be obtained. It is also important for the patient's tetanus immune status to be determined. Wounds should be irrigated thoroughly with a copious volume (>150 mL) of sterile normal saline. Proper irrigation reduces the bacterial count in the wound. Antibiotic or iodine solutions do not offer any advantage over saline and actually may increase tissue irritation. Several management techniques used in the treatment of bite wounds remain controversial, including the extent and type of debridement, suturing wounds within 8 hours of the injury, and indications for the use of antibiotics. The role of prophylactic antimicrobial therapy for the early, noninfected bite wound remains controversial. Unfortunately, suggestions concerning the use of prophylactic antibiotics are based on minimal data because few clinical trials have been performed. Most reports are of retrospective studies or observations of complicated cases. A systematic review of eight randomized trials of bite wounds (caused by both animals and humans) evaluated the use of antibiotics for the prevention of infectious complications and concluded that antibiotics did not significantly reduce the risk of infection in patients with dog or cat bites, but that wounds involving the hands may benefit from antimicrobial prophylaxis. However, this review also concluded that additional studies are required to support these conclusions. Controlled studies have not shown benefits definitively with prophylactic antibiotics for noninfected bites. Because up to 20% of bite wounds may become infected, a 3- to 5-day course of antimicrobial therapy generally is recommended. This is especially important for patients at greater risk for infection (patients older than 50 years of age and those with puncture wounds and wounds to the hands, and those who are immunocompromised). Treatment should be directed at the typical aerobic and anaerobic oral flora of dogs, as well as at potential pathogens from the skin flora of the bite victim. The length of antimicrobial therapy depends on the severity of the injury/infection. Table 114-4 Recommended Drugs and Dosing Regimens for Outpatient Treatment of Mild-Moderate Skin and Soft-Tissue Infections Infection Oral Adult Dose Oral Pediatric Dose Folliculitis None; warm saline compresses usually sufficient   Furuncles and carbuncles Dicloxacillin 250-500 mg every 6 h Dicloxacillin 25-50 mg/kg in four divided doses Cephalexin 250-500 mg every 6 h Cephalexin 25-50 mg/kg in four divided doses Clindamycin 300-600 mg every 6-8 ha Clindamycin 10-30 mg/kg/day in three to four divided dosesa Erysipelas Procaine penicillin G 600,000 units intramuscularly every 12 h Penicillin VK 25,000-90,000 units/kg in four divided doses Penicillin VK 250-500 mg every 6 h Clindamycin 10-30 mg/kg in three to four dosesa Clindamycin 150-300 mg every 6-8 ha Erythromycin 30-50 mg/kg in four divided dosesa Erythromycin 250-500 mg every 6 ha Impetigo Dicloxacillin 250-500 mg every 6 h Dicloxacillin 25-50 mg/kg in four divided doses Cephalexin 250-500 mg every 6 h Cephalexin 25-50 mg/kg in two to four divided doses Cefadroxil 500 mg every 12 h Cefadroxil 30 mg/kg in two divided doses Clindamycin 150-300 mg every 6-8 ha Clindamycin 10-30 mg/kg/day in three to four divided dosesa Mupirocin ointment every 8 ha Mupirocin ointment every 8 ha Lymphangitis Initial intravenous therapy, followed by penicillin VK 250-500 mg every 6 h Initial intravenous therapy, followed by penicillin VK 25,000-90,000 units/kg in four divided doses Clindamycin 150-300 mg every 6-8 ha Clindamycin 10-30 mg/kg/day in three to four divided dosesa Diabetic foot infections Amoxicillin-clavulanic acid 875 mg/125 mg every 12 h   Fluoroquinolone (levofloxacin 750 mg every 24 or moxifloxacin 400 mg every 24 h) + metronidazole 250-500 mg every 8 h or clindamycin 300-600 mg every 6-8 ha   Animal bite Amoxicillin-clavulanic acid 875 mg/125 mg every 12 h Amoxicillin-clavulanic acid 40 mg/kg (of the amoxicillin component) in two divided doses Doxycycline 100-200 mg every 12 ha Dicloxacillin 250-500 mg every 6 h + penicillin VK 250-500 mg every 6 h Dicloxacillin 25-50 mg/kg in four divided doses + penicillin VK 40,000-90,000 units/kg in four divided doses Cefuroxime axetil 500 mg every 12 h + metronidazole 250-500 mg every 8 h or clindamycin 300-600 mg every 6-8 h Cefuroxime axetil 20-30 mg/kg in two divided doses + metronidazole 30 mg/kg in three to four divided doses or clindamycin 10-30 mg/kg/day in three to four divided doses Fluoroquinolone (levofloxacin 500-750 mg every 24 h or moxifloxacin 400 mg every 24 h) or clindamycin 300-600 mg every 6-8 ha Trimethoprim-sulfamethoxazole 4-6 mg/kg (of the trimethoprim component) every 12 h + metronidazole 30 mg/kg in three to four divided doses or clindamycin 10-30 mg/kg/day in three to four divided dosesa Erythromycin 500 mg every 6 h + metronidazole 250-500 mg every 8 h or clindamycin 300-600 mg every 6-8 ha Erythromycin 30-50 mg/kg in four divided doses + every 12 h + metronidazole 30 mg/kg in three to four divided doses or clindamycin 10-30 mg/kg/day in three to four divided dosesa Human bite Amoxicillin-clavulanic acid 875 mg/125 mg every 12 h Amoxicillin-clavulanic acid 40 mg/kg (of the amoxicillin component) in two divided doses Doxycycline 100-200 mg every 12 ha Dicloxacillin 250-500 mg every 6 h + penicillin VK 250-500 mg every 6 h Dicloxacillin 25-50 mg/kg in four divided doses + penicillin VK 40,000-90,000 units/kg in four divided doses Cefuroxime axetil 500 mg every 12 h metronidazole 250-500 mg every 8 h or clindamycin 300-600 mg every 6-8 h Cefuroxime axetil 20-30 mg/kg in two divided doses + metronidazole 30 mg/kg in three to four divided doses or clindamycin 10-30 mg/kg/day in three to four divided doses Fluoroquinolone (levofloxacin 500-750 mg every 24 h or moxifloxacin 400 mg every 24 h) + metronidazole 250-500 mg every 8 h or clindamycin 300-600 mg every 6-8 ha Trimethoprim-sulfamethoxazole 4-6 mg/kg (of the trimethoprim component) every 12 h + metronidazole 30 mg/kg in three to four divided doses or clindamycin 10-30 mg/kg/day in 3-4 divided dosesa aRecommended for patients with penicillin allergy. Sidebar: Clinical Controversy   To date, there is no single, universally agreed-on treatment regimen for bite wounds. Penicillin provides excellent coverage for P. multocida but not for S. aureus and most of the other staphylococci that are commonly isolated from bite wounds. Although penicillinase-resistant penicillins, first-generation cephalosporins, erythromycin, and clindamycin have excellent activity against staphylococci, these agents are not active against most strains of P. multocida. Amoxicillin-clavulanic acid is commonly recommended for oral outpatient therapy. Alternative oral agents include doxycycline or the combination of penicillin VK and dicloxacillin. Trimethoprim-sulfamethoxazole and fluoroquinolones have activity against P. multocida and are recommended as alternatives for patients who are allergic to penicillins. However, these agents should not be used in children and/or pregnant women; trimethoprim-sulfamethoxazole also should be avoided during pregnancy. Macrolides or azalides may be considered as alternatives in growing children or pregnant women. If erythromycin or similar-class agent is selected, bacterial sensitivities should be obtained and clinical response monitored carefully because most strains of P. multocida are resistant. Cefuroxime is another viable alternative for patients with mild penicillin allergies. Many of these alternative agents will likely require an additional agent (metronidazole, clindamycin) with activity against anaerobes. Failure to provide adequate initial treatment of bite wounds results in treatment failures and increased need for hospitalization for administration of parenteral antibiotics. Treatment options for patients requiring intravenous therapy include β-lactam- β-lactamase inhibitor combinations (ampicillin-sulbactam, piperacillin-tazobactam), second-generation cephalosporins with antianaerobic activity (cefoxitin), and carbapenems. In addition to irrigation and antibiotics, when indicated, the injured area should be immobilized and elevated. Clinical failures due to edema have occurred despite appropriate antibiotic therapy. Therefore, it is important to stress to patients that the affected area should be elevated for several days or until edema has resolved. Tetanus does not occur commonly after dog bites; however, it is possible. If the immunization history of a patient with anything other than a clean, minor wound is unknown, tetanus-diphtheria (TD) toxoids should be administered (0.5 mL intramuscularly). Both TD toxoids and tetanus immune globulin (250 units intramuscularly) should be administered to patients who have never been immunized. Because the rabies virus can be transmitted via saliva, rabies may be a potential complication of a bite. When the symptoms of rabies develop after a bite, the prognosis for survival is poor. Roughly 3% of rabies cases documented in animals were in dogs (the most frequent vectors are skunks, raccoons, and bats). After a patient has been exposed to rabies, the treatment objectives consist of thorough irrigation of the wound, tetanus prophylaxis, antibiotic prophylaxis, if indicated, and immunization. Prompt, thorough irrigation of the wound with soap or iodine solution may reduce the development of rabies. Postexposure prophylaxis immunization against rabies consists of the administration of both passive antibody and vaccine. The vaccine is administered as a series of five 1-mL intramuscular injections given on days 0, 3, 7, 14, and 28, beginning on the day of exposure or as soon as possible afterward. Rabies hyperimmune globulin is administered at a dose of 40 international units/kg; as much of the total dose as possible should be infiltrated into and around the wound, with the remainder being injected intramuscularly at a site different from that of the vaccine. The only exceptions to administration of hyperimmune globulin are patients who were immunized previously and who have the appropriate degree of documented rabies antibody titers. However, even individuals who have been fully vaccinated should receive two doses of vaccine on days 0 and 3 after actual rabies exposure. The management of cat bites is similar to that discussed for dog bites. Cat scratches typically involve the same organisms as bites and should be treated accordingly. Evaluation of Therapeutic Outcomes   Bite victims treated on an outpatient basis with oral antimicrobials should be followed up within 24 hours either by phone or office visit. Hospitalization or change to intravenous therapy should be considered if the infection has progressed. For hospitalized patients with no improvement in signs and symptoms following 24 hours of appropriate therapy, then surgical debridement may be needed. Human Bites   Epidemiology   Human bites are the third most frequent type of bite. Infected human bites can occur as bites from the teeth or from blows to the mouth (clenched-fist injuries). Human bites generally are more serious than animal bites and carry a higher likelihood of infection than do most animal bites. Infectious complications occur in 10% to 50% of patients with human bites. Self-inflicted bites most commonly occur on the lips or around the fingernails (from sucking or biting the nails). Bites by others can occur to any part of the body, but most often involve the hands. Bites to the hand are most serious and become infected more frequently. The clenched-fist injury is a traumatic laceration caused by one person hitting another in the mouth and is a very serious bite wound. The areas most commonly affected by this injury are the third and fourth metacarpophalangeal joints. Etiology   Infections caused by these injuries are similar and are caused most often by the normal oral flora, which include both aerobic and anaerobic microorganisms. Streptococcus spp. (especially Streptococcus anginosus) are the most common isolates, followed by Staphylococcus spp. (predominately S. aureus). Eikenella corrodens is isolated from human bite wounds approximately 30% of the time. Anaerobic microorganisms have been isolated in approximately 40% of human bites and 55% of clenched-fist injuries. Common anaerobes recovered from human bite infections include Fusobacterium, Prevotella, Porphyromonas, and Peptostreptococcus species. Pathophysiology   Human bites generally are more serious and more prone to infection than animal bites, particularly clenched-fist injuries. While the force of a punch may sever a tendon or nerve or break a bone, it most often causes a breach in the capsule of the metacarpophalangeal joint, leading to direct inoculation of bacteria into the joint or bone. When the hand is relaxed, the tendons carry bacteria into deeper spaces of the hand, resulting in more extensive infection. Sidebar: Clinical Presentation   General Most clenched-fist injuries are already infected by the time patients seek medical care, and most require hospitalization. Symptoms Patients with infected bites to the hand may develop a painful, throbbing, swollen extremity. Wounds often have a purulent discharge, and the patient complains of a decreased range of motion. Signs Signs of infection include erythema, swelling, and clear or pussy discharge. Adjacent lymph nodes may be enlarged. In clenched-fist injuries, edema may limit the ability of tendons to glide in their sheaths, thereby limiting a joint's range of motion. Laboratory Tests Samples for bacterial cultures (aerobic and anaerobic) should be collected as per animal bites. In severe infections, a peripheral leukocytosis of 15,000 to 30,000 cells/mm3 may be seen; therefore, the white blood count should be monitored for resolution of infection. Other Diagnostic Tests If damage to a bone or joint is suspected, radiographic evaluation should be undertaken. Treatment: Human Bites   Table 114-4 lists the recommended drugs and dosing regimens for human bite wounds. Management of bite wounds consists of aggressive irrigation and topical wound cleansing. Surgical debridement and immobilization of the affected area is often required. Prophylactic antimicrobial agents should be given as soon as possible to all patients, regardless of the appearance of the wound, unless it can be documented that the wound does not involve hands, feet, or joints and penetrates no deeper than the epidermis. Patients with clenched-fist injuries should be seen by a specialist in hand care to evaluate for penetration into the synovium, joint capsule, and bone. Primary closure for human bites generally is not recommended. Tetanus toxoid and antitoxin may be indicated. Because transmission of viruses (HIV, herpes, hepatitides B and C) is a possibility with human bites, information about the biter is important. Although the possibility of acquiring HIV through bites is believed to be unlikely, the presence of the virus in the saliva makes disease transmission possible. If the biter is HIV-positive, the victim should have a baseline blood specimen drawn to determine preexposure HIV status and then be retested in 3 months and 6 months. The bite wound should be irrigated thoroughly and vigorously with a virucidal agent such as povidone-iodine. Bite victims exposed to blood-tainted saliva should be offered antiretroviral chemoprophylaxis. Patients with human bite injuries should receive prophylactic antibiotic therapy for 3 to 5 days. First-generation cephalosporins, macrolides, clindamycin, and aminoglycosides are not recommended because the sensitivity of these agents to E. corrodens is variable. Amoxicillin-clavulanic acid (500 mg every 8 hours) is commonly recommended. Alternatives for penicillin-allergic patients include fluoroquinolones or trimethoprim-sulfamethoxazole in combination with clindamycin or metronidazole. Hospitalization for minor wounds is unnecessary if surgical repair of vital structures has not been performed. Patients suffering serious injuries or clenched-fist injuries should be started on intravenous antibiotics. Recommended agents include cefoxitin (1 g every 6 to 8 hours), ampicillin-sulbactam (1.5 to 3 g every 6 hours), or ertapenem (1 g every 24 hours). Therapeutic failures have been documented when either first-generation cephalosporins or penicillinase-resistant penicillins have been used alone, most likely because of their poor and variable activity against E. corrodens. Therapy should be continued from 7 to 14 days. Evaluation of Therapeutic Outcomes   Evaluation of treatment should follow the same general guidelines as discussed for animal bite wounds. Complications with clenched-fist injuries are common and may result in residual joint stiffness and loss of function. Physical therapy can be needed to improve these complications. About AccessPharmacy | Core Curriculum | Subscription Information | Advisory Board | Contact Us | Help | Privacy Notice | Terms of Use | Notice | Additional Credits and Copyright Information Copyright © 2011 The McGraw-Hill Companies, Inc. All rights reserved. Any use is subject to the Terms of Use and Notice. For further information about this newsletter, contact onlinecustomer_service@mcgraw-hill.com. You have received this message because you opted-in to receive information and special offers from McGraw-Hill Professional. We hope you enjoyed receiving this message. 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