Hospital management of animal and human bites

The potential for the double risk of rabies and antimicrobial resistance in a high rabies endemic setting: detection of antibiotic resistance in bacterial isolates from infected dog bite wounds in Uganda

BACKGROUND

Post-exposure treatment for dog bites in humans aims at alleviating the risk of rabies and promoting wound healing. Wound healing may be complicated by bacteria. This study identified the different bacteria and their antibiotic susceptibilities in infected dog bite wounds (DBWs) in Uganda.

METHODS

A cross-sectional study was conducted among 376 dog bite patients. Wound swabs from patients with infected DBWs were collected and inoculated into recommended media. They were cultured for both aerobic and anaerobic bacteria. All isolated bacteria were identified based on colony characteristics, gram stain, and standard biochemical tests. Molecular identification was performed for strains that were resistant to three or more antibiotics. Antibiotic susceptibility testing was conducted using the disc diffusion method following the modified Kirby-Bauer method. The data were analysed using Stata version 15 software.

RESULTS

Approximately half of the patients (52.9%, 199/376) presented with infected wounds. Majority of the swabs (84.4%, 168/199) were culture positive, and yielded a total of 768 isolates where about half (52.9%, 406/768) were gram positive bacteria, and about two-thirds (64.6%, 496/768) were recovered from category II wounds. Among the gram positive bacteria, 339 (83.5%) were aerobes where Staphylococcus aureus (103, 30.4%), Coagulase-negative staphylococci (68, 20.1%), and Corynebacterium spp (33, 9.7%) had the highest prevalence. For the 362 Gram negative isolates, 217 (59.9%) were aerobes and the commonest isolates were P. maltocida (64, 29.5%), Capnocytophaga canimorsus (36, 16.6%) and P. canis (26, 12.0%). Gram-positive isolates were resistant to metronidazole (93.6%), oxacillin (68.5%), ceftriaxone (14.6%) and amoxicillin/clavulanic acid (14.0%). Gram negative isolates were resistant to metronidazole (100%), ampicillin (30.7%), oxacillin (29.3%), and doxycycline (22.9%). Multidrug resistance was in 105 (29.0%) and 121/406 (29.8%) of the gram-negative and gram-positive isolates, respectively. All gram-positive isolates were susceptible to vancomycin and ciprofloxacin.

CONCLUSIONS

Infection rates of DBWs in Uganda are high and the dominant bacterial isolates are Staphylococcus aureus, Pasteurella spps, and Capnocytophaga canimorsus. Multidrug resistance to commonly used antibiotics is high. The recommendation in the Uganda Clinical Guidelines to use metronidazole in the management of DBWs should be reviewed. DBWs should be enlisted for routine antimicrobial resistance surveillance and rational use of antimicrobial agents should be promoted.

Response to chicco et al. communication entitled 'Management and outcomes of mammalian bite injuries during COVID-19 and implications for future practice' Published: November 07, 2020DOI:https://doi.org/10.1016/j.bjps.2020.10.090

The Covid-19 pandemic has forced us to treat mammalian bite injuries more conservatively as resources were redirected to the Covid effort resulting in limited availability of hospital beds and theatre space. When comparing our outcomes before and during the first Covid-19 lockdown, this more conservative approach, which resulted in 24% less admissions and 19% less washouts in theatre, did not result in an increased infection rate. An increased rate of bite injuries during the national lockdown period was also noted. We support the conclusion by Chicco et al. that the majority of patients with bite injuries can ‘safely be managed with washout under local anaesthesia, oral antibiotics and discharge on the same day with safety net advice’. It is interesting that in some aspects of our care we may find Covid-19 has been beneficial in de-medicalising management of certain injuries and conditions.

Dog bites and diabetic peripheral neuropathy: a dangerous combination

All animal bites have the potential to cause significant infection. In the UK, dogs are the most common source of bites. Incidence of hospital attendances attributable to dog bites has risen over the last decade. Patient groups at particular risk of bites and/or complications of infection include those at extremes of age, immunosuppressed and patients with diabetes. We report the case of a patient with diabetic peripheral neuropathy, who was admitted on two separate occasions with unprovoked bites to his toes whilst asleep, by his pet dog. He ultimately required terminalisation of the affected digits. Although unusual, this mechanism of injury has been previously described in literature. However, we are unaware of cases reporting multiple separate incidences involving the same patient and animal. We present this case to highlight the perils of untrained pet ownership in diabetic patients with peripheral neuropathy and the importance of prompt medical and surgical treatment of injuries.

Diversity of Aerobic Bacteria Isolated from Oral and Cloacal Cavities from Free-Living Snakes Species in Costa Rica Rainforest

Costa Rica has a significant number of snakebites per year and bacterial infections are often complications in these animal bites. Hereby, this study aims to identify, characterize, and report the diversity of the bacterial community in the oral and cloacal cavities of venomous and nonvenomous snakes found in wildlife in Costa Rica. The snakes where captured by casual encounter search between August and November of 2014 in the Quebrada González sector, in Braulio Carrillo National Park. A total of 120 swabs, oral and cloacal, were taken from 16 individuals of the Viperidae and Colubridae families. Samples were cultured on four different media at room temperature. Once isolated in pure culture, colonies were identified with the VITEK® 2C platform (bioMérieux). In order to test the identification provided on environmental isolates, molecular analyses were conducted on 27 isolates of different bacterial species. Specific 16S rDNA PCR-mediated amplification for bacterial taxonomy was performed, then sequenced, and compared with sequences of Ribosomal Database Project (RDP). From 90 bacterial isolates, 40 different bacterial species were identified from both oral and cloacal swabs. These results indicate the diversity of opportunistic pathogens present and their potential to generate infections and zoonosis in humans.

[Mammal bite management]

BACKGROUND

Animal bites are a major public health problem, it is estimated that 2% of the population is bitten each year. Most bites are by dogs and the risk factors include young children, men, certain breeds of dogs and untrained dogs. The risk of infection after bites differs between animal species and depends on the animal teeth and oral flora.

CONCLUSIONS

Animal bites are still a major cause of morbidity in patients of all ages and have caused several preventable childhood deaths. These wounds often become infected. If the wound requires it, early surgical evaluation must be performed. The use of antibiotics is only recommended for high risk bite wounds.

Management of bite wounds in children and adults-an analysis of over 5000 cases at a level I trauma centre

BACKGROUND

Bite wounds are among the commonest types of trauma to which man is the subject. They account for 5 % of the total traumatic wounds evaluated in the emergency department (ED) and approximately 1 % of all the ED visits. Early estimation of infection risk, adequate antibiotic therapy and if indicated surgical treatment are the cornerstones of successful cure of bite wounds.

METHODS

A total of 5248 consecutive trauma patients were collected prospectively and analysed retrospectively over a period of 15 years in this study at a level I trauma centre, Department of Trauma Surgery, Medical University of Vienna, Austria.

RESULTS

The mean age was 33.8 years (range 0-97), 2620 (49.9 %) were male and 2628 (50.1 %) were female individuals. In our study population, a total of 2530 dog bites (48.2 %), 930 cat bites (17.8 %), 357 other animal bites (6.8 %), 426 human bites (8.1 %) and 1005 human self-bites (19.2 %) have been observed. A total of 995 wounds (19.0 %) have been infected. Surgery was done in 132 wounds (2.5 %).

CONCLUSION

We could show a six times higher infection rate of cat bites compared to dog bites. Human bites showed a total infection rate of 8.2 %. Observed infection rate of puncture wounds and wounds greater than 3 cm was 1.5 times higher than for all other wounds in the present study. Total infection rates within 24 h to antibiotic administration was 29.3 %, compared to 65.0 % < 48 h and 81.1 % < 72 h. Time interval also influenced the overall outcome showing a 2.6 increase in acceptable and 1.3 increase in poor outcome after 72 h.

Factors associated with delay to emergency department presentation, antibiotic usage and admission for human bite injuries

Objectives:

Evidence and consensus on best practices on the management of human bite injuries is lacking. Our objective was to identify factors that are associated with delay to emergency department (ED) presentation, antibiotic usage and patient admission.

Methods:

We present a retrospective chart review of adults treated for human bites. Multivariable logistic regression models used demographic characteristics and bite circumstances and characteristics as factors associated with ED presentation more than 24 hours after the bite, antibiotic usage and hospital admission.

Results:

Of the 388 patients evaluated for a human bite, 66.5% were bitten during an altercation; 23.8% presented more than 24 hours after the bite; 50.3% were bitten on the hands or fingers, 23.5% on an extremity and 17.8% on the head or neck. Only 7.7% of all patients sustained closed-fist injuries; the majority had occlusional or other kinds of bites. The majority of patients (77.3%) received antibiotics and 11.1% were admitted to hospital. Patients who had greater odds of presenting more than 24 hours after the bite were black (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.02–3.13), Hispanic (OR 2.68, 95% CI 1.22–5.89) and those who had a non-occupational bite (OR 3.87, 95% CI, 1.68–8.90). Patients had a greater chance of receiving antibiotics if they were bitten during an altercation (OR 1.87, 95% CI, 1.09–3.20) and were bitten on the hands or fingers (OR 2.23, 95% CI 1.31-3.80). Patients had a greater chance of being admitted to the hospital if they were bitten during an altercation (OR 4.91, 95% CI 1.65–14.64), bitten on the hands or fingers (OR 5.26, 95% CI, 1.74–15.87) and if they presented ≥ 24 hours after the bite.

Conclusion:

Most patients presented to the ED within 24 hours of their injury and received antibiotics. The circumstances surrounding the bite appeared to be associated with delay to ED presentation, receipt of antibiotics and admission to the hospital. There are ethnic background differences in delay to ED presentation. ED clinicians in our study favour antibiotic usage and admission based on the body location of the bite, despite little evidence to support these practices.

Bacteria isolated from conspecific bite wounds in Norway and black rats: implications for rat bite-associated infections in people

Bites associated with wild and domestic Norway and black rats (Rattus norvegicus and Rattus rattus) may have a variety of health consequences in people. Bite-related infections are among the most significant of these consequences; however, there is little data on the infectious agents that can be transmitted from rats to people through biting. This is problematic because without an accurate understanding of bite-related infection risks, it is difficult for health professionals to evaluate the adequacy of existing guidelines for empirical therapy. The objectives of this study were to increase our knowledge of the bacterial species associated with rat bites by studying bite wounds that wild rats inflict upon one another and to review the literature regarding rat bites and bite wound management. Wild Norway and black rats (n=725) were trapped in Vancouver, Canada, and examined for bite wounds in the skin. All apparently infected wounds underwent aerobic and anaerobic culture, and isolated bacteria were identified. Thirty-six rats had bite wound-related infections, and approximately 22 different species of bacteria belonging to 18 genera were identified. Staphylococcus aureus was the most common isolate; however, the majority of infections (72.5%) were polymicrobial. Rat bites can result in infection with a number of aerobic and anaerobic Gram-positive and Gram-negative bacteria. In humans, these wounds are best managed through early recognition and cleansing. The benefit of prophylactic antimicrobial treatment is debatable, but given the deep puncturing nature of rodent bites, we suggest that they should be considered a high risk for infection. Antibiotics selected should include coverage for a broad range of bacterial species.

Review: the important bacterial zoonoses in "one health" concept

An infectious disease that is transmitted from animals to humans, sometimes by a vector, is called zoonosis. The focus of this review article is on the most common emerging and re-emerging bacterial zoonotic diseases. The role of "One Health" approach, public health education, and some measures that can be taken to prevent zoonotic bacterial infections are discussed.

KEY POINTS

A zoonotic bacterial disease is a disease that can be very commonly transmitted between animals and humans. Global climate changes, overuse of antimicrobials in medicine, more intensified farm settings, and closer interactions with animals facilitate emergence or re-emergence of bacterial zoonotic infections.The global "One Health" approach, which requires interdisciplinary collaborations and communications in all aspects of health care for humans, animals, and the environment, will support public health in general.New strategies for continuous dissemination of multidisciplinary research findings related to zoonotic bacterial diseases are hence needed.

Primary closure versus non-closure of dog bite wounds. a randomised controlled trial

INTRODUCTION

Dog bite wounds represent a major health problem. Despite their importance, their management and especially the role of primary closure remain controversial. In this randomised controlled trial, the outcome between primary suturing and non-closure was compared.

METHODS

168 consecutive patients with dog bite injuries were included in this study. The wounds were allocated randomly in two treatment approaches: Group 1, consisting of eighty-two patients, had their wound sutured, whilst Group 2, consisting of eighty-six patients, did not have their wounds sutured. All wounds were cleansed using high-pressure irrigation and povidone iodine. All patients received the same type of antibiotic treatment. Our measured outcomes included presence of infection and cosmetic appearance. Cosmetic outcome was evaluated using the Vancouver Scar Scale (VSS). Wound and patient characteristics, such as time of management, wound location and size, and patient age, were recorded and analysed for their potential role in the resulting outcome.

RESULTS

The overall infection rate was 8.3%. No difference in the infection rate between primary suturing and non-suturing group was detected in the present study. The cosmetic appearance of the sutured wounds was significantly better (mean score 1.74) compared to the wounds that were left open (mean score 3.05) (p=0.0001). The infection rate was comparable among all age groups. Wounds treated within 8h of injury demonstrated an infection rate of 4.5%, which is lower compared to the 22.2% rate observed in wounds treated later than 8h. The wounds located at the head and neck exhibited better results in both infection rate and cosmetic outcome. Additionally, wounds >3 cm negatively affected the cosmetic appearance of the outcome.

CONCLUSIONS

Primary suturing of wounds caused by dog bites resulted in similar infection rate compared to non-suturing. However, primary suturing exhibited improved cosmetic appearance. Time of management appeared to be critical, as early treatment resulted in lower infection rate and improved cosmetic appearance regardless suturing or not. Furthermore, wounds located at the head and face demonstrated better results.

Antibiotic Management of Animal Bites in Children During the Methicillin-Resistant Staphylococcus aureus Era

Children presenting to an emergency department following an animal bite were found to be at risk for infection if they had puncture wounds, crush wounds, or were bitten by a cat. Of the infected wounds that were cultured, methicillin-resistant Staphylococcus aureus was not isolated as a pathogen.

Acute paediatric bite injuries treated on inpatient basis: a 10-year retrospective study and criteria for hospital admission

The aim of this study was to evaluate the acute bite wounds in children treated on an inpatient basis over a 10-year period and the criteria for inpatient treatment. This study comprised all acute mammalian bite injuries in relation to all paediatric bite injuries seen at the Emergency Surgical Department (ESD). Inclusion criteria were: aged between 0-18 years; acute human or animal bite injuries (presenting for the first time); and inpatient treatment. Exclusion criteria were: bite wounds treated elsewhere and referred for complications; bites treated on an outpatient basis referred for complications; and all insect bites. Over 10 years, 12,948 children were seen at the ESD. There were 167 children (0.77%) with mammalian bite wounds. Twelve of them responded to the inclusion criteria. They presented 7.18% of all mammalian bite injuries and 0.09% of all paediatric emergency visits at the ESD. The average age was 3.82 ± 1.63 years (from 1.3-7 years). The time elapsed between the accident to the wound debridement was 118.64 ± 101.39 minutes. There were 10 dogs, one horse, and one rabbit bite. Surgical treatment comprised debridement, saline irrigation, and primary closure or reconstruction. All patients received antibiotics in the postoperative period. The average hospital stay was 5.92 ± 2.39 days. In one case a partial distal flap necrosis occurred. Animal bite injuries treated on an inpatient basis are predominantly dog bites in young children under 10 years of age, with deep, extended, and commonly multiple injuries. Only 7% of paediatric bite injuries require inpatient treatment.

Diagnosis and management of skin and soft-tissue infections (SSTI): a literature review and consensus statement on behalf of the Italian Society of Infectious Diseases and International Society of Chemotherapy

Skin and soft-tissue infections (SSTIs) are among the most common bacterial infections, posing considerable diagnostic and therapeutic challenges and resulting in significant morbidity and mortality among patients as well as increased healthcare costs. eight members of the SSTI working group of the Italian Society of infectious Diseases prepared a draft of the statements, grading the quality of each piece of evidence after a careful review of the current literature using MEDLINE database and their own clinical experience. Statements were graded for their strength and quality using a system based on the one adopted by the Infectious Diseases Society of America (IDSA). The manuscript was successively reviewed by seven members of the SSTI working group of the international Society of Chemotherapy, and ultimately re-formulated by all e xperts. the microbiological and clinical aspects together with diagnostic features were considered for uncomplicated and complicated SSTIs. Antimicrobial therapy was considered as well -both empirical and targeted to methicillin-resistant Staphylococcus aureus (MRSA) and/or other main pathogens.

Managing human bites

Human bites are frequently overlooked in making a diagnosis in the emergency room. They are particularly notorious due to the polymicrobial nature of human saliva inoculated in the wound and the risk they pose for transmission of infectious diseases. Early treatment, appropriate prophylaxis and surgical evaluation are the key to achieving desired treatment outcomes. Through this article, we have tried to summarize the diagnostic features, complications as well as the recommended treatment alternatives for human bites based on the current available evidence.

Animal bite-associated infections: microbiology and treatment

Human and animal bites may lead to serious infection. The organisms involved tend to originate from the oral cavity of the offending biter, as well as the environment where the injury occurred. A variety of aerobic as well as anaerobic organisms have been isolated from bite wounds, with infection ranging from localized cellulitis to systemic dissemination, leading to severe disease ranging from abscess to bone and joint infection, to endocarditis and brain abscess. Immediate wound management, including recognition of the most commonly associated infectious pathogens, and judicious use of empiric antibiotics are crucial in providing the best care after a bite. Here, we discuss the common animal bite associated infections, and provide the most up to date information regarding their management.

Prevalence and current concepts of management of farmyard injuries

Farmyard injuries in young adults and the elderly usually result from machinery accidents, whereas children tend to be injured by runovers and motor vehicle collisions. A variety of farmyard injuries secondary to environmental and human factors may cause permanent disability or even death. Common injuries include lacerations, hand injuries, amputations, farm animal bites, fractures and dislocations. Special considerations should be taken into account when treating these injuries, focusing on their noteworthy bacterial load in order to minimise the risk of chronic morbidity.

Principles of Basic Wound Evaluation and Management in the Emergency Department

The primary objectives of basic wound management center around promoting optimal wound healing and cosmesis. These objectives may be achieved through the systematic assessment, preparation, and repair of the laceration supplemented with appropriate patient care instructions. The meticulous and methodical management of traumatic wounds described in this article will assist the emergency physician in decreasing overall complication rates and help improve patient satisfaction.