Evaluation of prophylactic oxacillin in cat bite wounds

Extensor Pollicis Longus Tendon Rupture Following a Cat Bite: A Case Report and Review of Literature

This case report describes the first reported occurrence of extensor pollicis longus (EPL) tendon rupture caused by a cat bite. Animal bites, particularly from cats, can cause various complications, including damage to tendons and bones. In our case, a 43-year-old female suffered an EPL rupture in her dominant hand after being bitten by her cat. The patient underwent EPL reconstruction by means of extensor indicis proprius (EIP) using standard techniques, with a positive functional outcome reported. The case highlights the importance of considering the risk of tendon injuries following animal bites and prompt treatment to prevent permanent disability. This report calls for a high index of suspicion for tendon injury following animal bites, even if there are no signs of infection.

Management of Nasal Trauma

Facial trauma can have long-lasting physical and mental consequences. Trauma to the nose is commonly seen in the emergency department. Nasal lacerations account for 7% of all facial lacerations. Thorough examination and documentation including photographs is important for documentation and creating a reconstruction plan. Underlying damage to cartilage or bone must be reconstructed initially or in a delayed fashion to recreate the pretrauma anatomy and function. There are several options for soft tissue nasal reconstruction, including local flaps, skin grafts, pedicle flaps, and free flaps. At present there is no standard of care for postoperative facial trauma wound care.

Infectious Complications of Bite Injuries

Animal and human bite injuries are a public health burden. Dog bites outnumber cat bites, but cat bites pose the greatest risk for infection. Skin and soft tissue infections are the most frequent infectious manifestations resulting from bite injury, although invasive infection may occur through direct inoculation or dissemination through the bloodstream. Although contemporary, well-designed trials are needed to inform clinical practice, preemptive antibiotic therapy after a bite injury is warranted for injuries posing high risk for infection and for patients at risk of developing severe infection; antibiotics should target aerobic and anaerobic microbes that comprise the oral and skin flora.

Hand Infections: Epidemiology and Public Health Burden

Upper extremity infections are common. Most infections can be effectively treated with minor surgical procedures and/or oral antibiotics; however, inappropriate or delayed care can result in significant, long-term morbidity. The basic principles of treating hand infections were described more than a century ago and most remain relevant today. Immunosuppressant medications, chronic health conditions such as diabetes and human immunodeficiency virus, and public health problems like intravenous drug use, have changed the landscape of hand infections and provide new challenges in treatment.

Laceration Management

BACKGROUND

Traumatic lacerations to the skin represent a fairly common reason for seeking emergency department care. Although the incidence of lacerations has decreased over the past decades, traumatic cutaneous lacerations remain a common reason for patients to seek emergency department care.

OBJECTIVE

Innovations in laceration management have the potential to improve patient experience with this common presentation.

DISCUSSION

Studies have confirmed that delays in wound closure rarely confer increased rates of infection, although comorbidities such as diabetes, chronic renal failure, obesity, human immunodeficiency virus, smoking, and cancer should be considered. Antibiotics should be reserved for high-risk wounds, such as those with comorbidities, gross contamination, involvement of deeper structures, stellate wounds, and selected bite wounds. Topical anesthetics, which are painless to apply, have a role in select populations. In most studies, absorbable sutures perform similarly to nonabsorbable sutures and do not require revisit for removal. Novel atraumatic closure devices and expanded use of tissue adhesives for wounds under tension further erode the primacy of regular sutures in wound closure. Maintaining a moist wound environment with occlusive dressings is more important than previously thought. Most topical wound agents are of limited benefit.

CONCLUSIONS

Recent innovations in wound closure are allowing emergency physicians to shift toward painless, atraumatic, and rapid closure of lacerations.

The Role of Antibiotic Prophylaxis in Clean Incised Hand Injuries: A Prospective Randomized Placebo Controlled Double Blind Trial

A prospective, randomized, double blind, placebo controlled trial was designed to investigate the effect of prophylactic flucloxacillin on the infection rate in clean incised hand injuries, which included trauma to skin, tendon and nerve in adults. Using strict exclusion criteria, a total of 170 patients were recruited into one of three trial groups; Group A – intravenous flucloxacillin on induction followed by an oral placebo; Group B – intravenous flucloxacillin on induction followed by an oral flucloxacillin course or Group C – oral placebo. Thirteen of the patients were subsequently withdrawn, leaving 92% available to complete the trial. Infection was diagnosed using clinical criteria. The infection rates in the three groups were Group A – 13%, Group B – 4% and Group C – 15%. Strictly, the results demonstrate no statistically significant difference in the infection rates between the groups.

Postoperative care of the facial laceration

The purpose of this investigation is to examine factors involved in the postoperative care of traumatic lacerations. An evidence-based comprehensive literature review was conducted. There are a limited number of scientifically proven studies that guide surgeons and emergency room physicians on postoperative care. Randomized controlled trials must be conducted to further standardize the postoperative protocol for simple facial lacerations.

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.

The role of prophylactic antibiotics in elective hand surgery

The current literature has poorly defined the role of antibiotic agents in elective hand surgery. The reason for this may be due to a small number of well-designed studies specifically addressing the efficacy of antibiotics in hand surgery. Our purpose is to critically review the current literature in an attempt to more precisely define the role of prophylactic antibiotics in elective hand surgery.

Dog and cat bites to the hand: treatment and cost assessment

PURPOSE

To assess the demographic patterns, clinical morbidity, and treatment costs associated with domestic animal bites to the hand.

METHODS

A retrospective review was performed on 111 patients who suffered either a dog or cat bite to the hand. Demographic data were collected for both the patient and the animal involved.

RESULTS

The patient population had suffered 71 dog bites and 40 cat bites. Two scenarios were identified that increased the likelihood of a bite: (1) attempting to separate fighting animals and (2) attempting to aid an injured animal. More than half of the victims (61 of 111) were bitten by an animal with which they were familiar. Bite injuries ranged from relatively minor wounds to major injuries that included open fractures, persistent deep infection including osteomyelitis, nerve laceration, tendon laceration, or tissue loss. Approximately two thirds of patients required hospital admission at least for intravenous antibiotics. Approximately one third of animal bite victims required at least 1 surgical procedure. Thirteen patients required long-term intravenous antibiotics and/or multiple surgeries and incurred medical expenses in excess of dollar 77,000.

CONCLUSIONS

Domestic animal bites to the hand are common injuries that can produce considerable morbidity. Stray animals did not account for the majority of incidents. Bite prevention strategies should focus on careful handling of animals that are fighting or injured. Animal bite wounds often require intravenous antibiotics and hospitalization and the cost of care for deep infections can be enormous. Our patient population was selected from a small geographic area over a relatively short collection period, suggesting that domestic animal bite injuries may represent a major public health issue.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic, Level IV.

Hospital management of animal and human bites

The management of bites severe enough to warrant hospital admission is complex. This review includes the epidemiology, clinical management, investigations, microbiology and role of antimicrobials for all types of animal and human bites likely to be encountered in UK hospitals.

Facial bite wounds: management update

Bite wounds are frequently located on the face; injuries inflicted by dogs are most common, especially in children. Bacteriology of infected dog and cat bite wounds includes Pasteurella multocida, Staphylococcus aureus, viridans streptococci, Capnocytophaga canimorsus, and oral anaerobes. Infected human bites yield a similar spectrum of bacteria except for Pasteurellae and C. canimorsus; instead human bites are frequently complicated by Eikenella corrodens. Antibiotic therapy against these bacteria is indicated both for infected bite wounds and fresh wounds considered at risk for infection. Amoxicillin-clavulanate (and other combinations of extended-spectrum penicillins with beta-lactamase inhibitors) and moxifloxacin offer the best in vitro coverage of the pathogenic flora. Initial wound management consisting in irrigation and debridement is at least equally important with antibiotics for prevention of infection. The need for prophylaxis against systemic infectious complications, particularly tetanus, should also be evaluated. Primary surgical repair is the treatment of choice for most clinically uninfected facial bite wounds, whereas delayed closure should be reserved for certain high risk or already infected wounds. Avulsive injuries with significant tissue loss represent the most difficult cases for definitive management and are also those most likely to require hospitalization.

Cat bites of the hand

BACKGROUND

Cat bites are the second most common mammalian bites. Cat bites of the hand in particular represent a potentially devastating problem in terms of wound infection and long-term disability if not treated appropriately. The purpose of the present study is to give an overview of demographics, management and follow up of the patients with cat bite injuries of the hand treated at the Royal Hobart Hospital.

METHODS

Retrospective and prospective data of all patients with cat bites of the hand seen at the Royal Hobart Hospital for a period of 3 years (January 2000 to April 2003) were collected. Demographics, anatomical site, presentation, assessment, investigations, management and follow up of the patients with this type of injury were analysed. The accuracy of the obtained data was checked by analysing questionnaires returned by our patients.

RESULTS

Forty-one patients were treated for cat bites of the hand. Twenty-six were managed in the department of emergency medicine and 15 were admitted and managed by the department of plastic and reconstructive surgery. Five of 15 admitted patients required surgery. Compliance was not a major problem in our study as very few patients were lost to follow up. Almost all patients had close follow up and extensive hand physiotherapy achieving overall good long-term results. Out of 39 patients who were sent questionnaires only one indicated long-term problems with the hand (response rate 46%).

CONCLUSION

Appropriate early treatment of cat bites of the hand is the key to success. Treatment with antibiotics, surgical drainage, debridement and copious irrigation, and use of corticosteroids in some cases, proved to be effective. Hand elevation and intensive physiotherapy after a short period of immobilization is critical. We believe that prophylactic antibiotics should be given even in case of a minor infection following cat bites of the hand. Clear guidelines for clinical recognition of infection, hospital admission and management are provided in our study.

Management of lacerations in the emergency department

The goals of wound management are simple: avoid infection and achieve a functional and aesthetically pleasing scar. This is achieved by reducing tissue contamination, debriding devitalized tissue, and restoring perfusion in poorly perfused wounds, in conjunction with a well-approximated skin closure.

Antibiotic prophylaxis for mammalian bites

BACKGROUND

Bites by mammals are a common problem and they account for up to 1% of all visits to hospital emergency rooms. Dog and cat bites are the most common and people are usually bitten by their own pets or by an animal known to them. School-age children make up almost a half of those bitten. Prevention of tetanus, rabies and wound infection are the priorities for staff in emergency rooms. The use of antibiotics may be useful to reduce the risk of developing a wound infection.

OBJECTIVES

To determine if the use of prophylactic antibiotics in mammalian bites is effective in preventing bite wound infection.

SEARCH STRATEGY

Relevant RCTs were identified by electronic searches of MEDLINE, EMBASE, LILACS and the Cochrane Controlled Trials Register databases in November 2000.

SELECTION CRITERIA

We included randomised controlled trials which studied patients with bites from all mammals. Comparisons were made between antibiotics and placebo or no intervention. The outcome of interest was the number of infections at the site of bite.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted the data independently. All analyses were performed according to the intention-to-treat method.

MAIN RESULTS

Eight studies were included. The use of prophylactic antibiotics was associated with a statistically significant reduction in the rate of infection after bites by humans. Prophylactic antibiotics did not appear to reduce the rate of infection after bites by cats or dogs. Wound type, e.g. laceration or puncture, did not appear to influence the effectiveness of the prophylactic antibiotic. Prophylactic antibiotics were associated with a statistically significant reduction in the rate of infection in hand bites (OR 0.10, 95% CI 0.01 to 0.86; NNT = 4, 95% CI 2 to 50).

REVIEWER'S CONCLUSIONS

There is evidence from one trial that prophylactic antibiotics reduces the risk of infection after human bites but confirmatory research is required. There is no evidence that the use of prophylactic antibiotics is effective for cat or dog bites. There is evidence that the use of antibiotic prophylactic after bites of the hand reduces infection but confirmatory research is required.

Treating mammalian bite wounds

The incidence of dog, cat and human bites has been increasing steadily and represents an important cause of morbidity and mortality in the United States. Approximately half of all Americans will suffer a bite wound during their lifetime, and the annual medical costs of managing these injuries has been estimated to be over $100 million. Possible complications may include disfigurement, dismemberment and infection. Effective management requires rapid medical evaluation and may necessitate surgical intervention and prophylactic antibiotic therapy. As bite wounds are microbiologically diverse and most often polymicrobial in nature, selection of an appropriate antibiotic regimen requires knowledge of common pathogens. Close clinical follow-up is recommended to minimize the risk of late complications.

Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group

BACKGROUND AND METHODS

To define better the bacteria responsible for infections of dog and cat bites, we conducted a prospective study at 18 emergency departments. To be eligible for enrollment, patients had to meet one of three major criteria for infection of a bite wound (fever, abscess, and lymphangitis) or four of five minor criteria (wound-associated erythema, tenderness at the wound site, swelling at the site, purulent drainage, and leukocytosis). Wound specimens were cultured for aerobic and anaerobic bacteria at a research microbiology laboratory and, in some cases, at local hospital laboratories.

RESULTS

The infected wounds of 50 patients with dog bites and 57 patients with cat bites yielded a median of 5 bacterial isolates per culture (range, 0 to 16) at the reference laboratory. Significantly more isolates grew at the reference laboratory than at the local laboratories (median, 1; range, 0 to 5; P<0.001). Aerobes and anaerobes were isolated from 56 percent of the wounds, aerobes alone from 36 percent, and anaerobes alone from 1 percent; 7 percent of cultures had no growth. Pasteurella species were the most frequent isolates from both dog bites (50 percent) and cat bites (75 percent). Pasteurella canis was the most common isolate of dog bites, and Past. multocida subspecies multocida and septica were the most common isolates of cat bites. Other common aerobes included streptococci, staphylococci, moraxella, and neisseria. Common anaerobes included fusobacterium, bacteroides, porphyromonas, and prevotella. Isolates not previously identified as human pathogens included Reimerella anatipestifer from two cat bites and Bacteroides tectum, Prevotella heparinolytica, and several porphyromonas species from dog and cat bites. Erysipelothrix rhusiopathiae was isolated from two cat bites. Patients were most often treated with a combination of a beta-lactam antibiotic and a beta-lactamase inhibitor, which, on the basis of the microbiologic findings, was appropriate therapy.

CONCLUSIONS

Infected dog and cat bites have a complex microbiologic mix that usually includes pasteurella species but may also include many other organisms not routinely identified by clinical microbiology laboratories and not previously recognized as bite-wound pathogens.

Dog, cat, and human bites: a review

It is estimated that half of all Americans will be bitten by an animal or another human being during their lifetimes. The vast majority of the estimated 2 million annual mammalian bite wounds are minor, and the victims never seek medical attention. Nonetheless, bite wounds account for approximately 1% of all emergency department visits and more than $30 million in annual health care costs. Infection is the most common bite-associated complication; the relative risk is determined by the species of the inflicting animal, bite location, host factors, and local wound care. Most infections caused by mammalian bites are polymicrobial, with mixed aerobic and anaerobic species. The clinical presentation and appropriate treatment of infected bite wounds vary according to the causative organisms. Human bite wounds have long had a bad reputation for severe infection and frequent complication. However, recent data demonstrate that human bites occurring anywhere other than the hand present no more of a risk for infection than any other type of mammalian bite. The increased incidence of serious infections and complications associated with human bites to the hand warrants their consideration and management in three different categories: occlusional/simple, clenched fist injuries, and occlusional bites to the hand. This article reviews dogs, cat, and human bite wounds, risk factors for complications, evaluation components, bacteriology, antimicrobial susceptibility patterns, and recommended treatments. Epidemiology, clinical presentation, and treatment of infections caused by Pasteurella multocida, Capnocytophaga canimorsus, Eikenella corrodens, and rhabdovirus (rabies only) receive particular emphasis.

Mammalian bites. Review of evaluation and management

Mammalian bites account for a large number of emergency department and doctor's visits. Children are the victims in more than half of reported cases. Dogs account for the majority of wounds, and almost all fatalities in these cases are due to dog bites. Human bites and cat bites account for the majority of infected wounds. Basic wound care, combined with appropriate antibiotic coverage in high risk wounds, is the most important principle of management.

Management of human and animal bite wounds

Bite wounds, usually by dogs, cats, and human beings, affect one of two Americans during his or her lifetime and 1 to 2 million Americans annually. Despite the relative frequency of bite wounds, there are few prospective studies to define optimal care; consequently, diverse methods are used. In this article I review the incidence, bacteriology, clinical spectrum, complications, and treatment of animal and human bite wounds. The spectrum of pathogenic bacteria that cause bite infections is broader than is generally appreciated and includes both aerobic and anaerobic bacteria. Pasteurella multocida is found in only 20% to 25% of dog bite wounds. In choosing empiric antimicrobial therapy, clinicians must consider the diverse causative bacteria and their characteristic susceptibility patterns. Liberal irrigation and elevation of the injured part are also cornerstones of therapy. Early, aggressive medical and surgical management can minimize, if not prevent, complications.

Mammalian bites

Mammalian bites account for one percent of all visits to emergency departments. More than 95% of all complications consist of local wound infections. Risk factors for infection include location on the hand or foot, puncture wounds, and treatment delay, as well as general risk factors for infection. "Clenched fist" injuries have a high risk for very severe complications. The mainstay of treatment is meticulous local wound care with debridement and irrigation. Antibiotics should only be considered as a secondary modality to prevent wound infection.

Lack of in vitro efficacy of oral forms of certain cephalosporins, erythromycin, and oxacillin against Pasteurella multocida

The in vitro susceptibility of human isolates of Pasteurella multocida to oral antimicrobial agents from our current study and from a review of the literature suggests that dicloxacillin (oxacillin), erythromycin, clindamycin, cephalexin, cefaclor, and cefadroxil should not be used for empiric therapy of animal bite wounds. Agents that were consistently active against P. multocida were penicillin, ampicillin, amoxicillin-clavulanic acid, tetracycline, minocycline, chloramphenicol, trimethoprim-sulfamethoxazole, and cefuroxime. Possible reasons for the confusion regarding the activity of oral cephalosporins are addressed.

Pasteurella multocida: bilateral septic knee joint prostheses from a distant cat bite

We report a case of septic arthritis and bacteremia caused by the Gram-negative rod, Pasteurella multocida. The patient was superficially bitten by her cat, and within two years infection necessitated removal of both of her artificial knee prostheses. P multocida is found in the mouths of cats, dogs, and other domestic animals. The pathogenesis, prevention, and treatment of infections caused by this organism, and the question of prophylactic antibiotics are discussed.