Animal bites. Guidelines to current management

​Primary closure versus delayed or no closure for traumatic wounds due to mammalian bite

BACKGROUND

Mammalian bites are a common presentation in emergency and primary healthcare facilities across the world. The World Health Organization recommends postponing the suturing of a bite wound but this has not been evaluated through a systematic review.

OBJECTIVES

To assess the effects of primary closure compared with delayed closure or no closure for mammalian bite wounds.

SEARCH METHODS

In July 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials which compared primary closure with delayed or no closure for traumatic wounds due to mammalian bite.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full-text publications, applied the inclusion criteria, and extracted data. We pooled data using a random-effects model, as appropriate. We used the Cochrane 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We found three trials (878 participants) that compared primary closure with no closure for dog bites and one trial (120 participants) that compared primary closure with delayed closure. No other mammalian bite studies were identified. The trials were from the UK (one trial), Greece (one trial) and China (two trials). Overall, participants from both sexes and all age groups were represented. We are uncertain whether primary closure improves the proportion of wounds which are infection-free compared with no closure, as the certainty of evidence for this outcome was judged to be very low (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.97 to 1.05; 2 studies, 782 participants; I2 = 0%). We downgraded the evidence by one level for high risk of bias and two levels for imprecision. There is no clinically important difference in cosmesis (acceptable physical/cosmetic appearance) of dog bite wounds when primary closure is compared with no closure (mean difference (MD) -1.31, 95% CI -2.03 to -0.59; 1 study, 182 participants). The certainty of evidence for this outcome was judged to be moderate (we downgraded our assessment by one level for imprecision). We are uncertain whether primary closure improves the proportion of dog bite wounds that are infection-free compared with delayed closure, as the evidence for this outcome was judged to be very low (RR 0.98, 95% CI 0.90 to 1.07; 1 study, 120 participants; I2 = 0%). We downgraded the evidence by one level for high risk of bias and two levels for imprecision. None of the four trials reported any adverse outcomes such as death or rabies but they were, in any case, unlikely to have been large enough to have satisfactory power to provide precise estimates for these. Important outcomes like time to complete wound healing, proportion of wounds healed, and length of hospital stay were not evaluated.

AUTHORS' CONCLUSIONS

All the studies we identified concerned dog bites. There is no high-certainty evidence to support or refute existing recommendations concerning primary closure for dog bites. The potential benefits and harms of primary closure compared with delayed or no closure for mammalian bites remain uncertain and more robust trials are needed.

Animal bite injuries in the accident and emergency unit at Mulago Hospital in Kampala, Uganda

Introduction

Animal bite injuries are a common public health concern in Uganda. We sought to characterize animal bite injuries among patients presenting to Mulago National Referral Hospital in Kampala, Uganda.

Methods

This was a cross sectional study from 1^st September to 30^th November 2011. Participants were animal bite injury victims presenting to the accident and emergency (A&E) unit at Mulago hospital and were consecutively enrolled into the study. Socio-demographics, severity and patterns of injury, health seeking and dog handling behaviours were assessed using a standardized questionnaire. Descriptive statistics was used to summarize participant characteristics and the animal bite injuries. Poisson regression model's incident rate ratios (IRR) was used to explore the relationship of the number of days to accessing treatment at Mulago hospital with; a) received prior first aid, b) animal bite injury sustained during day time, c) unknown dog and d) victim resident in Kampala. Data were analyzed using STATA version 12.0 and statistical significance set at P < 0.05.

Results

Of 25,420 patients that presented to the A&E unit during the study period, 207 (0.8%) had animal bite injuries, mean age 22.7 years (SD 14.3), 64.7% male, and 40.1% were <18 years. Majority 199 (96.1%) were bitten by a lone unrestrained and un-signaled dog that had bitten someone else in 22.2% of cases, and eight victims (0.4%) were attacked in canine gangs of 2-5 dogs. Rabies vaccination was confirmed in only 23 dogs (11.1%) as 109 (52.7%) were unknown to the victims or the communities. One hundred and eighteen victims (57.0%) sustained the dog bites within Kampala district whilst the rest occurred near or far from Kampala district, and the victims especially referred to access anti-rabies vaccine. Of 207, 189 victims (91.3%) presented within 2.6 days (SD ± 4.3). Two hundred victims (96.6%) sustained extremity injuries while the rest had injuries to other body parts. All injuries were minor and managed on out-patient basis with wound dressing, analgesics, prophylactic antibiotics and anti-rabies vaccination. Victims who received prior first aid had a rate of 1.7 times greater for seeking treatment at Mulago hospital (IRR 1.7, 95% CI 1.4-2.1) compared to those that had no prior first aid. Participants who sustained the animal bite injuries during day time had a rate of 1.6 times greater for seeking treatment at Mulago hospital (IRR 1.6, 95% CI 1.3-2.1) compared to those that sustained injuries at other times. Participants bitten by unknown dog and participants residing in Kampala had IRR 0.7, 95% CI 0.5-0.9 and IRR 0.6, 95% CI 0.5-0.8 respectively of accessing treatment at Mulago hospital compared to bitten by known dog and not residing in Kampala.

Conclusion

Dog bites injuries from unrestrained, un-signaled dogs are the commonest source of animal bite injuries especially among children (<18 years). Vaccination against rabies was only confirmed for a very small number of dogs, as majority were unknown and likely stray dogs. Government and public sensitization is urgently required to limit stray dogs, vaccinate dogs and restrain them to prevent a grave probability of a looming canine rabies epidemic.

Animal-inflicted open wounds in rural Turkey: lessons learned and a proposed treatment algorithm for uncertain scenarios

Uncertainty in the management of animal-inflicted injuries, especially in rural settings, usually results in a general approach to leave all wounds to heal with secondary intention, which can lead to unsightly scarring and functional loss. This study focusus on different circumstances dealt with by plastic surgeons in a rural setting in Turkey and aims to configure what the general approach should be through an analysis of a wide spectrum of patients. Between June 2013 and December 2014, 205 patients who presented to the emergency department for animal-inflicted injuries were retrospectively analysed. Patients who consulted for plastic surgery were included in the analysis to determine which wounds require further attention. Patients with past animal-inflicted injuries who presented to the outpatient plastic surgery clinic with concerns such as non-healing open wounds or cosmetic or functional impairment were also evaluated. Statistical analysis demostrated a significantly lower rate of infection encountered in animal-inflicted open wounds (AIOWs) of patients who consulted for plastic surgery from the emergency department than those who presented to the outpatient clinic (P < 0·05). The main concern in the management of animal-inflicted wounds is their potential for infection, but this does not mean that every wound will be infected. The most important factor is being able to distinguish wounds that have a higher potential for infection and to select the type of wound management accordingly. An algorithm has been proposed as a guidance for the management of AIOWs, which covers the approach towards both domestic and stray animal-inflicted injuries.

Rogue-elephant-inflicted panfacial injuries: a rare case report

Attacks by elephants, the largest of the “large animals,” produce many fatalities a year. Most attacks are provoked, although rogue elephants are occasionally responsible. Trampling, goring, tossing the individual with the trunk, or crushing with the knees produces the injuries. Injuries from encounters with large animals represent a significant health risk for rural communities. Wild-animal-inflicted maxillofacial injuries are rare, and limited literature is available describing their management. We present a case of severe maxillofacial injuries caused by the attack of a rogue elephant.

Injuries from leopard attacks in Kashmir

Increased incidence of wild-animal attacks has made these a serious threat to public health in Kashmir. To establish patterns of injury and management, 35 case histories were reviewed. After resuscitation, of paramount importance were vigorous irrigation, removal of all foreign material, administration of antibiotics, and prophylaxis against rabies and tetanus as indicated. A multidisciplinary approach and aggressive management are necessary to prevent death and provide acceptable cosmetic and functional results.

Cat bite in an old patient: is it a simple injury?

An 84-year-old woman bitten by her domestic cat developed a severe wound infection caused by Pasteurella multocida. Although she was treated with antibiotics according to the bacterial sensitivity, the infection progressed to sepsis and became complicated by transient renal failure caused by interstitial nephritis. The need in the emergency department for a thorough examination of patients with domestic animal-inflicted injuries, the indication for surgical debridement, and the isolation of the offender by early obtained cultures are considered. The administration of the properly chosen antibiotics and prophylactic vaccination against rabies and tetanus are discussed.

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.

Management of animal bite injuries of the face: experience with 94 patients

PURPOSE

Because of the large number of bacteria in the oral cavity, animal bite wounds are generally contaminated, and their treatment is difficult because of the risk of infection, especially in extensive injuries. This report describes the management of a large series of patients and recommends treatment guidelines on the basis of the results.

PATIENTS AND METHODS

Ninety-four animal bite wounds on the face and head were analyzed according to the type of animal, location and extent of the soft tissue wound, duration and type of surgical treatment, occurrence of infections and their pathogen spectrum, as well as the choice of antibiotic therapy.

RESULTS

Dogs caused 91% of the bite wounds. Infections developed in 4 of 53 patients who underwent primary wound closure with minor edge excision and prophylactic administration of oral penicillin. Without antibiotic administration, 2 of 15 patients had infections, which were treated on an outpatient basis. Of 26 patients with initially delayed treatment, 18 showed clinical inflammatory symptoms with a wide spectrum of pathogens (Escherichia coli, Streptococcus, Enterococcus, Staphylococcus epidermidis, and Proteus) on presentation.

CONCLUSION

Extensive animal bite wounds on the face, even with soft tissue defects, should be treated according to the criteria of a esthetic reconstructive facial surgery. In view of the low infection rate, routine antibiotic prophylaxis is not justified.

Do patients get the best deal when antibiotics are prescribed out of hours?

OBJECTIVE

To investigate patients' compliance in obtaining follow on prescriptions after being prescribed a "starter pack" by the accident and emergency (A&E) department, and to assess the cost of the starter pack system.

METHODS

During a study period of two months, out of hours prescriptions of antibiotic starter packs in A&E were monitored prospectively to determine how many patients returned to the hospital pharmacy or to their general practitioner (GP) for the remainder of the prescribed course. Current costs of out of hours antibiotic prescriptions were calculated, as were the costs of providing a full course of antibiotics on the patient's first visit to the A&E department.

RESULTS

During the study period, 571 antibiotic items were prescribed as starter packs (three days' supply) to 437 patients. Of these, 232 (53%) chose to return to the hospital and 175 (40%) to their GP for the follow on prescription to complete their course. In 29 cases (7%) the information was not recorded and those patients were excluded from analysis. Only 50% of patients electing to obtain the follow on prescription from their GP did so compared with 83.7% of those electing to return to the hospital pharmacy. Failure to obtain the follow on prescription was termed "late primary non-compliance". There was an estimated annual saving to the hospital of Pounds 3131 if the patients were given the full course of antibiotics at their primary attendance at A&E.

CONCLUSIONS

Patients prescribed antibiotics out of hours should be dispensed full courses. This would eliminate late primary non-compliance at no extra cost to the health authority.

Wound care in the accident and emergency department

Wound assessment in the accident and emergency (A&E) department has a different focus from that in other clinical areas because of the lack of available clinical information about the patient. A wound may have had a greater-physical impact than is immediately apparent and therefore a comprehensive skin assessment is often necessary. The wound will require thorough exploration and debridement to enable healing to take place with minimal complications. The methods of debridement and cleansing used in the A&E department are often unique because of the complexity of wound contamination. The variety of wounds encountered in this setting necessitate a large repertoire of dressing regimens. Modern wound management products can be adapted to meet the needs of the wounded patient in the A&E department.

Bite wounds. Early treatment and prophylaxis against infectious complications

Patient education is important for decreasing the incidence and morbidity of animal bites. When bites do occur, immediate treatment should be given according to established recommended guidelines. Copious irrigation may be the most important aspect of wound care. In addition, early initiation of antimicrobial therapy, particularly in patients at high risk for infection, can decrease morbidity and mortality. A patient's tetanus status and risk of rabies must also be identified and appropriate immunoprophylaxis administered.

Overview of the etiology of wound infections with particular emphasis on community-acquired illnesses

Wound cultures represent a general catchall category for a group of extremely diverse anatomic samples that range from superficial specimens of cutaneous structures (folliculitis, cellulitis) to specimens revealing invasive infections involving deep fascial planes and muscle (myonecrosis). Because of the complex nature of these infective processes, the terminology associated with such infections is often imprecise and confusing. Wounds are the result of trauma, either intentionally or accidentally induced. Nosocomial wound infections result primarily from surgical procedures, the development of pressure sores, or catheterization. Community-acquired wound infections are often preceded by injuries resulting from occupational exposure or recreational activities and are associated with a greater diversity of microorganisms due to the exposure of open wounds to inhabitants of the microbial biosphere. This review provides a general overview of the categories of wound infections and describes their acquisition and clinical significance. Particular emphasis is placed on selected community-acquired wound infections and the etiologic agents associated with such conditions.

When the Dog Bites

In brief The physician treating an active brief Patient's dog bite injury faces some controversial treatment decisions: Should the wound be sutured? Is tetanus or rabies immunization indicated? Are prophylactic antibiotics appropriate?