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Bonilla-Aldana DK, Bonilla-Aldana JL, Ulloque-Badaracco JR, Al-Kassab-Córdova A, Hernandez-Bustamante EA, Alarcon-Braga EA, Siddiq A, Benites-Zapata VA, Rodriguez-Morales AJ, Luna C, Suarez JA. Snakebite-Associated Infections: A Systematic Review and Meta-Analysis. Am J Trop Med Hyg 2024; 110:874-886. [PMID: 38507793 PMCID: PMC11066359 DOI: 10.4269/ajtmh.23-0278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 11/20/2023] [Indexed: 03/22/2024] Open
Abstract
Snakebites still constitute a significant public health problem in developing countries and are considered a neglected tropical condition by the WHO. Snake accidents are associated with substantial morbidity and mortality and may produce secondary complications, such as severe infections. The objective of this systematic review was to determine the prevalence of snakebite infections and characterize the bacteria isolated from these infections. A systematic literature review in five databases was carried out to assess the prevalence of snakebite infection. A meta-analysis was performed using a random-effects model to calculate the pooled prevalence and 95% CIs. Cochran's Q test and the I2 statistic were used to assess between-study heterogeneity. The pooled prevalence of infection due to snakebite was 27.0% (95% CI: 22.0-32.0%), with high heterogeneity among studies (I2 = 99.7%). The prevalence was higher in Asia (32%) than in the Americas (21%). Snakebite infections required surgical interventions in 68% (95% CI: 37.0-98.0%). The leading group of pathogens identified corresponded to Gram-negative bacteria (63%), particularly Morganella morganii (32%), but also, Gram-positive cocci (40%), especially Enterococcus spp. (23%) and Staphylococcus aureus (15%). However, multiple other pathogens, including anaerobes, were found. A high prevalence of snakebite-associated infection has been described, primarily due to M. morganii, with the corresponding implications for empirical therapy. Rational use of antimicrobials is recommended, and this should guide initial empirical treatment. Moreover, isolation and identification of the possible bacteria present in snakebite wounds is recommended in all cases to confirm or rule out associated infection.
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Affiliation(s)
| | - Jorge Luis Bonilla-Aldana
- Grupo de Investigación en Ciencias Animales Macagual, Universidad de La Amazonia, Florencia, Colombia
| | | | - Ali Al-Kassab-Córdova
- Centro de Excelencia en Investigaciones Económicas y Sociales en Salud, Universidad San Ignacio de Loyola, Lima, Peru
| | - Enrique A Hernandez-Bustamante
- Grupo Peruano de Investigación Epidemiológica, Unidad para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Perú
- Sociedad Científica de Estudiantes de Medicina de la Universidad Nacional de Trujillo, Peru
| | | | | | - Vicente A Benites-Zapata
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Vicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima, Peru
| | - Alfonso J Rodriguez-Morales
- Grupo de Investigación Biomedicina, Faculty of Medicine, Fundación Universitaria Autónoma de las Américas-Institución Universitaria Visión de las Américas, Pereira, Colombia
- Faculty of Health Sciences, Universidad Científica del Sur, Lima, Peru
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Camila Luna
- Faculty of Health Sciences, Universidad Científica del Sur, Lima, Peru
| | - Jose A Suarez
- Universidad de Panama, Investigator 1 of the SNI, Senacyt, Panama City, Panama
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Hung YL, Chen YC, Tsai TS, Chang YI, Chuang PC. Incidence and Risk Factors for Wound Infections after Trimeresurus stejnegeri Snakebites in Taiwan. Am J Trop Med Hyg 2024; 110:295-302. [PMID: 38109772 PMCID: PMC10859800 DOI: 10.4269/ajtmh.23-0302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 09/30/2023] [Indexed: 12/20/2023] Open
Abstract
Snakebite envenomation is a neglected tropical disease. Taiwan, with its subtropical and Southeast Asian environment, provides suitable habitat for several venomous snake species. Trimeresurus stejnegeri, an arboreal pit viper, is the most common cause of venomous snakebite in Taiwan. Trimeresurus stejnegeri envenomation can cause local swelling, occasional ecchymosis, and wound infection. The primary treatment of T. stejnegeri envenomation is the binary antivenom, vacuum freeze-dried F(ab')2 fragments of equine antibodies, against T. stejnegeri and Protobothrops mucrosquamatus. This study aimed to analyze the incidence of post-envenomation wound infections caused by T. stejnegeri based on data collected over a decade from institutions affiliated with the Chang Gung Memorial Hospital in Taiwan. A total of 254 patients were enrolled in this study. Clinical and laboratory data, treatment information, and patient outcomes were extracted from electronic medical records. Wound infection was associated with delay in antivenom initiation (adjusted odds ratio: 3.987; 95% CI: 1.406-11.302). The infection rates were 20.5%, 12.5%, 31.3%, and 48.1% for antivenom administration within 2 hours, 2-4 hours, 4-6 hours, and > 6 hours, respectively. Therefore, early initiation of antivenom treatment (within 6 hours) is recommended. Morganella morganii was cultured from wounds of the patients, whereas Enterobacter cloacae and Enterococcus faecalis were cultured from both the oral cavity of snakes and the wounds of the patients. For post-envenomation patients who develop a local infection, empiric antibiotics such as third-generation cephalosporins, quinolones, and piperacillin/tazobactam are recommended because snakebite wound infections are often polymicrobial in nature.
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Affiliation(s)
- Yu-Lun Hung
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yi-Chun Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tein-Shun Tsai
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, Pingtung, Taiwan
| | - Ye-In Chang
- Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Po-Chun Chuang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan
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3
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Lin WH, Tsai TS, Chuang PC. The Presence of Four Pathogenic Oral Bacterial Species in Six Wild Snake Species from Southern Taiwan: Associated Factors. Microorganisms 2024; 12:263. [PMID: 38399667 PMCID: PMC10891919 DOI: 10.3390/microorganisms12020263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/23/2024] [Accepted: 01/23/2024] [Indexed: 02/25/2024] Open
Abstract
The oral cavity of snakes serves as a habitat for various microorganisms, some of which may include potential zoonotic pathogens posing risks to hosts and causing wound infections in snakebite victims. Clinical studies on snakebite cases in Taiwan have identified specific pathogens, such as Enterococcus faecalis (Gram-positive), Morganella morganii, Aeromonas hydrophila, and Pseudomonas aeruginosa (Gram-negative). However, the prevalence of these bacteria in the oral cavity of wild snakes remains largely unknown. This study investigated the occurrence of these bacteria in six wild snake species (Naja atra, Bungarus multicinctus, Trimeresurus stejnegeri, Protobothrops mucrosquamatus, Boiga kraepelini, and Elaphe taeniura friesi) from southern Taiwan, along with factors influencing their presence. Oropharyngeal swab samples were collected from a substantial number of wild-caught snakes (n = 1104), followed by DNA extraction, polymerase chain reaction, and gel electrophoresis. The band positions of samples were compared with positive and negative controls to determine the presence of target bacteria in each sample. The overall occurrence rates were 67.4% for E. faecalis, 31.5% for M. morganii, 8.2% for A. hydrophila, and 7.7% for P. aeruginosa. Among snake species, B. kraepelini exhibited dominance in E. faecalis (93.4%), A. hydrophila (17.1%), and P. aeruginosa (14.5%), while male N. atra showed dominance in M. morganii (51.3%). The occurrence of E. faecalis was lowest in winter. The results of multiple logistic regression analyses suggest that factors such as species, sex, temperature, season, and coexisting pathogens may have a significant impact on the occurrence of target bacteria. These findings have implications for wildlife medicine and snakebite management.
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Affiliation(s)
- Wen-Hao Lin
- Institute of Wildlife Conservation, National Pingtung University of Science and Technology, Pingtung 912301, Taiwan;
| | - Tein-Shun Tsai
- Institute of Wildlife Conservation, National Pingtung University of Science and Technology, Pingtung 912301, Taiwan;
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, Pingtung 912301, Taiwan
| | - Po-Chun Chuang
- Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung 804201, Taiwan;
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan
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Brenes-Chacon H, Gutiérrez JM, Avila-Aguero ML. Use of Antibiotics following Snakebite in the Era of Antimicrobial Stewardship. Toxins (Basel) 2024; 16:37. [PMID: 38251253 PMCID: PMC10820409 DOI: 10.3390/toxins16010037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/21/2023] [Accepted: 01/03/2024] [Indexed: 01/23/2024] Open
Abstract
Even though there are guidelines for the management of snakebite envenoming (SBE), the use of antibiotics in this pathology remains controversial. The aim of this study is to provide a narrative review of the literature and recommendations based on the best available evidence regarding antibiotic use in SBE. We performed a narrative review of relevant literature regarding SBE and antibiotic use as prophylaxis or treatment. A total of 26 articles were included. There is wide use of antibiotics in SBE; nevertheless, infection was not necessarily documented. The antibiotics used varied according to the study, from beta lactams to lincosamide and nitroimidazoles, and from monotherapy to combined antimicrobials. The most common recommendations were to manage skin and soft tissue infections and avoid infectious complications, but these suggestions are not necessarily based on bacteriological findings. Prophylactic use of antibiotics in SBE is discouraged in most studies. Antibiotic prescription in SBE should be based on the susceptibility of microorganisms isolated from the affected tissue or identified in snakes' oral cavities. Antibiotics should be reserved only for patients with a demonstrated infection, or those at a high risk of developing an infection, i.e., presenting severe local envenoming, local signs of infection, or those with incorrect manipulation of wounds. Prospective studies are needed to correlate microbiological findings at the wound site and the response to antibiotic use.
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Affiliation(s)
- Helena Brenes-Chacon
- Pediatric Infectious Diseases Division, Hospital Nacional de Niños “Dr. Carlos Sáenz Herrera”, Centro de Ciencias Médicas, Caja Costarricense de Seguro Social (CCSS), San José 10103, Costa Rica;
| | - José María Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José 11501, Costa Rica;
| | - María L. Avila-Aguero
- Pediatric Infectious Diseases Division, Hospital Nacional de Niños “Dr. Carlos Sáenz Herrera”, Centro de Ciencias Médicas, Caja Costarricense de Seguro Social (CCSS), San José 10103, Costa Rica;
- Escuela de Medicina, Universidad de Ciencias Médicas (UCIMED), San José 10108, Costa Rica
- Affiliated Researcher, Center for Infectious Disease Modeling and Analysis (CIDMA), Yale University New Haven, New Haven, CT 06520, USA
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Salim A, Williams J, Abdel Wahab S, Adeshokan T, Almeida JR, Williams HF, Vaiyapuri R, Senthilkumaran S, Thirumalaikolundusubramanian P, Patel K, Baksh MF, Lewin MR, Vaiyapuri S. Identifying key factors contributing to treatment costs for snakebite envenoming in private tertiary healthcare settings in Tamil Nadu, India. PLoS Negl Trop Dis 2023; 17:e0011699. [PMID: 37844081 PMCID: PMC10602377 DOI: 10.1371/journal.pntd.0011699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/26/2023] [Accepted: 10/05/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND India suffers ~58,000 annual deaths due to snakebites. The 'Big Four' snakes (Russell's viper, Indian cobra, common krait, and saw-scaled viper) that are responsible for most bites cause diverse clinical effects. Delayed treatment increases the risk of serious complications and treatment costs. Although government hospitals offer free treatment for snakebites in India, most patients opt for private healthcare, which is an out-of-pocket expense as they often lack health insurance coverage. This study aims to analyse snakebite treatment costs in private tertiary care hospitals in Tamil Nadu, India and identifies the key factors contributing to treatment costs. METHODOLOGY/PRINCIPAL FINDINGS The treatment cost details for 913 snakebite victims were collected from 10 private tertiary care hospitals across Tamil Nadu. The data were classified into hospital, pharmacy, investigation, and laboratory costs, and analysed to determine various factors that contribute to the costs. The results demonstrate that the average treatment costs vary widely for different snakes. The hospital and pharmacy costs are higher than investigation and laboratory costs for all snakebites. Notably, Russell's viper bites cost significantly more than the bites from other snakes. Overall, the type of snake, nature of complications, specialist treatments required, and arrival time to hospitals were identified as some of the key factors for higher treatment costs. CONCLUSIONS/SIGNIFICANCE These data demonstrate that ~80% of snakebite patients can be treated with INR 100,000 (~GBP 1000 or USD 1200) or less. This study emphasises the urgent need to improve rural medical care by providing appropriate training for healthcare professionals and essential resources to facilitate early assessment of patients, administer the initial dose of antivenom and refer the patients to tertiary care only when needed. Moreover, the outcome of this study forms a basis for developing appropriate policies to regulate snakebite treatment costs and provide affordable medical insurance for vulnerable communities.
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Affiliation(s)
- Anika Salim
- School of Pharmacy, University of Reading, Reading, United Kingdom
| | - Jarred Williams
- School of Pharmacy, University of Reading, Reading, United Kingdom
| | | | - Tade Adeshokan
- School of Pharmacy, University of Reading, Reading, United Kingdom
| | - José R. Almeida
- School of Pharmacy, University of Reading, Reading, United Kingdom
| | | | | | | | | | - Ketan Patel
- School of Biological Sciences, University of Reading, Reading, United Kingdom
| | - M. Fazil Baksh
- Department of Mathematics and Statistics, University of Reading, Reading, United Kingdom
| | - Matthew R. Lewin
- California Academy of Sciences, San Francisco, California, United States of America
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Lin WH, Tsai TS. Comparisons of the Oral Microbiota from Seven Species of Wild Venomous Snakes in Taiwan Using the High-Throughput Amplicon Sequencing of the Full-Length 16S rRNA Gene. BIOLOGY 2023; 12:1206. [PMID: 37759605 PMCID: PMC10525742 DOI: 10.3390/biology12091206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/26/2023] [Accepted: 09/02/2023] [Indexed: 09/29/2023]
Abstract
A venomous snake's oral cavity may harbor pathogenic microorganisms that cause secondary infection at the wound site after being bitten. We collected oral samples from 37 individuals belonging to seven species of wild venomous snakes in Taiwan, including Naja atra (Na), Bungarus multicinctus (Bm), Protobothrops mucrosquamatus (Pm), Trimeresurus stejnegeri (Ts), Daboia siamensis (Ds), Deinagkistrodon acutus (Da), and alpine Trimeresurus gracilis (Tg). Bacterial species were identified using full-length 16S rRNA amplicon sequencing analysis, and this is the first study using this technique to investigate the oral microbiota of multiple Taiwanese snake species. Up to 1064 bacterial species were identified from the snake's oral cavities, with 24 pathogenic and 24 non-pathogenic species among the most abundant ones. The most abundant oral bacterial species detected in our study were different from those found in previous studies, which varied by snake species, collection sites, sampling tissues, culture dependence, and analysis methods. Multivariate analysis revealed that the oral bacterial species compositions in Na, Bm, and Pm each were significantly different from the other species, whereas those among Ts, Ds, Da, and Tg showed fewer differences. Herein, we reveal the microbial diversity in multiple species of wild snakes and provide potential therapeutic implications regarding empiric antibiotic selection for wildlife medicine and snakebite management.
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Affiliation(s)
- Wen-Hao Lin
- Institute of Wildlife Conservation, National Pingtung University of Science and Technology, Pingtung 912301, Taiwan;
| | - Tein-Shun Tsai
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, Pingtung 912301, Taiwan
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7
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The secretory phenotypes of envenomed cells: Insights into venom cytotoxicity. ADVANCES IN PROTEIN CHEMISTRY AND STRUCTURAL BIOLOGY 2023; 133:193-230. [PMID: 36707202 DOI: 10.1016/bs.apcsb.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Snake envenomation is listed as Category A Neglected Tropical Diseases (NTD) by World Health Organization, indicates a severe public health problem. The global figures for envenomation cases are estimated to be more than 1.8 million annually. Even if the affected victims survive the envenomation, they might suffer from permanent morbidity due to local envenomation. One of the most prominent local envenomation is dermonecrosis. Dermonecrosis is a pathophysiological outcome of envenomation that often causes disability in the victims due to surgical amputations, deformities, contracture, and chronic ulceration. The key venom toxins associated with this local symptom are mainly attributed to substantial levels of enzymatic and non-enzymatic toxins as well as their possible synergistic actions. Despite so, the severity of the local tissue damage is based on macroscopic observation of the bite areas. Furthermore, limited knowledge is known about the key biomarkers involved in the pathogenesis of dermonecrosis. The current immunotherapy with antivenom is also ineffective against dermonecrosis. These local effects eventually end up as sequelae. There is also a global shortage of toxins-targeted therapeutics attributed to inadequate knowledge of the actual molecular mechanisms of cytotoxicity. This chapter discusses the characterization of secretory phenotypes of dermonecrosis as an advanced tool to indicate its severity and pathogenesis in envenomation. Altogether, the secretory phenotypes of envenomed cells and tissues represent the precise characteristics of dermonecrosis caused by venom toxins.
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Yeh H, Gao SY, Lin CC. Wound Infection of Snakebite from Venomous Protobothrops mucrosquamatus, Viridovipera stejnegeri and Naja atra in Taiwan: Validation of BITE and Cobra BITE Scoring Systems and their Bacteriological Differences in Wound Cultures. Toxins (Basel) 2023; 15:78. [PMID: 36668897 PMCID: PMC9861491 DOI: 10.3390/toxins15010078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/08/2023] [Accepted: 01/10/2023] [Indexed: 01/17/2023] Open
Abstract
Patients bitten by Protobothrops mucrosquamatus, Viridovipera stejnegeri, and Naja atra develop different degrees of wound infection. This study validated BITE and Cobra BITE scoring systems that we established previously. Bacteriological studies of patients with wound infection were conducted. The operating characteristic curves and area under the curve (AUC) and wound infection rates were compared between the derivation set (our previous study patient population) and the validation set (new patient cohorts enrolled between June 2017 and May 2021). No significant differences in the AUC for both the BITE (0.84 vs. 0.78, p = 0.27) and Cobra BITE (0.88 vs. 0.75, p = 0.21) scoring systems were observed between the derivation and validation sets. Morganella morganii and Enterococcus faecalis were the two most commonly detected bacteria in the microbiological study. More bacterial species were cultured from N. atra-infected wounds. Antibiotics such as amoxicillin with clavulanic acid, oxacillin, and ampicillin may not be suitable for treating patients with P. mucrosquamatus, V. stejnegeri, and N. atra bites in Taiwan. Carbapenem, third-generation cephalosporins, and fluoroquinolone may be superior alternatives.
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Affiliation(s)
- Heng Yeh
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Shi-Ying Gao
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Chih-Chuan Lin
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
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Basse J, Ruha AM, Baumgartner K, Mullins ME, Greene S, Wax PM, Brent J, Campleman S, Schwarz ES. Clinical Presentations, Treatments, and Outcomes of Non-native Snake Envenomations in the United States Reported in the North American Snakebite Registry. J Med Toxicol 2023; 19:16-25. [PMID: 36175787 DOI: 10.1007/s13181-022-00912-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/31/2022] [Accepted: 09/06/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Non-native snake envenomations in the United States are uncommon with much unknown about a patient's presenting signs and symptoms. Antivenoms for non-native snake envenomations are not typically available in hospital pharmacies which may limit their administration. What are the clinical presentations, treatments, and outcomes of non-native snake envenomation cases reported to the North American Snakebite Registry (NASBR) of the Toxicology Investigators Consortium (ToxIC)? METHODS This is a descriptive review of all non-native envenomations reported to the NASBR from 2013 to March 2022. Data abstracted included snake species, patient history, clinical signs, diagnostics, treatment (including antivenom usage), follow-up, and final outcome. RESULTS We identified 19 non-native snake envenomations resulting from encounters with eleven different species, eight of which belonged to the Viperidae family. The most common presenting symptoms were edema (18 patients), ecchymosis (seven patients), and necrosis (six patients). Systemic effects and hematologic abnormalities were less common. The most common treatments were extremity elevation and analgesia, with two patients receiving mechanical ventilation. Ten patients received antivenom. No patients died. Three patients had loss of mobility in a digit at the last follow-up visit. One patient had permanent tissue loss of a small area on a finger. CONCLUSIONS The results of this study suggest that non-native snake envenomations in the United States frequently cause local soft tissue effects and less frequently cause systemic or hematologic effects. Most patients received antivenom, although several patients envenomated by snakes for which a specific antivenom exists did not receive any. Sequelae at the last follow-up of such encounters consisted of local mobility deficits.
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Affiliation(s)
- Jack Basse
- Washington University School of Medicine, 660 S. Euclid Ave, Campus, Box 8072, St. Louis, MO, 63110, USA
| | - Anne-Michelle Ruha
- Banner University Medical Center Phoenix, 1012 E Willetta ST, Phoenix, AZ, Fl285006, USA
| | - Kevin Baumgartner
- Washington University School of Medicine, 660 S. Euclid Ave, Campus, Box 8072, St. Louis, MO, 63110, USA
| | - Michael E Mullins
- Washington University School of Medicine, 660 S. Euclid Ave, Campus, Box 8072, St. Louis, MO, 63110, USA
| | - Spencer Greene
- University of Houston College of Medicine, Kingwood, TX, 22999 US Hwy 59N773394, USA
| | - Paul M Wax
- American College of Medical Toxicology, 10645 N. Tatum Blvd, Suite 200-111, Phoenix, AZ, 85028, USA
| | - Jeffrey Brent
- School of Medicine, University of Colorado, 12401 East 17th Avenue, 7th floor, Aurora, CO, 80045, USA
| | - Sharan Campleman
- American College of Medical Toxicology, 10645 N. Tatum Blvd, Suite 200-111, Phoenix, AZ, 85028, USA
| | - Evan S Schwarz
- Washington University School of Medicine, 660 S. Euclid Ave, Campus, Box 8072, St. Louis, MO, 63110, USA.
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Valladales-Restrepo LF, Rojas-Ramirez AS, Santander-Pai MJ, Lozada-Castaño V, Bedoya-Duque LV, Sabogal-Sanchez DY, Gómez-Gómez NS, Machado-Alba JE. Clinical characteristics and use of antibiotics in a group of patients with snake bites in Colombia. Ther Adv Infect Dis 2023; 10:20499361231210400. [PMID: 37954406 PMCID: PMC10637142 DOI: 10.1177/20499361231210400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/09/2023] [Indexed: 11/14/2023] Open
Abstract
Introduction Millions of snake bites occur worldwide each year. Clinical practice guidelines generally do not recommend the use of prophylactic antibiotics. Objective To determine the sociodemographic, clinical, and pharmacological variables and the use of antibiotics in a group of patients with snake bites in Colombia. Methods A retrospective cross-sectional study was carried out. Patients affiliated with a Colombian health insurer who presented with snake bites between 2015 and 2022 were included. The cases were identified from the National Public Health Surveillance System. Sociodemographic, clinical and pharmacological variables were identified. Descriptive and bivariate analyses were performed. Results A total of 643 patients were analyzed, with a median age of 30.8 years, and 74.7% were men. The most frequently identified genus of snake was Bothrops (88.8%), and most incidents were classified as mild ophidian accidents (61.6%). A total of 59.7% of patients received snake antivenom. A total of 13.8% and 2.2% of the patients had cellulitis or abscesses, respectively. A total of 63.5% received antibiotics (50.6% for prophylaxis and 12.9% for treatment), especially cephalexin (25.9%), and most of the antibiotic management was considered inappropriate (91.7%). Conclusion Most patients with snake bites received antibiotics, especially for prophylactic purposes, a clinical behavior that goes against current evidence. The use of antibiotics with an unsuitable spectrum for the microorganisms that are usually found in the wounds of these patients is frequent. The development of local clinical practice guidelines is required to help reduce the overprescription of antibiotics, as the excessive use of antimicrobials is the main determinant of antimicrobial resistance.
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Affiliation(s)
- Luis Fernando Valladales-Restrepo
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Risaralda, Colombia
- Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
- Semillero de Investigación en Farmacología Geriátrica, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia
| | - Ana Sofia Rojas-Ramirez
- Semillero de Investigación en Farmacología Geriátrica, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia
| | - Melba Jasbleidy Santander-Pai
- Semillero de Investigación en Farmacología Geriátrica, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia
| | - Valeria Lozada-Castaño
- Semillero de Investigación en Farmacología Geriátrica, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia
| | - Laura Valentina Bedoya-Duque
- Semillero de Investigación en Farmacología Geriátrica, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia
| | - Dayana Yuliet Sabogal-Sanchez
- Semillero de Investigación en Farmacología Geriátrica, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia
| | - Nicolas Stiven Gómez-Gómez
- Semillero de Investigación en Farmacología Geriátrica, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia
| | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Calle 105 # 14-140, Pereira, Risaralda 660003, Colombia
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11
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Hu S, Lou Z, Shen Y, Tu M. Bacteriological Studies of Venomous Snakebite Wounds in Hangzhou, Southeast China. Am J Trop Med Hyg 2022; 107:925-929. [PMID: 36067984 PMCID: PMC9651534 DOI: 10.4269/ajtmh.21-1314] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 06/26/2022] [Indexed: 11/07/2022] Open
Abstract
Snakebite is a common occurrence in Hangzhou, and identifying bacteria in wounds is very important for snakebite treatment. To define the pattern of wound bacterial flora of venomous snakebites and their susceptibility to common antibiotics, we reviewed the medical charts of patients admitted with snakebite at Hangzhou TCM Hospital from January 2019 to December 2020. A total of 311 patients were enrolled in this study. Among them, bacteria culture was positive in 40 patients, and 80 organisms were isolated. The most frequent pathogens were Morganella morganii and Staphylococcus aureus. According to the results of susceptibility testing, a majority of the isolates were resistant to some common first-line antibiotics, such as ampicillin, ampicillin/sulbactam, amoxicillin/clavulanic acid, cefoxitin, and cephazolin. Quinolones, however, have shown a better antibacterial effect. In conclusion, snakebite wounds involve a wide range of bacteria. Fluoroquinolones, such as levofloxacin and ciprofloxacin, could be an alternative for empirical treatment in patients with snakebite when the effect of other antibiotics is poor.
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Affiliation(s)
- Sipin Hu
- Department of Vascular Surgery, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
| | - Zhengqing Lou
- Department of Clinical Laboratory, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, People’s Republic of China
| | - Yuchen Shen
- Department of Dermatology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, People’s Republic of China
| | - Mengyun Tu
- Department of Clinical Laboratory, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, People’s Republic of China
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12
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Bites by Non-Native Reptiles in France: Species, Circumstances and Outcome. Toxins (Basel) 2022; 14:toxins14080570. [PMID: 36006232 PMCID: PMC9412768 DOI: 10.3390/toxins14080570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 08/17/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
We aimed to make an exhaustive assessment of circumstances of bites by exotic reptiles bred in France. A retrospective observational study was conducted in all the reported cases from 2000 to 2020 in French poison control centers (PCCs). Two hundred and eighteen cases of bites were recorded. The sex ratio (M/F) of the patients was 1.79 and the mean age of the patients was 29.0 ± 15.8 years. Twenty-two cases (10.1%) occurred during the deep night. One hundred and eighty-six bites (85.7%) occurred in a private context; however, there were more cases of high severity when it occurred in a professional setting (60.0% vs. 11.2%, p < 0.01). The feeding/nursing activity accounted for 54.7% cases. Forty-three species of snake were identified; 28 were considered venomous. There were no deaths among the patients in the study. Most of the cases (85.8%) were of mild severity. All of the patients bitten by a venomous reptile were hospitalized: 10 patients received an antivenom; and 2 required surgery. Bites occurred at home and by a small number of popular non-venomous reptile species (pythons and boas, colubrids). These occurred mainly when handling the animals. The rare envenomations were mainly by Asian and American crotalids, followed by elapids. One-third of them were treated with antivenom when available.
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13
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Laupland KB, Paterson DL, Edwards F, Stewart AG, Harris PNA. Morganella morganii, an Emerging Cause of Bloodstream Infections. Microbiol Spectr 2022; 10:e0056922. [PMID: 35467403 PMCID: PMC9241912 DOI: 10.1128/spectrum.00569-22] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/08/2022] [Indexed: 11/20/2022] Open
Abstract
Although recent reports of extensively antibiotic-resistant strains have highlighted the importance of Morganella morganii as an emerging pathogen, the epidemiology of serious infections due to this organism is not well defined. The objective of this study was to determine the incidence, determinants, and outcomes of Morganella morganii bloodstream infections (BSIs). Retrospective, population-based surveillance for Morganella morganii BSIs was conducted in Queensland, Australia, in 2000 to 2019; 709 cases were identified, for an annual incidence of 9.2 cases per million population. Most cases were of community onset, with 280 (39.5%) community-associated cases and 226 (31.9%) health care-associated cases. Morganella morganii BSIs were rare in children and young adults, and the incidence increased markedly with advancing age. The most common foci of infection were skin and soft tissue (131 cases [18.5%]), genitourinary (97 cases [13.7%]), and intraabdominal (90 cases [12.7%]). Most patients (580 cases [81.8%]) had at least one comorbid medical illness, with diabetes mellitus (250 cases [35.3%]), renal disease (208 cases [29.3%]), and congestive heart failure (167 cases [23.6%]) being most prevalent. Resistance to one or more of quinolones, co-trimoxazole, aminoglycosides, or carbapenems was observed in 67 cases (9.5%), and this did not change significantly over the study. The 30-day all-cause case fatality rate was 21.2%, and increasing age, nonfocal infection, heart failure, dementia, and cancer were independently associated with increased risk of death. Morganella morganii BSIs are increasing in our population, and elderly male subjects and individuals with comorbidities are at highest risk. Although antibiotic resistance is not a major contributor to the current burden in Queensland, ongoing surveillance is warranted. IMPORTANCE Recent reports of extensively antibiotic-resistant strains have highlighted the importance of Morganella morganii as an emerging pathogen. Despite its present and evolving importance as an agent of human disease, there is a limited body of literature detailing the epidemiology of serious infections due to Morganella morganii. Therefore, the objectives of this study were to examine the incidence and determinants of Morganella morganii BSIs and to examine risk factors for death in a large Australian population in 2000 to 2019.
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Affiliation(s)
- Kevin B. Laupland
- Department of Intensive Care Services, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - David L. Paterson
- University of Queensland, Faculty of Medicine, University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
- Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Felicity Edwards
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Adam G. Stewart
- University of Queensland, Faculty of Medicine, University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
- Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Patrick N. A. Harris
- University of Queensland, Faculty of Medicine, University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
- Department of Microbiology, Pathology Queensland, Brisbane, Queensland, Australia
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14
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Lin JH, Sung WC, Mu HW, Hung DZ. Local Cytotoxic Effects in Cobra Envenoming: A Pilot Study. Toxins (Basel) 2022; 14:toxins14020122. [PMID: 35202149 PMCID: PMC8877591 DOI: 10.3390/toxins14020122] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/24/2022] [Accepted: 02/05/2022] [Indexed: 01/31/2023] Open
Abstract
The cobra (genus Naja (N.)) is one of the most common venomous snakes. Due to its frequency and deadly complications of muscle paralysis, local necrosis, and chronic musculoskeletal disability, it should not be ignored. The pathology of devastating tissue destruction, even though specific antivenoms exist, is not fully clear. Here, we attempted to dig in envenomed tissues to study the clinical toxicology of cobra venom. Four cases of N. atra snake envenomation, in which the subjects developed advanced tissue injury, were involved in this study. We used enzyme-ligand sandwich immunoassay (ELISA) to assay the whole venom, cytotoxin A3 and short-chain neurotoxin (sNTX) in blood, bullae, wound discharge, and debrided tissue. We found that persistently high concentrations of venom and toxins, especially cytotoxin A3, were detected in bullae, wound discharge fluid and necrotic tissue of these patients even after large doses of specific antivenom treatment, and wide excision and advanced debridement could largely remove these toxins, lessen the size of necrosis, and promote wound healing. We also found that the point-of-care apparatus, ICT-Cobra kit, might be used to promptly monitor the wound condition and as one of the indicators of surgical intervention in cases of cobra envenomation in Taiwan.
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Affiliation(s)
- Jing-Hua Lin
- Division of Toxicology, China Medical University Hospital, Taichung 40447, Taiwan; (J.-H.L.); (H.-W.M.)
| | - Wang-Chou Sung
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli 35053, Taiwan;
| | - Han-Wei Mu
- Division of Toxicology, China Medical University Hospital, Taichung 40447, Taiwan; (J.-H.L.); (H.-W.M.)
| | - Dong-Zong Hung
- Division of Toxicology, China Medical University Hospital, Taichung 40447, Taiwan; (J.-H.L.); (H.-W.M.)
- Correspondence: ; Tel.: +886-4-2205-2121
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Abstract
SNAKE ENVENOMATION REPRESENTS AN IMPORTANT HEALTH PROBLEM IN much of the world. In 2009, it was recognized by the World Health Organization (WHO) as a neglected tropical disease, and in 2017, it was elevated into Category A of the Neglected Tropical Diseases list, further expanding access to funding for research and antivenoms. However, snake envenomation occurs in both tropical and temperate climates and on all continents except Antarctica. Worldwide, the estimated number of annual deaths due to snake envenomation (80,000 to 130,000) is similar to the estimate for drug-resistant tuberculosis and for multiple myeloma., In countries with adequate resources, deaths are infrequent (e.g., <6 deaths per year in the United States, despite the occurrence of 7000 to 8000 bites), but in countries without adequate resources, deaths may number in the tens of thousands. Venomous snakes kept as pets are not rare, and physicians anywhere might be called on to manage envenomation by a nonnative snake. Important advances have occurred in our understanding of the biology of venom and the management of snake envenomation since this topic was last addressed in the Journal two decades ago. For the general provider, it is important to understand the spectrum of snake envenomation effects and approaches to management and to obtain specific guidance, when needed.
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Affiliation(s)
- Steven A Seifert
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
| | - James O Armitage
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
| | - Elda E Sanchez
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
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