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Hsu JY, Chiang SO, Yang CC, Mao YC. A Nationwide Study on the Risks of Complications and Healthcare Costs of Snakebite Envenomation in Taiwan. Am J Trop Med Hyg 2024; 111:205-215. [PMID: 38714189 PMCID: PMC11229656 DOI: 10.4269/ajtmh.24-0030] [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: 01/18/2024] [Accepted: 03/04/2024] [Indexed: 05/09/2024] Open
Abstract
In Taiwan, six medically important venomous snakes, Trimeresurus stejnegeri stejnegeri, Protobothrops mucrosquamatus, Deinagkistrodon acutus, Daboia siamensis, Naja atra, and Bungarus multicinctus, are found. However, comprehensive research on the complications and associated healthcare costs of snakebite envenomation (SBE) is lacking. We retrospectively analyzed pertinent information from the Taiwan National Health Insurance Research Database dated January 2002 to December 2014. We investigated the risk factors for complications and their impact on healthcare costs. Among the 12,542 patients with SBE, those from N. atra or B. multicinctus were more likely to experience wound infections and neurological complications than were those from T. s. stejnegeri or P. mucrosquamatus. In addition, being female, being elderly, and having a Charlson Comorbidity Index equal to or greater than 3 points were associated with an increased likelihood of wound infections and psychological complications. The annual national economic burden averaged US$1,083,624, with an average healthcare cost of US$1,129 per SBE. Snakebite envenomations from N. atra or B. multicinctus, as well as various complications, resulted in significantly higher costs. It is crucial to comprehend the risk factors for complications and their role in increasing expenses to provide insight for tailored healthcare interventions, mitigate complications, and reduce the economic burdens associated with SBEs.
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Affiliation(s)
- Jen-Yu Hsu
- Department of Occupational Medicine and Clinical Toxicology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Shu-O Chiang
- ESTAT Statistical Consulting Co., Ltd, Taipei, Taiwan
| | - Chen-Chang Yang
- Department of Occupational Medicine and Clinical Toxicology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Environmental and Occupational Health Sciences, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yan-Chiao Mao
- PhD Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
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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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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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Hu X, Yang L, Zhang Y, Yang M, Li J, Fan Y, Guo P, Tian Z. Fecal and oral microbiome analysis of snakes from China reveals a novel natural emerging disease reservoir. Front Microbiol 2024; 14:1339188. [PMID: 38274764 PMCID: PMC10808610 DOI: 10.3389/fmicb.2023.1339188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
Introduction The gastrointestinal tract and oral cavity of animal species harbor complex microbial communities, the composition of which is indicative of the behavior, co-evolution, diet, and immune system of the host. Methods This study investigated the microbial composition in snakes from varying altitudinal ranges by assessing the fecal and oral bacterial communities in Protobothrops mucrosquamatus, Elaphe dione, and Gloydius angusticeps from Sichuan Province, China, using metagenomic sequencing. Results and discussion It was revealed that Bacteroidetes, Proteobacteria, Firmicutes, and Fusobacteria were the core microbial phyla in fecal samples across all three species, while Proteobacteria, Bacteroidetes, Actinobacteria, and Firmicutes were the core microbial phyla in oral samples across all three species. Notably, the dominance of Armatimonadetes was documented for the first time in the feces of all three species. Comparative analysis of the microbiomes of the three species indicated distinct microbiological profiles between snakes living at low- and high-altitude regions. Furthermore, 12 to 17 and 22 to 31 bacterial pathogens were detected in the oral and fecal samples, respectively, suggesting that snakes may serve as a novel reservoir for emerging diseases. Overall, this study provides a comparative analysis of the fecal and oral microbiomes in three snake species. Future investigations are anticipated to further elucidate the influence of age, genetics, behavior, diet, environment, ecology, and evolution on the gut and oral microbial communities of snakes.
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Affiliation(s)
| | | | | | | | | | | | | | - Zhige Tian
- Yibin Key Laboratory of Zoological Diversity and Ecological Conservation, Faculty of Agriculture, Forestry, and Food Engineering, Yibin University, Yibin, China
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Zhang Z, Yang J, Fang J, Zhang J, Zeng L, Li J. Case Report: Snake Venom Ophthalmia Caused by Cobra Exposure: A Report of 26 Cases. Am J Trop Med Hyg 2023; 109:1393-1396. [PMID: 37931316 DOI: 10.4269/ajtmh.23-0374] [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: 06/08/2023] [Accepted: 09/14/2023] [Indexed: 11/08/2023] Open
Abstract
We report 26 cases of eye injuries resulting from cobra venom sprayed by Naja atra. This accounts for 14.5% of patients (26/173) treated for cobra injuries who presented to the emergency department of a snakebite treatment center in Guangzhou, South China. Pain, blurred vision, lacrimation, photophobia, and foreign body sensation were the most common symptoms, found in 24 patients. Ophthalmic examination revealed eyelid swelling and conjunctival congestion. Eye slit lamp examination showed obvious punctate corneal epithelial defects in four patients. Five patients received an intravenous infusion of antivenom. All patients' eyes were rinsed completely with normal saline after their arrival at the hospital. Prophylactic topical antibiotics were given to all patients. All eyes were cured without long-term sequelae.
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Affiliation(s)
- Zehan Zhang
- Department of Medicine, Guangzhou Medical University, Guangzhou, China
| | - Jieyi Yang
- Department of Medicine, Guangzhou Medical University, Guangzhou, China
| | - Jing Fang
- Department of Medicine, Guangzhou Medical University, Guangzhou, China
| | - Jiasheng Zhang
- Department of Ophthalmology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Liangbo Zeng
- Department of Emergency Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jianjing Li
- Department of Ophthalmology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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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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Cavalcante TTA, de Souza MBS, Neves JCF, Ibiapina HNS, Barbosa FBA, Bentes KO, Alves EC, Marques HO, Colombini M, Sampaio SV, Pucca MB, da Silva IM, Ferreira LCDL, Sampaio VDS, Moura-da-Silva AM, Costa AG, Monteiro WM, Sachett JAG, Sartim MA. Inflammatory Profile Associated with Secondary Infection from Bothrops atrox Snakebites in the Brazilian Amazon. Toxins (Basel) 2023; 15:524. [PMID: 37755950 PMCID: PMC10537699 DOI: 10.3390/toxins15090524] [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: 07/17/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 09/28/2023] Open
Abstract
Bothrops snakebite envenomation (SBE) is consider an important health problem in Brazil, where Bothrops atrox is mainly responsible in the Brazilian Amazon. Local effects represent a relevant clinical issue, in which inflammatory signs and symptoms in the bite site represent a potential risk for short and long-term disabilities. Among local complications, secondary infections (SIs) are a common clinical finding during Bothrops atrox SBE and are described by the appearance of signs such as abscess, cellulitis or necrotizing fasciitis in the affected site. However, the influence of SI in the local events is still poorly understood. Therefore, the present study describes for the first time the impact of SBE wound infection on local manifestations and inflammatory response from patients of Bothrops atrox SBE in the Brazilian Amazon. This was an observational study carried out at the Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus (Brazil), involving victims of Bothrops SBE. Clinical and laboratorial data were collected along with blood samples for the quantification of circulating cytokines and chemokines before antivenom administrations (T0) and 24 h (T1), 48 h (T2), 72 h (T3) and 7 days after (T4). From the 94 patients included in this study, 42 presented SI (44.7%) and 52 were without SI (NSI, 55.3%). Patients classified as moderate envenoming presented an increased risk of developing SI (OR = 2.69; CI 95% = 1.08-6.66, p = 0.033), while patients with bites in hands showed a lower risk (OR = 0.20; CI 95% = 0.04-0.96, p = 0.045). During follow-up, SI patients presented a worsening of local temperature along with a sustained profile of edema and pain, while NSI patients showed a tendency to restore and were highlighted in patients where SI was diagnosed at T2. As for laboratorial parameters, leukocytes, erythrocyte sedimentation ratio, fibrinogen and C-reactive protein were found increased in patients with SI and more frequently in patients diagnosed with SI at T3. Higher levels of circulating IL-2, IL-10, IL-6, TNF, INF-γ and CXCL-10 were observed in SI patients along with marked correlations between these mediators and IL-4 and IL-17, showing a plurality in the profile with a mix of Th1/Th2/Th17 response. The present study reports for the first time the synergistic effects of local infection and envenoming on the inflammatory response represented by local manifestations, which reflected on laboratorial parameters and inflammatory mediators and thus help improve the clinical management of SI associated to Bothrops SBE.
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Affiliation(s)
- Távila Tatiane Amorim Cavalcante
- Programa de Pós-Graduação em Imunologia Básica e Aplicada, Instituto de Ciências Biológicas, Universidade Federal do Amazonas-UFAM, Manaus 69080-900, Brazil
| | | | - Juliana Costa Ferreira Neves
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas-UEA, Manaus 69040-000, Brazil (J.A.G.S.)
| | | | | | - Karolaine Oliveira Bentes
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas-UEA, Manaus 69040-000, Brazil (J.A.G.S.)
| | - Eliane Campos Alves
- Instituto Federal de Educação, Ciência e Tecnologia do Amazonas-IFAM, Manaus 69025-010, Brazil
| | - Hedylamar Oliveira Marques
- Diretoria de Ensino e Pesquisa, Fundação Hospitalar de Hematologia e Hemoterapia do Amazonas-HEMOAM, Manaus 69050-001, Brazil
| | - Monica Colombini
- Laboratório de Imunopatologia, Instituto Butantan, São Paulo 05503-900, Brazil
| | - Suely Vilela Sampaio
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo-USP, Ribeirão Preto 14040-903, Brazil
| | - Manuela Berto Pucca
- Curso de Medicina, Universidade Federal de Roraima-UFRR, Boa Vista 69310-000, Brazil
- Departamento de Análises Clínicas, Faculdade de Ciências Farmacêuticas, Universidaed Estadual Paulista-UNESP, Araraquara 14800-903, Brazil
| | - Iran Mendonça da Silva
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas-UEA, Manaus 69040-000, Brazil (J.A.G.S.)
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado–FMT-HVD, Manaus 69040-000, Brazil
| | - Luiz Carlos de Lima Ferreira
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas-UEA, Manaus 69040-000, Brazil (J.A.G.S.)
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado–FMT-HVD, Manaus 69040-000, Brazil
| | - Vanderson de Souza Sampaio
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas-UEA, Manaus 69040-000, Brazil (J.A.G.S.)
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado–FMT-HVD, Manaus 69040-000, Brazil
| | | | - Allyson Guimarães Costa
- Programa de Pós-Graduação em Imunologia Básica e Aplicada, Instituto de Ciências Biológicas, Universidade Federal do Amazonas-UFAM, Manaus 69080-900, Brazil
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas-UEA, Manaus 69040-000, Brazil (J.A.G.S.)
- Diretoria de Ensino e Pesquisa, Fundação Hospitalar de Hematologia e Hemoterapia do Amazonas-HEMOAM, Manaus 69050-001, Brazil
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado–FMT-HVD, Manaus 69040-000, Brazil
| | - Wuelton Marcelo Monteiro
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas-UEA, Manaus 69040-000, Brazil (J.A.G.S.)
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado–FMT-HVD, Manaus 69040-000, Brazil
| | - Jacqueline Almeida Gonçalves Sachett
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas-UEA, Manaus 69040-000, Brazil (J.A.G.S.)
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado–FMT-HVD, Manaus 69040-000, Brazil
| | - Marco Aurélio Sartim
- Programa de Pós-Graduação em Imunologia Básica e Aplicada, Instituto de Ciências Biológicas, Universidade Federal do Amazonas-UFAM, Manaus 69080-900, Brazil
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas-UEA, Manaus 69040-000, Brazil (J.A.G.S.)
- Pró-Reitoria de Pesquisa e Pós-Graduação, Universidade Nilton Lins, Manaus 69058-030, Brazil
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Hsu JY, Chiang SO, Yang CC, Hsieh TW, Chung CJ, Mao YC. Nationwide and long-term epidemiological research of snakebite envenomation in Taiwan during 2002-2014 based on the use of snake antivenoms: A study utilizing National Health Insurance Database. PLoS Negl Trop Dis 2023; 17:e0011376. [PMID: 37289739 DOI: 10.1371/journal.pntd.0011376] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/12/2023] [Indexed: 06/10/2023] Open
Abstract
INTRODUCTION In Taiwan, six venomous snake species with medical importance have been found; however, long-term epidemiological data of snakebite envenomation (SBE) is lacking. This study aimed to explore the epidemiology of SBE based on the distribution and use of different antivenoms in different parts of Taiwan to facilitate the development of prevention strategies and resource allocation. METHODS AND RESULTS This retrospective study was conducted using the Taiwan National Health Insurance Research Database from 2002 to 2014. A total of 12,542 patients were treated with antivenoms. The directly standardized cumulative incidence was 3.6 cases per 100,000 individuals based on the 2000 World Standard Population. The incidence of SBEs peaked in the summer (35.9%). The relative risk (RR) of male patients versus female patients was 2.5 (p < 0.0001). The RRs of patients aged 18-64 and ≥65 years versus those aged <18 years were 6.0 (p < 0.0001) and 14.3 (p < 0.0001), respectively. Furthermore, the RR of eastern Taiwan versus northern Taiwan was 6.8 (p < 0.0001). The RR of agricultural workers versus laborers was 5.5 (p < 0.0001). Compared with patients envenomed by Trimeresurus stejnegeri stejnegeri or Protobothrops mucrosquamatus, those envenomed by Naja atra or Bungarus multicinctus multicinctus were more likely to occur in central (adjusted odds ratio [aOR] = 2.6, p < 0.0001) or southern (aOR = 3.2, p < 0.0001) Taiwan, but less frequently among agricultural workers (aOR = 0.6, p < 0.0001). The overall case-fatality rate was 0.11%. CONCLUSIONS Among Asian countries, Taiwan had low incidence and case-fatality rates of SBE. Risk factors included male gender, old age, summer season, being in eastern Taiwan, and being an agricultural worker. Differences of the epidemiological findings between snake species should be focused on when developing strategies for snakebite prevention.
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Affiliation(s)
- Jen-Yu Hsu
- Department of Occupational Medicine and Clinical Toxicology, Taipei Veterans General Hospital, Taipei, Taiwan
- Office of Preventive Medicine, Centers for Disease Control, Ministry of Health and Welfare, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shu-O Chiang
- ESTAT Statistical Consulting Co., Ltd., Taipei, Taiwan
| | - Chen-Chang Yang
- Department of Occupational Medicine and Clinical Toxicology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Environmental and Occupational Health Sciences, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tan-Wen Hsieh
- Institute of Public Health, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chi-Jung Chung
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Yan-Chiao Mao
- PhD Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
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10
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Lu HY, Mao YC, Liu PY, Lai KL, Wu CY, Tsai YC, Yen JH, Chen IC, Lai CS. Clinical predictors of early surgical intervention in patients with venomous snakebites. Eur J Med Res 2023; 28:131. [PMID: 36945006 PMCID: PMC10029284 DOI: 10.1186/s40001-023-01101-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/16/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Venomous snakebites induce tissue destruction and secondary infection; however, the optimal timing of surgical intervention for these complications remains unknown. This study assessed the clinical predictors of early surgical intervention in patients with snakebites. METHODS This retrospective study included 63 patients (45 men and 18 women) with venomous snakebites. In addition to the snake species, the demographics, affected body parts, clinical characteristics, and ultrasound findings of the patients in the surgical (32 patients) and nonsurgical (31 patients) groups were analyzed and compared. RESULTS A higher incidence of acute compartment syndrome, local ecchymosis, skin necrosis, bullae, blisters, and fever was found in the surgical group than in the nonsurgical group, and ultrasound findings of the absence of Doppler flow were more frequently noted in the surgical group than in the nonsurgical group. After adjustment using a multivariate logistic regression model, only advanced age, Naja atra bite, local ecchymosis, and bulla or blister formation remained significant factors for surgical intervention. Furthermore, comparison of the outcomes of patients who received early (≤ 24 h) and late (> 24 h) surgical intervention revealed that the duration of continuous negative pressure wound therapy (6 vs. 15 days; P = 0.006), duration of hospital stay (13 vs. 26 days; P = 0.002), and duration of outpatient follow-up (15 vs. 36 days; P < 0.001) were significantly lower in patients who received early surgical intervention. The final reconstructive surgery was simple among the patients who received surgical intervention within 24 h of being bitten (P = 0.028). CONCLUSION In patients with snakebites, advanced age, high-risk clinical manifestations (e.g., local ecchymosis and bulla or blister formation), and Naja atra envenomation are predictors of surgical intervention within 24 h.
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Affiliation(s)
- Hsiao-Yu Lu
- Department of Orthopedic, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Yan-Chiao Mao
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Republic of China
- Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
- School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Po-Yu Liu
- Division of Infection, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan, Republic of China
| | - Kuo-Lung Lai
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Cheng-Yeu Wu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Yueh-Chi Tsai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, Republic of China
| | - Jung-Hsing Yen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - I-Chen Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Chih-Sheng Lai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China.
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, Republic of China.
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11
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Warrell DA, Williams DJ. Clinical aspects of snakebite envenoming and its treatment in low-resource settings. Lancet 2023; 401:1382-1398. [PMID: 36931290 DOI: 10.1016/s0140-6736(23)00002-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/26/2022] [Accepted: 12/18/2022] [Indexed: 03/16/2023]
Abstract
There is increasing recognition of the public health importance of snakebite envenoming. Worldwide annual incidence is likely to be 5 million bites, with mortality exceeding 150 000 deaths, and the resulting physical and psychological morbidity leads to substantial social and economic repercussions. Prevention through community education by trained health workers is the most effective and economically viable strategy for reducing risk of bites and envenoming. Clinical challenges to effective treatment are most substantial in rural areas of low-resource settings, where snakebites are most common. Classic skills of history taking, physical examination, and use of affordable point-of-care tests should be followed by monitoring of evolving local and systemic envenoming. Despite the profusion of new ideas for interventions, hyperimmune equine or ovine plasma-derived antivenoms remain the only specific treatment for snakebite envenoming. The enormous interspecies and intraspecies complexity and diversity of snake venoms, revealed by modern venomics, demands a radical redesign of many current antivenoms.
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Affiliation(s)
- David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Experimental Medicine Division, John Radcliffe Hospital, Headington, UK.
| | - David J Williams
- Regulation and Prequalification Department, World Health Organization, Geneva, Switzerland
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12
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Senthilkumaran S, Salim A, Almeida JR, Williams J, Vijayakumar P, Thirunavukarasu A, Christopoulos MA, Williams HF, Thirumalaikolundusubramanian P, Patel K, Vaiyapuri S. The Effectiveness of Antibiotics in Managing Bacterial Infections on Bite Sites following Snakebite Envenomation. Toxins (Basel) 2023; 15:190. [PMID: 36977081 PMCID: PMC10057039 DOI: 10.3390/toxins15030190] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
Snakebite envenomation (SBE) is a life-threatening medical emergency with a high mortality rate. Common secondary complications following SBE, such as wound infections, are significant due to their impact on worsening local tissue damage and causing systemic infection. Antivenoms are not effective to treat wound infections following SBE. Moreover, in several rural clinical settings, broad-spectrum antibiotics are often used without clear guidelines or based on limited laboratory data, resulting in undesirable side effects and exacerbated treatment costs. Therefore, robust antibiotic strategies should be developed to tackle this critical issue. Currently, there is limited information available on the bacterial profiles of SBE-induced infections and antibiotic susceptibility. Hence, it is essential to improve the knowledge of bacterial profiles and their antibiotic sensitivity in SBE victims to develop better treatment strategies. This study aimed to address this issue by examining the bacterial profiles of SBE victims with a specific focus on Russell's viper envenomation. The most frequently found bacteria in the bites of SBE victims were Staphylococcus aureus, Klebsiella sp., Escherichia coli, and Pseudomonas aeruginosa. Linezolid, clindamycin, colistin, meropenem, and amikacin were some of the most effective antibiotics for commonly grown bacteria in SBE victims. Similarly, ciprofloxacin, ampicillin, amoxiclave, cefixime, and tetracyclin were the least effective antibiotics for common bacteria found in the wound swabs of SBE victims. These data provide robust guidance for infection management following SBE and offer useful insights to aid in designing effective treatment protocols for SBE with serious wound infections in rural areas where laboratory facilities may not be readily available.
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Affiliation(s)
| | - Anika Salim
- School of Pharmacy, University of Reading, Reading RG6 6UB, UK
| | - José R Almeida
- School of Pharmacy, University of Reading, Reading RG6 6UB, UK
| | - Jarred Williams
- School of Pharmacy, University of Reading, Reading RG6 6UB, UK
| | | | | | | | - Harry F Williams
- Toxiven Biotech Private Limited, Coimbatore 641042, Tamil Nadu, India
| | | | - Ketan Patel
- School of Biological Sciences, University of Reading, Reading RG6 6UB, UK
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13
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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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14
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Wang CC, Yang CHO, Hsu CP, Liu CC, Yu JS, Lo CH, Fann WC, Chen YC, Lin CC. Taiwan cobra envenoming: serum venom concentration before and after specific treatment and relationship with debridement of necrotic wound tissue. J Venom Anim Toxins Incl Trop Dis 2023; 29:e20220027. [PMID: 36721427 PMCID: PMC9851669 DOI: 10.1590/1678-9199-jvatitd-2022-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/01/2022] [Indexed: 01/15/2023] Open
Abstract
Background Bivalent freeze-dried neurotoxic (FN) antivenom has been the primary treatment since the 1980s for Taiwan cobra (Naja atra) envenomation in Taiwan. However, envenomation-related wound necrosis is a significant problem after cobra snakebites. In the present study, we analyzed the changes in serum venom concentration before and after antivenom administration to discover their clinical implications and the surgical treatment options for wound necrosis. Methods The patients were divided into limb swelling and wound necrosis groups. The clinical outcome was that swelling started to subside 12 hours after antivenom treatment in the first group. Serum venom concentrations before and after using antivenoms were measured to assess the antivenom's ability to neutralize the circulating cobra venom. The venom levels in wound wet dressing gauzes, blister fluids, and debrided tissues were also investigated to determine their clinical significance. We also observed the evolutional changes of wound necrosis and chose a better wound debridement timing. Results We prospectively enrolled 15 Taiwan cobra snakebite patients. Males accounted for most of this study population (n = 11, 73%). The wound necrosis group received more antivenom doses than the limb swelling group (4; IQR:2-6 vs 1; IQR:1-2, p = 0.05), and less records of serum venom concentrations changed before/after antivenom use (p = 0.0079). The necrotic wound site may release venom into circulation and cause more severe envenomation symptoms. Antivenom can efficiently diminish limb swelling in cobra bite patients. However, antivenom cannot reduce wound necrosis. Patients with early debridement of wound necrosis had a better limb outcome, while late or without debridement may have long-term hospital stay and distal limb morbidity. Conclusions Antivenom can efficiently eliminate the circulating cobra venom in limb swelling patients without wound necrosis. Early debridement of the bite site wound and wet dressing management are suggestions for preventing extended tissue necrosis and hospital stay.
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Affiliation(s)
- Chia-Cheng Wang
- Department of Traumatology and Emergency Surgery, Chang Gung
Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Hsiang Ou Yang
- Department of Traumatology and Emergency Surgery, Chang Gung
Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Po Hsu
- Department of Traumatology and Emergency Surgery, Chang Gung
Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Chun Liu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan,
Taiwan
| | - Jau-Song Yu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan,
Taiwan.,Department of Cell and Molecular Biology, College of Medicine, Chang
Gung University, Taoyuan, Taiwan.,Liver Research Center, Chang Gung Memorial Hospital, Linkou,
Taiwan.,Research Center for Food and Cosmetic Safety, Research Center for
Chinese Herbal Medicine, College of Human Ecology, Chang Gung University of Science
and Technology, Taoyuan, Taiwan
| | - Chih-Hong Lo
- Department of General Surgery, Chang Gung Memorial Hospital,
Taoyuan, Taiwan
| | - Wen-Chih Fann
- Department of Emergency Medicine, Chiayi Chang Gung Memorial
Hospital, Chiayi, Taiwan
| | - Yen-Chia Chen
- Department of Emergency Medicine, Taipei Veterans General Hospital,
Taipei, Taiwan.,Department of Emergency Medicine, School of Medicine, National
Yang-Ming University, Taipei, Taiwan
| | - Chih Chuan Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Emergency Medicine, Linkou Chang Gung Memorial
Hospital, Taoyuan, Taiwan.,Correspondence:
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15
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Zeng L, Hou J, Ge C, Li Y, Gao J, Zhang C, Huang P, Du J, Mo Z, Liu Y, Zeng Z. Clinical study of anti-snake venom blockade in the treatment of local tissue necrosis caused by Chinese cobra (Naja atra) bites. PLoS Negl Trop Dis 2022; 16:e0010997. [PMID: 36525460 PMCID: PMC9803274 DOI: 10.1371/journal.pntd.0010997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 12/30/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the clinical therapeutic efficacy of anti-snake venom serum blockade in treating local tissue necrosis caused by Chinese cobra (Naja atra) bites. METHODS Patients bitten by a Chinese cobra (Naja atra) (n = 50) that met the inclusion criteria were randomly divided into two groups: the experimental group (n = 25) and the control group (n = 25). The experimental group received regular as well as anti-snake venom serum blocking treatment, whereas regular treatment plus chymotrypsin blocking therapy was given to the control group. The necrotic volumes around snake wounds in these groups were detected on the first, third and seventh days. On the third day of treatment, some local tissues in the wounds were randomly selected for pathological biopsy, and the necrosis volume of the local tissue was observed. Furthermore, the amount of time required for wound healing was recorded. RESULTS On the third and seventh days post-treatment, the necrotic volume of the wound of the experimental group was much smaller than that of the control group, and the experimental group's wound healing time was shorter than that of the control group (all p < 0.05). Moreover, the pathological biopsies taken from the control group showed nuclear pyknosis, fragmentation, sparse nuclear density, and blurred edges, and the degree of necrosis was much higher than that of the experimental group. CONCLUSIONS Anti-snake venom blocking therapy is a new and improved therapy with good clinical effect on local tissue necrosis caused by Chinese cobra bites; moreover, it is superior to conventional chymotrypsin blocking therapy in the treatment of cobra bites. It can better neutralize and prevent the spread of the toxin, reduce tissue necrosis, and shorten the course of the disease by promoting healing of the wound. Furthermore, this treatment plan is also applicable to wound necrosis caused by other snake toxins, such as tissue necrosis caused by elapidae and viper families. CLINICAL TRIAL REGISTRATION This trial is registered in the Chinese Clinical Trial Registry, a primary registry of International Clinical Trial Registry Platform, World Health Organization (Registration No. ChiCTR2200059070; trial URL:http://www.chictr.org.cn/edit.aspx?pid=134353&htm=4).
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Affiliation(s)
- Linsheng Zeng
- Department of Emergency, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Jingjing Hou
- Department of Emergency, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Cuihong Ge
- Guangzhou University of Chinese Medicine, Guangzhou Panyu Central Hospital,Guangzhou,China
| | - Yanjun Li
- Department of Emergency, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Jianhua Gao
- Department of Emergency, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Congcong Zhang
- Department of Emergency, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Peiying Huang
- The Second Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jiayu Du
- Department of Emergency, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Zhizhun Mo
- Department of Emergency, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Yuxiang Liu
- Department of Emergency, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
- * E-mail: (YL); (ZZ)
| | - Zhongyi Zeng
- Department of Emergency, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
- * E-mail: (YL); (ZZ)
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16
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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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17
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Bhaumik S, Gopalakrishnan M, Kirubakaran R, Jagnoor J. Antibiotics for preventing wound infections after snakebite. Hippokratia 2022. [DOI: 10.1002/14651858.cd015114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Soumyadeep Bhaumik
- The George Institute for Global Health, Faculty of Medicine; University of New South Wales; Sydney Australia
- Meta-research and Evidence Synthesis Unit; The George Institute for Global Health; New Delhi India
| | - Maya Gopalakrishnan
- Department of Internal Medicine; All India Institute of Medical Sciences, Jodhpur; Jodhpur India
| | - Richard Kirubakaran
- Cochrane India-CMC Vellore Affiliate, Prof. BV Moses Centre for Evidence Informed Healthcare and Health Policy; Christian Medical College; Vellore India
| | - Jagnoor Jagnoor
- The George Institute for Global Health, Faculty of Medicine; University of New South Wales; Sydney Australia
- Injury Division; The George Institute for Global Health; New Delhi India
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18
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Liu CC, Wu CJ, Chou TY, Liaw GW, Hsiao YC, Chu LJ, Lee CH, Wang PJ, Hsieh CH, Chen CK, Yu JS. Development of a Monoclonal scFv against Cytotoxin to Neutralize Cytolytic Activity Induced by Naja atra Venom on Myoblast C2C12 Cells. Toxins (Basel) 2022; 14:toxins14070459. [PMID: 35878197 PMCID: PMC9320128 DOI: 10.3390/toxins14070459] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 06/30/2022] [Accepted: 06/30/2022] [Indexed: 11/29/2022] Open
Abstract
The Taiwanese cobra, Naja atra, is a clinically significant species of snake observed in the wild in Taiwan. Victims bitten by N. atra usually experience severe pain and local tissue necrosis. Although antivenom is available for treatment of cobra envenomation, its neutralization potency against cobra-induced necrosis is weak, with more than 60% of cobra envenoming patients developing tissue necrosis after antivenom administration. The present study found that cytotoxin (CTX) is a key component of N. atra venom responsible for cytotoxicity against myoblast cells. Anti-CTX IgY was generated in hens, and the spleens of these hens were used to construct libraries for the development of single chain variable fragments (scFv). Two anti-CTX scFv, S1 and 2S7, were selected using phage display technology and biopanning. Both polyclonal IgY and monoclonal scFv S1 reacted specifically with CTX in cobra venom. In a cell model assay, the CTX-induced cytolytic effect was inhibited only by monoclonal scFv S1, not by polyclonal IgY. Moreover, the neutralization potency of scFv S1 was about 3.8 mg/mg, approximately three times higher than that of conventional freeze-dried neurotoxic antivenom (FNAV). Collectively, these results suggest that scFv S1 can effectively neutralize CTX-induced cytotoxicity and, when combined with currently available antivenom, can improve the potency of the latter, thereby preventing tissue damage induced by cobra envenoming.
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Affiliation(s)
- Chien-Chun Liu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan; (C.-C.L.); (Y.-C.H.); (L.-J.C.); (P.-J.W.)
| | - Cho-Ju Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan;
| | - Tsai-Ying Chou
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan;
| | - Geng-Wang Liaw
- Department of Emergency Medicine, Yeezen General Hospital, Taoyuan 32645, Taiwan;
| | - Yung-Chin Hsiao
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan; (C.-C.L.); (Y.-C.H.); (L.-J.C.); (P.-J.W.)
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan;
- Liver Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan
| | - Lichieh-Julie Chu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan; (C.-C.L.); (Y.-C.H.); (L.-J.C.); (P.-J.W.)
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan;
- Liver Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan
| | - Chi-Hsin Lee
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 11042, Taiwan;
- Ph.D. Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 11042, Taiwan
| | - Po-Jung Wang
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan; (C.-C.L.); (Y.-C.H.); (L.-J.C.); (P.-J.W.)
| | - Cheng-Hsien Hsieh
- Department of Emergency Medicine, En Chu Kong Hospital, New Taipei City 23741, Taiwan;
| | - Chun-Kuei Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan;
- Correspondence: (C.-K.C.); (J.-S.Y.); Tel.: +88-63-2118800 (ext. 5171) (J.-S.Y.); Fax: +88-63-2118891 (J.-S.Y.)
| | - Jau-Song Yu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan; (C.-C.L.); (Y.-C.H.); (L.-J.C.); (P.-J.W.)
- Liver Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan
- Research Center for Food and Cosmetic Safety, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan 33302, Taiwan
- Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- Correspondence: (C.-K.C.); (J.-S.Y.); Tel.: +88-63-2118800 (ext. 5171) (J.-S.Y.); Fax: +88-63-2118891 (J.-S.Y.)
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Esmaeilishirazifard E, Usher L, Trim C, Denise H, Sangal V, Tyson GH, Barlow A, Redway KF, Taylor JD, Kremyda-Vlachou M, Davies S, Loftus TD, Lock MMG, Wright K, Dalby A, Snyder LAS, Wuster W, Trim S, Moschos SA. Bacterial Adaptation to Venom in Snakes and Arachnida. Microbiol Spectr 2022; 10:e0240821. [PMID: 35604233 PMCID: PMC9248900 DOI: 10.1128/spectrum.02408-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/14/2022] [Indexed: 11/20/2022] Open
Abstract
Animal venoms are considered sterile sources of antimicrobial compounds with strong membrane-disrupting activity against multidrug-resistant bacteria. However, venomous bite wound infections are common in developing nations. Investigating the envenomation organ and venom microbiota of five snake and two spider species, we observed venom community structures that depend on the host venomous animal species and evidenced recovery of viable microorganisms from black-necked spitting cobra (Naja nigricollis) and Indian ornamental tarantula (Poecilotheria regalis) venoms. Among the bacterial isolates recovered from N. nigricollis, we identified two venom-resistant, novel sequence types of Enterococcus faecalis whose genomes feature 16 virulence genes, indicating infectious potential, and 45 additional genes, nearly half of which improve bacterial membrane integrity. Our findings challenge the dogma of venom sterility and indicate an increased primary infection risk in the clinical management of venomous animal bite wounds. IMPORTANCE Notwithstanding their 3 to 5% mortality, the 2.7 million envenomation-related injuries occurring annually-predominantly across Africa, Asia, and Latin America-are also major causes of morbidity. Venom toxin-damaged tissue will develop infections in some 75% of envenomation victims, with E. faecalis being a common culprit of disease; however, such infections are generally considered to be independent of envenomation. Here, we provide evidence on venom microbiota across snakes and arachnida and report on the convergent evolution mechanisms that can facilitate adaptation to black-necked cobra venom in two independent E. faecalis strains, easily misidentified by biochemical diagnostics. Therefore, since inoculation with viable and virulence gene-harboring bacteria can occur during envenomation, acute infection risk management following envenomation is warranted, particularly for immunocompromised and malnourished victims in resource-limited settings. These results shed light on how bacteria evolve for survival in one of the most extreme environments on Earth and how venomous bites must be also treated for infections.
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Affiliation(s)
- Elham Esmaeilishirazifard
- Department of Biomedical Sciences, Faculty of Science and Technology, University of Westminster, London, United Kingdom
- Westminster Genomic Services, Faculty of Science and Technology, University of Westminster, London, United Kingdom
| | - Louise Usher
- Department of Biomedical Sciences, Faculty of Science and Technology, University of Westminster, London, United Kingdom
- Westminster Genomic Services, Faculty of Science and Technology, University of Westminster, London, United Kingdom
| | - Carol Trim
- School of Psychology and Life Sciences, Faculty of Science, Engineering and Social Sciences, Canterbury Christ Church University, Canterbury, Kent, United Kingdom
| | - Hubert Denise
- EMBL-EBI European Bioinformatics Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, United Kingdom
| | - Vartul Sangal
- Department of Applied Sciences, Faculty of Health and Life Sciences, Northumbria University, Newcastle, Tyne and Wear, United Kingdom
| | - Gregory H. Tyson
- Food and Drug Administration, Center for Veterinary Medicine, Office of Research, Laurel, Maryland, USA
| | - Axel Barlow
- Institute for Biochemistry and Biology, University of Potsdam, Potsdam, Germany
| | - Keith F. Redway
- Department of Biomedical Sciences, Faculty of Science and Technology, University of Westminster, London, United Kingdom
| | - John D. Taylor
- Department of Biomedical Sciences, Faculty of Science and Technology, University of Westminster, London, United Kingdom
- Westminster Genomic Services, Faculty of Science and Technology, University of Westminster, London, United Kingdom
- School of Environment and Life Sciences, University of Salford, Salford, Greater Manchester, United Kingdom
| | - Myrto Kremyda-Vlachou
- Department of Biomedical Sciences, Faculty of Science and Technology, University of Westminster, London, United Kingdom
| | - Sam Davies
- Department of Applied Sciences, Faculty of Health and Life Sciences, Northumbria University, Newcastle, Tyne and Wear, United Kingdom
| | | | | | - Kstir Wright
- Department of Biomedical Sciences, Faculty of Science and Technology, University of Westminster, London, United Kingdom
| | - Andrew Dalby
- Department of Biomedical Sciences, Faculty of Science and Technology, University of Westminster, London, United Kingdom
| | - Lori A. S. Snyder
- School of Life Sciences, Pharmacy, and Chemistry, Kingston University, London, United Kingdom
| | - Wolfgang Wuster
- Molecular Ecology and Evolution at Bangor, School of Biological Sciences, College of Natural Sciences, Bangor University, Bangor, Wales, United Kingdom
| | - Steve Trim
- Venomtech, Ltd., Sandwich, Kent, United Kingdom
| | - Sterghios A. Moschos
- Department of Biomedical Sciences, Faculty of Science and Technology, University of Westminster, London, United Kingdom
- Westminster Genomic Services, Faculty of Science and Technology, University of Westminster, London, United Kingdom
- Department of Applied Sciences, Faculty of Health and Life Sciences, Northumbria University, Newcastle, Tyne and Wear, United Kingdom
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20
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Chuang PC, Lin WH, Chen YC, Chien CC, Chiu IM, Tsai TS. Oral Bacteria and Their Antibiotic Susceptibilities in Taiwanese Venomous Snakes. Microorganisms 2022; 10:microorganisms10050951. [PMID: 35630396 PMCID: PMC9147925 DOI: 10.3390/microorganisms10050951] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/15/2022] [Accepted: 04/28/2022] [Indexed: 12/07/2022] Open
Abstract
Wound infections after venomous snakebites are clinically important. Information regarding the nature and antibiotic susceptibilities of snake oral bacterial flora could support empiric antibiotic therapy. Wild venomous snakes were collected from southern Taiwan: a total of 30 each of Bungarus multicinctus, Naja atra, Protobothrops mucrosquamatus, and Trimeresurus stejnegeri; 3 Deinagkistrodon acutus; and 4 Daboia siamensis. The species and antibiotic susceptibilities of their oral bacteria were determined. Aerobic gram-negative bacteria, especially Pseudomonas aeruginosa and Proteus vulgaris, were the most abundant. Proteus vulgaris were more abundant in B. multicinctus, N. atra, and P. mucrosquamatus than in T. stejnegeri (40%, 43.3%, and 40% vs. 13.3%, respectively). The gram-negative species were less susceptible to first- and second-generation cephalosporins and ampicillin-sulbactam than to third-generation cephalosporins, fluoroquinolones, carbapenems, or piperacillin-tazobactam. The most abundant aerobic gram-positive species cultured was Enterococcus faecalis, which was more abundant in N. atra than in other snakes (p < 0.001) and was highly susceptible to ampicillin, high-level gentamicin, penicillin, teicoplanin, and vancomycin. Bacteroides fragilis and Clostridium species were the most common anaerobic bacteria. The anaerobic organisms were highly susceptible to metronidazole and piperacillin. As a reference for empiric antimicrobial therapy, third-generation cephalosporins, fluoroquinolones, carbapenems, or piperacillin-tazobactam can be initiated in venomous snakebites wound infections.
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Affiliation(s)
- Po-Chun Chuang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan; (P.-C.C.); (I.-M.C.)
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
| | - Wen-Hao Lin
- Institute of Wildlife Conservation, National Pingtung University of Science and Technology, Pingtung 912301, Taiwan;
| | - Yi-Chun Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan;
| | - Chun-Chih Chien
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan;
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan; (P.-C.C.); (I.-M.C.)
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
| | - Tein-Shun Tsai
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, Pingtung 912301, Taiwan
- Correspondence: or
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21
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Lai CS, Liu PY, Lee CH, Ho CH, Chen WL, Lai KL, Su HY, Lin WL, Chung KC, Yang YY, You CW, Chen KT, Mao YC. The development of surgical risk score and evaluation of necrotizing soft tissue infection in 161 Naja atra envenomed patients. PLoS Negl Trop Dis 2022; 16:e0010066. [PMID: 35143522 PMCID: PMC8830662 DOI: 10.1371/journal.pntd.0010066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 12/06/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Naja atra bites cause wound necrosis, secondary infection, and necrotizing soft tissue infection (NSTI) requiring repetitive surgeries. Little information is known about the predictors for surgery after these bites. MATERIALS AND METHODS We retrospectively evaluated 161 patients envenomed by N. atra, 80 of whom underwent surgery because of wound necrosis and infection. We compared the patients' variables between surgical and non-surgical groups. To construct a surgical risk score, we converted the regression coefficients of the significant factors in the multivariate logistic regression into integers. We also examined the deep tissue cultures and pathological findings of the debrided tissue. RESULTS A lower limb as the bite site, a ≥3 swelling grade, bullae or blister formation, gastrointestinal (GI) effects, and fever were significantly associated with surgery in the multivariate logistic regression analysis. The surgical risk scores for these variables were 1, 1, 2, 1, and 2, respectively. At a ≥3-point cutoff value, the model has 71.8% sensitivity and 88.5% specificity for predicting surgery, with an area under the receiver operating characteristic curve of 0.88. The histopathological examinations of the debrided tissues supported the diagnosis of snakebite-induced NSTI. Twelve bacterial species were isolated during the initial surgery and eleven during subsequent surgeries. DISCUSSION AND CONCLUSIONS From the clinical perspective, swelling, bullae or blister formation, GI effects, and fever appeared quickly after the bite and before surgery. The predictive value of these factors for surgery was acceptable, with a ≥3-point risk score. The common laboratory parameters did not always predict the outcomes of N. atra bites without proper wound examination. Our study supported the diagnosis of NSTI and demonstrated the changes in bacteriology during the surgeries, which can have therapeutic implications for N. atra bites.
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Affiliation(s)
- Chih-Sheng Lai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Po-Yu Liu
- Division of Infection, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University
| | - Chi-Hsin Lee
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- PhD Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- Core Laboratory of Antibody Generation and Research, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Hsuan Ho
- Department of Emergency Medicine, Tri-Service General Hospital, Taipei, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Ling Chen
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Psychiatry Department, Chiayi Branch, Taichung Veterans General Hospital, Chiayi, Taiwan
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kuo-Lung Lai
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hung-Yuan Su
- Department of Emergency Medicine, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan
- The School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung, Taiwan
| | - Wen-Loung Lin
- Taichung Wildlife Conservation Group, Taichung, Taiwan
| | - Kuo-Chen Chung
- Division of Traumatology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Yuan Yang
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- PhD Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- Core Laboratory of Antibody Generation and Research, Taipei Medical University, Taipei, Taiwan
| | | | | | - Yan-Chiao Mao
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- * E-mail:
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22
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Characteristics of Snakebite-Related Infection in French Guiana. Toxins (Basel) 2022; 14:toxins14020089. [PMID: 35202117 PMCID: PMC8878173 DOI: 10.3390/toxins14020089] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 02/06/2023] Open
Abstract
Wound infection is frequently reported following snakebite (SB). This study is retrospective. It was conducted in the emergency department and the Intensive Care Unit (ICU) of Cayenne General Hospital between 1 January 2016 and 31 July 2021. We included 172 consecutive patients hospitalized for SB envenoming. All patients were monitored for wound infection. Sixty-three patients received antibiotics at admission (36.6%). The main antibiotic used was amoxicillin–clavulanate (92.1%). Wound infection was recorded in 55 cases (32%). It was 19% in grade 1, 35% in grade 2, and 53% in grade 3. It included abscess (69.1%), necrotizing fasciitis (16.4%), and cellulitis (21.8%). The time from SB to wound infection was 6 days (IQR: 3–8). The main isolated microorganisms were A. hydrophila and M. morganii (37.5% and 18.8% of isolated organisms). Surgery was required in 48 patients (28.1%), and a necrosectomy was performed on 16 of them (33.3%). The independent factors associated with snakebite-associated infection were necrosis (p < 0.001, OR 13.15, 95% CI: 4.04–42.84), thrombocytopenia (p = 0.002, OR: 3.37, 95% CI: 1.59–7.16), and rhabdomyolysis (p = 0.046, OR: 2.29, 95% CI: 1.02–5.19). In conclusion, wound infection following SB is frequent, mainly in grade 2 and 3 envenomed patients, especially those with necrosis, thrombocytopenia, and rhabdomyolysis. The main involved bacteria are A. hydrophila and M. morganii.
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23
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Personal Experience of Daboia siamensis Envenomation. Case Rep Med 2022; 2021:3396373. [PMID: 34976069 PMCID: PMC8719983 DOI: 10.1155/2021/3396373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/08/2021] [Indexed: 11/24/2022] Open
Abstract
Reports of envenomation induced by Daboia siamensis, a medically important venomous snake in Taiwan, are rare, and species identification might not be definitive. This article reports the complete course of a definite D. siamensis bite. The patient in this report was one of the authors who was bitten on the right palm near the base of the index finger by D. siamensis. The patient experienced local effects, neurological manifestations, and acute kidney injury. The laboratory analysis revealed elevated D-dimer and coagulopathy. The patient was administered 8 vials of antivenom and did not undergo surgical intervention or endotracheal tube intubation, but serum sickness occurred 8 days after antivenom administration. The horse immunoglobulin produced by the Centers for Disease Control, R. O. C. (Taiwan), against D. siamensis was effective and safe in the treatment of the patient. However, the best antivenom administration strategy remains unclear and requires further study.
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24
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Mendes VKDG, Pereira HDS, Elias IC, Soares GS, Santos M, Talhari C, Cordeiro-Santos M, Monteiro WM, Sachett JDAG. Secondary infection profile after snakebite treated at a tertiary referral center in the Brazilian Amazon. Rev Soc Bras Med Trop 2022; 55:e0244. [PMID: 35239899 PMCID: PMC8909433 DOI: 10.1590/0037-8682-0244-2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 11/24/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | | | - Gean Souza Soares
- Universidade do Estado do Amazonas, Brasil; Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Brasil
| | - Monica Santos
- Universidade do Estado do Amazonas, Brasil; Fundação Alfredo da Matta, Brasil; Universidade do Estado do Amazonas, Brasil
| | - Carolina Talhari
- Universidade do Estado do Amazonas, Brasil; Fundação Alfredo da Matta, Brasil; Universidade do Estado do Amazonas, Brasil
| | - Marcelo Cordeiro-Santos
- Universidade do Estado do Amazonas, Brasil; Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Brasil
| | - Wuelton Marcelo Monteiro
- Universidade do Estado do Amazonas, Brasil; Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Brasil
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25
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Ho CH, Chiang LC, Mao YC, Lan KC, Tsai SH, Shih YJ, Tzeng YS, Lin CS, Lin WL, Fang WH, Chen KT, Lee CH, Chiang DML, Liu SH. Analysis of the Necrosis-Inducing Components of the Venom of Naja atra and Assessment of the Neutralization Ability of Freeze-Dried Antivenom. Toxins (Basel) 2021; 13:toxins13090619. [PMID: 34564623 PMCID: PMC8473173 DOI: 10.3390/toxins13090619] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/28/2021] [Accepted: 08/31/2021] [Indexed: 11/16/2022] Open
Abstract
Patients bitten by Naja atra who are treated with bivalent freeze-dried neurotoxic antivenom in Taiwan have an improved survival rate but develop necrotic wound changes. The World Health Organization (WHO) has suggested using the minimum necrotizing dose (MND) of venom as a method of evaluating the neutralization effect of antivenom. The aim of this study was to evaluate the effectiveness of antivenom for the prevention of necrosis based on the MND and clarify which component of the venom of N. atra induces necrosis. The neurotoxins (NTXs) were removed from the crude venom (deNTXs), and different concentrations of deNTXs were injected intradermally into the dorsal skin of mice. After three days, the necrotic lesion diameter was found to be approximately 5 mm, and the MND was calculated. A reduction in the necrotic diameter of 50% was used to identify the MND50. Furthermore, both phospholipase A2 (PLA2) and cytotoxins (CTXs) were separately removed from the deNTXs to identify the major necrosis-inducing factor, and the necrotic lesions were scored. All mice injected with deNTXs survived for three days and developed necrotic wounds. The MND of the deNTXs for mice was 0.494 ± 0.029 µg/g, that of the deNTXs-dePLA2 (major component retained: CTXs) was 0.294 ± 0.05 µg/g, and that of the deNTX-deCTX (major component retained: PLA2) venom was greater than 1.25 µg/g. These values show that CTX is the major factor inducing necrosis. These results suggest that the use of the deNTXs is necessary to enable the mice to survive long enough to develop venom-induced cytolytic effects. CTXs play a major role in N. atra-related necrosis. However, the MND50 could not be identified in this study, which meant that the antivenom did not neutralize venom-induced necrosis.
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Affiliation(s)
- Cheng-Hsuan Ho
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan; (C.-H.H.); (K.-C.L.); (S.-H.T.)
- Institute of Toxicology, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Liao-Chun Chiang
- College of Life Sciences, National Tsing Hua University, Hsinchu 300, Taiwan;
- Institute of Biology and Anatomy, National Defense Medical Center, Taipei 114, Taiwan
| | - Yan-Chiao Mao
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 407, Taiwan;
| | - Kuo-Cheng Lan
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan; (C.-H.H.); (K.-C.L.); (S.-H.T.)
| | - Shih-Hung Tsai
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan; (C.-H.H.); (K.-C.L.); (S.-H.T.)
| | - Yu-Jen Shih
- Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan; (Y.-J.S.); (Y.-S.T.)
| | - Yuan-Sheng Tzeng
- Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan; (Y.-J.S.); (Y.-S.T.)
| | - Chin-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
| | - Wen-Loung Lin
- Taichung Wildlife Conservation Group, Taichung 436, Taiwan; (W.-L.L.); (W.-H.F.)
| | - Wei-Hsuan Fang
- Taichung Wildlife Conservation Group, Taichung 436, Taiwan; (W.-L.L.); (W.-H.F.)
| | - Kuang-Ting Chen
- Department of Chinese Medicine, Chang Bing Show Chwan Memorial Hospital, Changhua 505, Taiwan;
| | - Chi-Hsin Lee
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan;
| | - Dapi Meng-Lin Chiang
- Division of Animal Physiology and Immunology, TUM School of Life Sciences Weihenstephan, Technical University Munich, 85354 Freising, Germany;
| | - Shing-Hwa Liu
- Institute of Toxicology, College of Medicine, National Taiwan University, Taipei 100, Taiwan
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung 404, Taiwan
- Department of Pediatrics, College of Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
- Correspondence: ; Tel.: +886-2-23123456 (ext. 88605)
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26
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Nascimento LS, Nogueira-Souza PD, Rocha-Junior JRS, Monteiro-Machado M, Strauch MA, Prado SAL, Melo PA, Veiga-Junior VF. Phytochemical composition, antisnake venom and antibacterial activities of ethanolic extract of Aegiphila integrifolia (Jacq) Moldenke leaves. Toxicon 2021; 198:121-131. [PMID: 33984369 DOI: 10.1016/j.toxicon.2021.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/30/2021] [Accepted: 05/05/2021] [Indexed: 10/21/2022]
Abstract
Snakebites are considered a major neglected tropical disease, resulting in around 100,000 deaths per year. The recommended treatment by the WHO is serotherapy, which has limited effectiveness against the toxins involved in local tissue damage. In some countries, patients use plants from folk medicines as antivenoms. Aegiphila species are common plants from the Brazilian Amazon and are used to treat snakebites. In this study, leaves from Aegiphila integrifolia (Jacq) Moldenke were collected from Roraima state, Brazil and its ethanolic extract was evaluated through in vitro and in vivo experiments to verify their antiophidic activity against Bothrops atrox crude venom. The isolated compounds from A. integrifolia were analyzed and the chemical structures were elucidated on the basis of infrared, ultraviolet, mass, 1H and 1³C NMR spectrometry data. Among the described compounds, lupeol (7), betulinic acid (1), β-sitosterol (6), stigmasterol (5), mannitol (4), and the flavonoids, pectolinarigenin (2) and hispidulin (3), were identified. The ethanolic extract and flavonoids (2 and 3) partially inhibited the proteolytic, phospholipase A2 and hyaluronidase activities of B. atrox venom, and the skin hemorrhage induced by this venom in mice. Antimicrobial activity against different bacteria was evaluated and the extract partially inhibited bacterial growth. Thus, taken together, A. integrifolia ethanolic extract has promising use as an antiophidic and antimicrobial.
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Affiliation(s)
- Leandro S Nascimento
- Chemical Engineering Section, Military Institute of Engineering, Rio de Janeiro, RJ, Brazil
| | - Pâmella D Nogueira-Souza
- Federal University of Rio de Janeiro, Pharmacology and Medicinal Chemistry Program, Rio de Janeiro, RJ, Brazil
| | - José R S Rocha-Junior
- Federal University of Rio de Janeiro, Pharmacology and Medicinal Chemistry Program, Rio de Janeiro, RJ, Brazil
| | - Marcos Monteiro-Machado
- Federal University of Rio de Janeiro, Pharmacology and Medicinal Chemistry Program, Rio de Janeiro, RJ, Brazil
| | | | - Simone A L Prado
- Federal University of Roraima, Department of Chemistry, Boa Vista, RR, Brazil
| | - Paulo A Melo
- Federal University of Rio de Janeiro, Pharmacology and Medicinal Chemistry Program, Rio de Janeiro, RJ, Brazil
| | - Valdir F Veiga-Junior
- Chemical Engineering Section, Military Institute of Engineering, Rio de Janeiro, RJ, Brazil.
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27
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Kriengkrairut S, Othong R. Bacterial infection secondary to Trimeresurus species bites: A retrospective cohort study in a university hospital in Bangkok. Emerg Med Australas 2021; 33:1006-1012. [PMID: 33942528 DOI: 10.1111/1742-6723.13788] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Trimeresurus spp. (green pit viper [GPV]) inhabit several Southeast Asian countries. They account for more than 90% of snake envenomations in Bangkok. GPV venom causes coagulopathy from a thrombin-like effect and thrombocytopaenia. Envenomation can also cause local tissue reactions. The present study primarily aimed to determine the bacterial infection rate from GPV (Trimeresurus spp.) bites. Antibiotic use, microbiology report, and clinical course between those with and without infection were secondary objectives. METHODS The present study took place at Vajira Hospital, Navamindradhiraj University. Medical records of patients more than 15 years old, bitten by GPV from our Toxicology Registry between 2015 and 2019, were reviewed by two chart extractors. Vital signs, pain scores, local reactions, time from bite to diagnosis of infection, use of antibiotics, bacterial culture samplings and complications were recorded. The infection rate was reported in percentages. Univariate analysis was utilised to determine risk factors for infection. RESULTS The study included 123 patients over a 5-year period. The majority were male, 83 cases (67.5%). Overall, bacterial infection occurred in eight cases (6.5%). The median time from bite to infection diagnosis was 41.5 h (interquartile range 25.5-68.5). The antibiotic prescription rate was 12.2%. Haemorrhagic bleb was the only risk factor for infection (OR 22.4, 95% confidence interval 3.6-140.2). All bacterial culture samplings were negative. The non-infection group had a decreasing pain score throughout each follow-up visit. CONCLUSIONS We found a low infection rate from GPV bites even without antibiotics suggesting prophylactic antibiotics should not be routinely prescribed in cases of GPV bite.
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Affiliation(s)
- Suppanut Kriengkrairut
- Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Rittirak Othong
- Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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28
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Snake Bite Management: A Scoping Review of the Literature. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3506. [PMID: 33936914 PMCID: PMC8084039 DOI: 10.1097/gox.0000000000003506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/21/2021] [Indexed: 01/20/2023]
Abstract
Background: Around the world, snake bite envenomation remains an underreported human health hazard. Envenomation can cause local and systemic complications, especially when there is a lack of antivenom availability. Although there are established guidelines regarding snake bite management acute care, there is a paucity of data regarding surgical intervention and the plastic surgeon’s role treating this unique patient population. Methods: A review was conducted identifying relevant published articles involving snake bite management and treatment in PubMed and EMBASE. Results: One hundred ten articles were identified and 77 met inclusion criteria. Snake bite envenomation can result in complications that are dependent upon a variety of variables. The literature has shown the best field treatment to be timely transportation to the nearest medical facility, along with antivenom administration. The cytotoxic, hemotoxic, and neurotoxic effects of venom can cause a variety of local soft tissue and systemic complications. Surgical interventions such as fasciotomies, wound debridements, skin grafts, and tissue flaps may be necessary in these patients to optimize functional and aesthetic outcomes. Disparities in access to care in resource limited settings are discussed. Conclusions: Global health disparities and insufficient antivenom distribution create an inequality of care in snake bite patients. Plastic surgeons have an important role in managing acute and chronic complications of snake bite envenomations that can lead to improved patient outcomes.
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Mao YC, Chuang HN, Shih CH, Hsieh HH, Jiang YH, Chiang LC, Lin WL, Hsiao TH, Liu PY. An investigation of conventional microbial culture for the Naja atra bite wound, and the comparison between culture-based 16S Sanger sequencing and 16S metagenomics of the snake oropharyngeal bacterial microbiota. PLoS Negl Trop Dis 2021; 15:e0009331. [PMID: 33857127 PMCID: PMC8078740 DOI: 10.1371/journal.pntd.0009331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 04/27/2021] [Accepted: 03/25/2021] [Indexed: 01/11/2023] Open
Abstract
Naja atra is a major venomous snake found in Taiwan. The bite of this snake causes extensive wound necrosis or necrotizing soft tissue infection. Conventional microbial culture-based techniques may fail to identify potential human pathogens and render antibiotics ineffective in the management of wound infection. Therefore, we evaluated 16S Sanger sequencing and next-generation sequencing (NGS) to identify bacterial species in the oropharynx of N. atra. Using conventional microbial culture methods and the VITEK 2 system, we isolated nine species from snakebite wounds. On the basis of the 16S Sanger sequencing of bacterial clones from agar plates, we identified 18 bacterial species in the oropharynx of N. atra, including Morganella morganii, Proteus vulgaris, and Proteus mirabilis, which were also present in the infected bite wound. Using NGS of 16S metagenomics, we uncovered more than 286 bacterial species in the oropharynx of N. atra. In addition, the bacterial species identified using 16S Sanger sequencing accounted for only 2% of those identified through NGS of 16S metagenomics. The bacterial microbiota of the oropharynx of N. atra were modeled better using NGS of 16S metagenomics compared to microbial culture-based techniques. Stenotrophomonas maltophilia, Acinetobacter baumannii, and Proteus penneri were also identified in the NGS of 16S metagenomics. Understanding the bacterial microbiota that are native to the oropharynx of N. atra, in addition to the bite wound, may have additional therapeutic implications regarding empiric antibiotic selection for managing N. atra bites. Naja atra bites induce extensive wound necrotizing soft tissue infections in a substantial proportion of patients. Empiric antibiotic administration in snakebite patients is a common practice, but clinical reports indicate that this treatment was ineffective in preventing secondary infection given that the microbiota of the infected wound and oropharynx of the culprit snake were not properly established. In this study, only 9 species were detected in cobra bites using a conventional microbial culture method and the VITEK 2 system, whereas 18 species were detected in the cobra oropharynx using microbial culture-based 16S Sanger sequencing. Among these, Morganella morganii, Proteus vulgaris, and Proteus mirabilis were identified as common bacteria. Compared to microbial culture-based 16S Sanger sequencing, NGS-based 16S metagenomic sequencing detected more than 286 bacterial species. Stenotrophomonas maltophilia, Acinetobacter baumannii, and Proteus penneri only appeared with 16S metagenomic sequencing. These results suggest that NGS-based 16S metagenomic sequencing is a better tool for uncovering the bacterial microbiota of the N. atra oropharynx, which may help in developing a proper therapeutic strategy for patients with N. atra bites.
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Affiliation(s)
- Yan-Chiao Mao
- Department of Emergency Medicine, Division of Clinical Toxicology, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Medicine, Division of Clinical Toxicology and Occupational Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Han-Ni Chuang
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Precision Medicine Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chien-Hung Shih
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Precision Medicine Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Han-Hsueh Hsieh
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Precision Medicine Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Han Jiang
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Liao-Chun Chiang
- Department of Emergency Medicine, Division of Clinical Toxicology, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Medicine, Division of Clinical Toxicology and Occupational Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- National Tsing Hua University, College of Life Sciences, Hsinchu, Taiwan
| | - Wen-Loung Lin
- Taichung Wildlife Conservation Group, Taichung, Taiwan
| | - Tzu-Hung Hsiao
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Precision Medicine Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Public Health, Fu Jen Catholic University, New Taipei City, Taiwan
- Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung, Taiwan
- * E-mail: (T-HH); (P-YL)
| | - Po-Yu Liu
- Department of Internal Medicine, Division of Infectious Diseases, Taichung Veterans General Hospital, Taichung, Taiwan
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- * E-mail: (T-HH); (P-YL)
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Huang WH, Kao CC, Mao YC, Lai CS, Lai KL, Lai CH, Tseng CH, Huang YT, Liu PY. Shewanella algae and Morganella morganii Coinfection in Cobra-Bite Wounds: A Genomic Analysis. Life (Basel) 2021; 11:life11040329. [PMID: 33920102 PMCID: PMC8069671 DOI: 10.3390/life11040329] [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: 02/24/2021] [Revised: 03/28/2021] [Accepted: 04/07/2021] [Indexed: 11/16/2022] Open
Abstract
Naja atra bites cause severe soft tissue injury and are prone to wound infections. The pathogens of Naja atra bite-wound infections are highly variable in different geographical regions. Here, we report the first coinfection with Shewanella algae and Morganella morganii from a Naja atra bite wound with resistome analysis using whole genome sequencing.
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Affiliation(s)
- Wei-Hsuan Huang
- Division of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (W.-H.H.); (C.-H.T.)
| | - Chin-Chuan Kao
- Division of Infectious Disease, Department of Internal Medicine, Tungs’ Taichung Metroharbor Hospital, Taichung 43503, Taiwan;
| | - Yan-Chiao Mao
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
- School of Medicine, National Defense Medical Center, Taipei 11490, Taiwan
| | - Chih-Sheng Lai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
| | - Kuo-Lung Lai
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
| | - Chung-Hsu Lai
- Division of Infectious Diseases, Department of Internal Medicine, E-Da Hospital, Kaohsiung 840, Taiwan;
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung 804, Taiwan
| | - Chien-Hao Tseng
- Division of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (W.-H.H.); (C.-H.T.)
| | - Yao-Ting Huang
- Department of Computer Science and Information Engineering, National Chung Cheng University, Chia-Yi 62102, Taiwan
- Correspondence: (Y.-T.H.); (P.-Y.L.)
| | - Po-Yu Liu
- Division of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (W.-H.H.); (C.-H.T.)
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
- Correspondence: (Y.-T.H.); (P.-Y.L.)
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Yeh H, Gao SY, Lin CC. Wound Infections from Taiwan Cobra ( Naja atra) Bites: Determining Bacteriology, Antibiotic Susceptibility, and the Use of Antibiotics-A Cobra BITE Study. Toxins (Basel) 2021; 13:toxins13030183. [PMID: 33801318 PMCID: PMC7999477 DOI: 10.3390/toxins13030183] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/17/2021] [Accepted: 02/25/2021] [Indexed: 02/04/2023] Open
Abstract
Wound necrosis and secondary infection are common complications after Naja atra bites. Clinical tools to evaluate the infection risk after Taiwan cobra bites are lacking. In this Cobra BITE study, we investigated the prevalence of wound infection, bacteriology, and corresponding antibiotic usage in patients presenting with Taiwan cobra snakebites. Patients with wound infection lacking tissue necrosis were included in developing Cobra BITE score utilizing univariate and multiple logistic regression, as patients with wound necrosis require antibiotics for infection treatment. 8,295,497 emergency department visits occurred in the span of this study, with 195 of those patients being diagnosed as having cobra bites. Of these patients, 23 had wound necrosis, and 30 had wound infection, resulting in a wound infection rate of 27.2% (53/195). Enterococcus faecalis and Morganella morganii were the main bacteria identified in the culture report regardless of whether patients’ wounds had necrosis. As per our Cobra BITE score, the three factors predicting secondary wound infection after cobra bites are hospital admission, a white blood cell count (in 103/µL) × by neu-trophil-lymphocyte ratio value of ≥114.23, and the use of antivenin medication. The area under the receiver operating characteristic curve for the Cobra BITE score system was 0.88; ideal sensitivity and specificity were 0.89 and 0.76. This scoring system enables the assessment of wound infections after N. atra bites, and it could be modified and improved in the future for other Naja spp. bites.
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Affiliation(s)
- Heng Yeh
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (H.Y.); (S.-Y.G.)
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Shi-Ying Gao
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (H.Y.); (S.-Y.G.)
| | - Chih-Chuan Lin
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (H.Y.); (S.-Y.G.)
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Correspondence:
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Liang Q, Huynh TM, Konstantakopoulos N, Isbister GK, Hodgson WC. An Examination of the Neutralization of In Vitro Toxicity of Chinese Cobra ( Naja atra) Venom by Different Antivenoms. Biomedicines 2020; 8:biomedicines8100377. [PMID: 32992934 PMCID: PMC7599741 DOI: 10.3390/biomedicines8100377] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 01/23/2023] Open
Abstract
The Chinese Cobra (Naja atra) is an elapid snake of major medical importance in southern China. We describe the in vitro neurotoxic, myotoxic, and cytotoxic effects of N. atra venom, as well as examining the efficacy of three Chinese monovalent antivenoms (N. atra antivenom, Gloydius brevicaudus antivenom and Deinagkistrodon acutus antivenom) and an Australian polyvalent snake antivenom. In the chick biventer cervicis nerve-muscle preparation, N. atra venom (1–10 µg/mL) abolished indirect twitches in a concentration-dependent manner, as well as abolishing contractile responses to exogenous acetylcholine chloride (ACh) and carbamylcholine chloride (CCh), indicative of post-synaptic neurotoxicity. Contractile responses to potassium chloride (KCl) were also significantly inhibited by venom indicating myotoxicity. The prior addition of Chinese N. atra antivenom (0.75 U/mL) or Australian polyvalent snake antivenom (3 U/mL), markedly attenuated the neurotoxic actions of venom (3 µg/mL) and prevented the inhibition of contractile responses to ACh, CCh, and KCl. The addition of Chinese antivenom (0.75 U/mL) or Australian polyvalent antivenom (3 U/mL) at the t90 time point after the addition of venom (3 µg/mL), partially reversed the inhibition of twitches and significantly reversed the venom-induced inhibition of responses to ACh and CCh, but had no significant effect on the response to KCl. Venom (30 µg/mL) also abolished direct twitches in the chick biventer cervicis nerve-muscle preparation and caused a significant increase in baseline tension, further indicative of myotoxicity. N. atra antivenom (4 U/mL) prevented the myotoxic effects of venom (30 µg/mL). However, G. brevicaudus antivenom (24 U/mL), D. acutus antivenom (8 U/mL) and Australian polyvalent snake antivenom (33 U/mL) were unable to prevent venom (30 µg/mL) induced myotoxicity. In the L6 rat skeletal muscle myoblast cell line, N. atra venom caused concentration-dependent inhibition of cell viability, with a half maximal inhibitory concentration (IC50) of 2.8 ± 0.48 μg/mL. N. atra antivenom significantly attenuated the cytotoxic effect of the venom, whereas Australian polyvalent snake antivenom was less effective but still attenuated the cytotoxic effects at lower venom concentrations. Neither G. brevicaudus antivenom or D. acutus antivenom were able to prevent the cytotoxicity. This study indicates that Chinese N. atra monovalent antivenom is efficacious against the neurotoxic, myotoxic and cytotoxic effects of N. atra venom but the clinical effectiveness of the antivenom is likely to be diminished, even if given early after envenoming. The use of Chinese viper antivenoms (i.e., G. brevicaudus and D. acutus antivenoms) in cases of envenoming by the Chinese cobra is not supported by the results of the current study.
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Affiliation(s)
- Qing Liang
- Monash Venom Group, Department of Pharmacology, Biomedical Discovery Institute, Monash University, Clayton 3800, Australia; (Q.L.); (T.M.H.); (N.K.); (G.K.I.)
- Department of Emergency Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Rd, Guangzhou 510120, China
| | - Tam Minh Huynh
- Monash Venom Group, Department of Pharmacology, Biomedical Discovery Institute, Monash University, Clayton 3800, Australia; (Q.L.); (T.M.H.); (N.K.); (G.K.I.)
| | - Nicki Konstantakopoulos
- Monash Venom Group, Department of Pharmacology, Biomedical Discovery Institute, Monash University, Clayton 3800, Australia; (Q.L.); (T.M.H.); (N.K.); (G.K.I.)
| | - Geoffrey K. Isbister
- Monash Venom Group, Department of Pharmacology, Biomedical Discovery Institute, Monash University, Clayton 3800, Australia; (Q.L.); (T.M.H.); (N.K.); (G.K.I.)
- Clinical Toxicology Research Group, University of Newcastle, Callaghan 2308, Australia
| | - Wayne C. Hodgson
- Monash Venom Group, Department of Pharmacology, Biomedical Discovery Institute, Monash University, Clayton 3800, Australia; (Q.L.); (T.M.H.); (N.K.); (G.K.I.)
- Correspondence:
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Chiang LC, Tsai WJ, Liu PY, Ho CH, Su HY, Lai CS, Lai KL, Lin WL, Lee CH, Yang YY, Doan UV, Maharani T, Mao YC. Envenomation by Trimeresurus stejnegeri stejnegeri: clinical manifestations, treatment and associated factors for wound necrosis. J Venom Anim Toxins Incl Trop Dis 2020; 26:e20200043. [PMID: 32983233 PMCID: PMC7500479 DOI: 10.1590/1678-9199-jvatitd-2020-0043] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Trimeresurus stejnegeri stejnegeri bite induces tissue swelling, pain, thrombocytopenia, rhabdomyolysis, and acute renal failure. However, the incidence of coagulopathy, factors associated with wound necrosis, and the appropriate management of this condition have not been well characterized yet. Materials This study included patients bitten by T. s. stejnegeri that were admitted to the study hospitals from 2001 to 2016. Patient characteristics, laboratory data, and management approaches were compared in victims with and without wound necrosis. Results A total of 185 patients were evaluated: three patients (1.6%) were asymptomatic; whereas tissue swelling and pain, local ecchymosis, wound necrosis, coagulopathy, thrombocytopenia, rhabdomyolysis, and renal impairment were present in 182, 53, 13, 15, 10, 1, and 3 patients, respectively. One patient died from coagulopathy and hemorrhagic shock. Antivenom was administered to all envenomed patients at a median time of 1.8 h after the bite. The median total dose of antivenom was five vials. Chi-square analysis showed that bitten fingers, using cold packs during first aid, presence of bullae or blisters, lymphangitis or lymphadenitis, local numbness and suspected infection to be significantly associated with wound necrosis. After adjustment using a multivariate logistic regression model, only cold packs as first aid, bulla or blister formation, and wound infection remained significant. Conclusions The main effects of T. s. stejnegeri envenomation are tissue swelling, pain, and local ecchymosis. We do not recommend the use of cold packs during first aid to reduce wound pain, as this may be a risk factor for wound necrosis. In addition, patients with bulla or blister formation should be carefully examined for subsequent wound necrosis. Antiplatelet use may worsen systemic bleeding. No severe rhabdomyolysis or renal failure was observed in this large case series, we therefore considered that they were not prominent effects of T. s. stejnegeri bite.
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Affiliation(s)
- Liao-Chun Chiang
- National Tsing Hua University, College of Life Sciences, Hsinchu, Taiwan.,School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Division of Clinical Toxicology and Occupational Medicine, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Jen Tsai
- Division of Clinical Toxicology and Occupational Medicine, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Po-Yu Liu
- Division of Infection, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Cheng-Hsuan Ho
- School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Department of Emergency Medicine, Tri-Service General Hospital, Taipei, Taiwan
| | - Hung-Yuan Su
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung, Taiwan.,The School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung, Taiwan
| | - Chih-Sheng Lai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kuo-Lung Lai
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wen-Loung Lin
- Taichung Wildlife Conservation Group, Taichung, Taiwan
| | - Chi-Hsin Lee
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Graduate Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Core Laboratory of Antibody Generation and Research, Taipei Medical University, Taipei, Taiwan
| | - Yi-Yuan Yang
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Graduate Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Core Laboratory of Antibody Generation and Research, Taipei Medical University, Taipei, Taiwan
| | - Uyen Vy Doan
- Department of Clinical Toxicology, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Tri Maharani
- Department of Emergency Medicine, Daha Husada Hospital, Kediri, East Java, Indonesia
| | - Yan-Chiao Mao
- School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Division of Clinical Toxicology and Occupational Medicine, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Lin CC, Chen YC, Goh ZNL, Seak CK, Seak JCY, Shi-Ying G, Seak CJ. Wound Infections of Snakebites from the Venomous Protobothrops mucrosquamatus and Viridovipera stejnegeri in Taiwan: Bacteriology, Antibiotic Susceptibility, and Predicting the Need for Antibiotics-A BITE Study. Toxins (Basel) 2020; 12:toxins12090575. [PMID: 32906845 PMCID: PMC7551380 DOI: 10.3390/toxins12090575] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/03/2020] [Accepted: 09/03/2020] [Indexed: 12/18/2022] Open
Abstract
Snakebites from Taiwan habus (Protobothrops mucrosquamatus) and green bamboo vipers (Viridovipera stejnegeri) account for two-thirds of all venomous snakebites in Taiwan. While there has been ongoing optimization of antivenin therapy, the proper management of superimposed bacterial wound infections is not well studied. In this Bacteriology of Infections in Taiwanese snake Envenomation (BITE) study, we investigated the prevalence of wound infection, bacteriology, and corresponding antibiotic usage in patients presenting with snakebites from these two snakes. We further developed a BITE score to evaluate the probability of wound infections and guide antibiotic usage in this patient population. All snakebite victims who presented to the emergency departments of seven training and research hospitals and received at least one vial of freeze-dried hemorrhagic antivenin between January 2001 and January 2017 were identified. Patient biodata, laboratory investigation results, and treatment modalities were retrieved. We developed our BITE score via univariate and multiple logistic regression analyses. The receiver operating characteristic (ROC) curve was plotted to evaluate the predictive performance of the BITE score. Out of 8,295,497 emergency department visits, 726 patients presented with snakebites from a Taiwan habu or a green bamboo viper. The wound infection rate was 22.45%, with seven positive wound cultures, including six polymicrobial infections. Morganella morganii, Enterococcus spp., Bacteroides fragilis, and Aeromonas hydrophila were most frequently cultured. There were no positive blood cultures. A total of 33.0% (n = 106) of snakebite patients who received prophylactic antibiotics nevertheless developed wound infections, while 44.8% (n = 73) of wound infection patients were satisfactorily treated with one of the following antibiotics: amoxicillin/clavulanic acid, oxacillin, cefazolin, and ampicillin/sulbactam. With the addition of gentamicin, the success of antibiotic therapy increased by up to 66.54%. The prognostic factors for the secondary bacterial infection of snakebites were white blood cell counts, the neutrophil lymphocyte ratio, and the need for hospital admission. The area under the ROC curve for the BITE score was 0.839. At the optimal cut-off point of 5, the BITE score had a 79.58% accuracy, 82.31% sensitivity, and 79.71% specificity when predicting infection in snakebite patients. Our BITE score may help with antibiotic stewardship by guiding appropriate antibiotic use in patients presenting with snakebites. It may also be employed in further studies into antibiotic prophylaxis in snakebite patients for the prevention of superimposed bacterial wound infections.
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Affiliation(s)
- Chih-Chuan Lin
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (C.-C.L.); (G.S.-Y.); (S.I.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Yen-Chia Chen
- Department of Emergency medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan;
- Department of Emergency Medicine, School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan
| | - Zhong Ning Leonard Goh
- Sarawak General Hospital, Kuching, Sarawak 93586, Malaysia; (Z.N.L.G.); (C.-K.S.); (J.C.-Y.S.)
| | - Chen-Ken Seak
- Sarawak General Hospital, Kuching, Sarawak 93586, Malaysia; (Z.N.L.G.); (C.-K.S.); (J.C.-Y.S.)
| | - Joanna Chen-Yeen Seak
- Sarawak General Hospital, Kuching, Sarawak 93586, Malaysia; (Z.N.L.G.); (C.-K.S.); (J.C.-Y.S.)
| | - Gao Shi-Ying
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (C.-C.L.); (G.S.-Y.); (S.I.)
| | - Chen-June Seak
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (C.-C.L.); (G.S.-Y.); (S.I.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Emergency Medicine, New Taipei Municipal Tucheng Hospital, New Taipei City 23652, Taiwan
- Correspondence:
| | - SPOT Investigators
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (C.-C.L.); (G.S.-Y.); (S.I.)
- Sarawak General Hospital, Kuching, Sarawak 93586, Malaysia; (Z.N.L.G.); (C.-K.S.); (J.C.-Y.S.)
- Department of Emergency Medicine, New Taipei Municipal Tucheng Hospital, New Taipei City 23652, Taiwan
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Ngo ND, Le QX, Pham AQ, Nguyen NT, Ha HT, Dinh MMQ, Le TQ. Clinical Features, Bacteriology, and Antibiotic Treatment Among Patients with Presumed Naja Bites in Vietnam. Wilderness Environ Med 2020; 31:151-156. [DOI: 10.1016/j.wem.2020.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 12/15/2019] [Accepted: 01/09/2020] [Indexed: 10/24/2022]
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Mao YC, Liu PY, Chiang LC, Lee CH, Lai CS, Lai KL, Lin WL, Su HY, Ho CH, Doan UV, Maharani T, Yang YY, Yang CC. Clinical manifestations and treatments of Protobothrops mucrosquamatus bite and associated factors for wound necrosis and subsequent debridement and finger or toe amputation surgery. Clin Toxicol (Phila) 2020; 59:28-37. [PMID: 32400229 DOI: 10.1080/15563650.2020.1762892] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Protobothrops mucrosquamatus bite induces wound necrosis, coagulopathy, thrombocytopenia, rhabdomyolysis, and acute renal failure. The severity of the hematological derangements and associated factors for wound necrosis and subsequent surgery and the appropriate management of these conditions have not been well characterized. Although severe renal failure requiring hemodialysis has been reported following P. mucrosquamatus bite, the culprit snake may be erroneously classified. MATERIALS AND METHODS A total of 186 patients with P. mucrosquamatus bites were retrospectively evaluated. They were categorized into group 1 (patients receiving debridement or finger/toe amputation) and group 2 (all other patients) to identify the associated factors for surgery. Characteristic data were compared between groups 1 and 2 and between definite and suspected cases. RESULTS No differences were observed between definite and suspected cases in terms of symptomatology and management. Of the 186 patients, 7 (3.8%) were asymptomatic, 179 (96.2%) experienced tissue swelling and pain, and 107 (57.5%) had local ecchymosis. Coagulopathy, thrombocytopenia, and renal impairment were found in 13 (7%), 19 (10.2%), and 7 (3.8%) patients, respectively. None of the patients required transfusion therapy or hemodialysis. Furthermore, no systemic bleeding or death occurred. Antivenom was administered to all 179 envenomed patients at a median of 1.5 h post-bite. The median total dose of the specific antivenom was 5.5 vials. In multivariate logistic regression analysis, finger as the bite site, bullae and blister formation, and wound infection were significantly associated with wound necrosis; whereas finger as the bite site and bullae and blister formation were related to debridement or finger/toe amputation. DISCUSSION AND CONCLUSIONS Protobothrops mucrosquamatus envenomation mainly exerts effects on local tissue. Systemic effects are uncommon and generally nonsevere and transient after the treatment with the specific antivenom. We speculated that severe renal failure requiring hemodialysis is not a typical finding of P. mucrosquamatus envenomation. Patients with finger as the bite site and bullae or blister formation should be carefully examined for wound necrosis, secondary infection, and subsequent surgery. Further evaluations of the efficacy of antivenom against local tissue effects and the effect of selective antibiotics in the management of bite wound infection are urgently required. Although the antivenom manufacturer suggested a skin test prior to use, we believed that it could be omitted because it does not accurately predict the allergic responses.
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Affiliation(s)
- Yan-Chiao Mao
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Po-Yu Liu
- Division of Infection, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Liao-Chun Chiang
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,College of Life Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Chi-Hsin Lee
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,PhD Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Core Laboratory of Antibody Generation and Research, Taipei Medical University, Taipei, Taiwan
| | - Chih-Sheng Lai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kuo-Lung Lai
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wen-Loung Lin
- Taichung Wildlife Conservation Group, Taichung, Taiwan
| | - Hung-Yuan Su
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung, Taiwan.,The School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung, Taiwan
| | - Cheng-Hsuan Ho
- School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Department of Emergency Medicine, Tri-Service General Hospital, Taipei, Taiwan
| | - Uyen Vy Doan
- Clinical Toxicology, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Tri Maharani
- Department of Emergency Medicine, Daha Husada Hospital, East Java, Kediri, Indonesia
| | - Yi-Yuan Yang
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,PhD Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Core Laboratory of Antibody Generation and Research, Taipei Medical University, Taipei, Taiwan
| | - Chen-Chang Yang
- Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Resiere D, Gutiérrez JM, Névière R, Cabié A, Hossein M, Kallel H. Antibiotic therapy for snakebite envenoming. J Venom Anim Toxins Incl Trop Dis 2020; 26:e20190098. [PMID: 32095137 PMCID: PMC7011479 DOI: 10.1590/1678-9199-jvatitd-2019-0098] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 12/12/2019] [Indexed: 11/22/2022] Open
Abstract
There are numerous conflicting recommendations available on the use of antibiotics following snakebite. The present letter to the editor presents some recommendations based on recent studies, and aims to stimulate debate on this topic.
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Affiliation(s)
- Dabor Resiere
- Intensive Care Unit, University Hospital of Martinique, Fort-de-France, Martinique
| | - José María Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Rémi Névière
- Intensive Care Unit, University Hospital of Martinique, Fort-de-France, Martinique
| | - André Cabié
- Department of Infectious Diseases, University Hospital of Martinique, Fort-de-France, Martinique
| | - Mehdaoui Hossein
- Intensive Care Unit, University Hospital of Martinique, Fort-de-France, Martinique
| | - Hatem Kallel
- Intensive Care Unit, Cayenne General Hospital, Cayenne, French Guiana
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Tsai TH, Lin CC, Mao YC, Hung CL, Yang YC, Yang CC, Jeng MJ. Naja atra venom-spit ophthalmia in Taiwan: An epidemiological survey from 1990 to 2016. J Chin Med Assoc 2020; 83:77-83. [PMID: 31714443 DOI: 10.1097/jcma.0000000000000223] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Venomous snakebites are common during hot seasons in Taiwan. However, rarely is venom spat directly into the subject's eyes, causing eye injury. Despite being uncommon, analytical data regarding venom-spit ophthalmia in Taiwan have been lacking. This study thus aimed to conduct an epidemiological survey on Naja atra venom-spit ophthalmia in Taiwan during the past decades to improve future care of such patients. METHODS Registered records of cases with snake venom injuries at the Taiwan National Poison Control Center from 1990 to 2016 were retrospectively reviewed, enrolling those with records of cobra venom-spit eye injuries and excluding exotic species. Demographic data, clinical symptoms, snake species, ocular conditions, management, and outcomes were recorded and analyzed. RESULTS A total of 39 cases suffering from Naja atra venom-spit ophthalmia were enrolled. The overall incidence rate was 1.6 cases per million people from 1990 to 2016. Among the included cases, most were unilaterally injured (82%), male (95%), aged 18 to 59 years (90%), injured during catching (51%), and injured in spring and summer (92%). Ocular symptoms occurred in 90% of the cases, majority of which included ocular pain (90%) and redness (85%). Conjunctivitis (67%) and corneal injury (59%) of involved eyes were common. Immediate water irrigations were done in all cases, most of whom received further topical eye drops, including antibiotics, corticosteroids, and vasoconstrictors. Although topical or intravenous antivenoms were administered in 11 cases, no obviously superior outcome was observed. Most cases (77%) were symptom free after the acute stage. CONCLUSION Although Naja atra venom-spit ophthalmia in Taiwan is uncommon, the risk for transient ocular symptoms and corneal/conjunctival injury does exists. Prompt ocular irrigation and professional ophthalmic care after envenomation help prevent serious ocular sequelae. Moreover, superior outcomes were not achieved with the use of antivenom. Nonetheless, further studies are required to clarify the role antivenoms play in venom-spit ophthalmia.
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Affiliation(s)
- Tsung-Han Tsai
- Institute of Emergency and Critical Care Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
- Department of Emergency, Taichung Armed Forces General Hospital, Taichung, Taiwan, ROC
- Department of Emergency, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
- School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chun-Chi Lin
- Division of Occupational Medicine, Department of Family Medicine, National Yang-Ming University Hospital, I-Lan, Taiwan, ROC
- Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yan-Chiao Mao
- School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
- Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Chia-Lien Hung
- Department of Medical Education and Research, Taichung Armed Forces General Hospital, Taichung, Taiwan, ROC
| | - Yi-Chiang Yang
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chen-Chang Yang
- School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Mei-Jy Jeng
- Institute of Emergency and Critical Care Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Resiere D, Mehdaoui H, Névière R, Olive C, Severyns M, Beaudoin A, Florentin J, Brouste Y, Banydeen R, Cabié A, Mégarbane B, Gutiérrez JM, Kallel H. Infectious Complications Following Snakebite by Bothrops lanceolatus in Martinique: A Case Series. Am J Trop Med Hyg 2020; 102:232-240. [PMID: 31628740 PMCID: PMC6947800 DOI: 10.4269/ajtmh.19-0369] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 07/12/2019] [Indexed: 11/24/2022] Open
Abstract
Infections secondary to snakebite occur in a number of patients and are potentially life-threatening. Bothrops lanceolatus bites in Martinique average 30 cases per year and may result in severe thrombotic and infectious complications. We aimed to investigate the infectious complications related to B. lanceolatus bite. A retrospective single-center observational study over 7 years (2011-2018) was carried out, including all patients admitted to the hospital because of B. lanceolatus bite. One hundred seventy snake-bitten patients (121 males and 49 females) were included. Thirty-nine patients (23%) presented grade 3 or 4 envenoming. Twenty patients (12%) developed wound infections. The isolated bacteria were Aeromonas hydrophila (3 cases), Morganella morganii (two cases), group A Streptococcus, and group B Streptococcus (one case each). Patients were treated empirically with third-generation cephalosporin (or amoxicillin-clavulanate), aminoglycoside, and metronidazole combinations. Outcome was favorable in all patients. The main factor significantly associated with the occurrence of infection following snakebite was the severity of envenoming (P < 0.05). Our findings clearly point toward the frequent onset of infectious complications in B. lanceolatus-bitten patients presenting with grade 3 and 4 envenoming. Thus, based on the bacteria identified in the wounds, we suggest that empiric antibiotic therapy including third-generation cephalosporin should be administered to those patients on hospital admission.
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Affiliation(s)
- Dabor Resiere
- Department of Critical Care, University Hospital of Martinique, Fort-de-France, France
| | - Hossein Mehdaoui
- Department of Critical Care, University Hospital of Martinique, Fort-de-France, France
| | - Rémi Névière
- Department of Cardiology, University Hospital of Martinique, Fort-de-France, France
| | - Claude Olive
- Department of Microbiology, University Hospital of Martinique, Fort-de-France, France
| | - Mathieu Severyns
- Department of Orthopedic Surgery, University Hospital of Martinique, Fort-de-France, France
| | - Adeline Beaudoin
- Department of Orthopedic Surgery, University Hospital of Martinique, Fort-de-France, France
| | - Jonathan Florentin
- Department of Critical Care, University Hospital of Martinique, Fort-de-France, France
| | - Yannick Brouste
- Department of Critical Care, University Hospital of Martinique, Fort-de-France, France
| | - Rishika Banydeen
- Department of Critical Care, University Hospital of Martinique, Fort-de-France, France
| | - André Cabié
- Department of Infectious Diseases, University Hospital of Martinique, INSERM CIC 1424, Antilles University, Fort-de-France, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris-Diderot University, INSERM UMRS1144, Paris, France
| | - José María Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Hatem Kallel
- Intensive Care Unit, Cayenne General Hospital, Cayenne, France
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Bammigatti C, Reddy PA, Hanumanthappa N, Harichandrakumar KT, Swaminathan RP. Serum Procalcitonin Concentration and Its Relationship with Local Manifestations after Snakebites. Am J Trop Med Hyg 2019; 100:146-149. [PMID: 30457093 DOI: 10.4269/ajtmh.17-0892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The local signs and symptoms following snakebites are similar to those of cellulitis caused by bacterial infections. This leads to empirical treatment with antibiotics, which however is not supported by evidence. Procalcitonin (PCT) is a biomarker with good diagnostic accuracy for bacterial infection. We studied serum PCT concentration in 100 patients aged 13 years or more, presenting to the hospital with significant local manifestations (crossing the joint proximal to the bitten wound) within 24 hours after snakebite. The extent and progression of local manifestations were monitored 12 hourly. Baseline PCT measurement was carried out for all patients and measurement was repeated 12 hourly only in those patients with progressive local manifestations. The median interqartile range PCT concentration did not differ significantly by the severity of local manifestation at presentation (Grade 2 = 0.28 [0.26-0.30]; Grade 3 = 0.28 [0.26-0.32]; Grade 4 = 0.27 [0.26-0.32] ng/mL; P = 0.15). Furthermore, we did not observe an increase in PCT concentration on serial estimation in those with progressive local manifestation (0.28, 0.29, and 0.29 ng/mL) over 36 hours. These observations suggest that the local manifestations following snakebites were not caused by bacterial infection.
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Affiliation(s)
- Chanaveerappa Bammigatti
- Departments of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Preetham A Reddy
- Departments of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nandeesha Hanumanthappa
- Departments of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - K T Harichandrakumar
- Departments of Biostatistics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Rathinam Palamalai Swaminathan
- Departments of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Minnullina L, Pudova D, Shagimardanova E, Shigapova L, Sharipova M, Mardanova A. Comparative Genome Analysis of Uropathogenic Morganella morganii Strains. Front Cell Infect Microbiol 2019; 9:167. [PMID: 31231616 PMCID: PMC6558430 DOI: 10.3389/fcimb.2019.00167] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/03/2019] [Indexed: 12/02/2022] Open
Abstract
Morganella morganii is an opportunistic bacterial pathogen shown to cause a wide range of clinical and community-acquired infections. This study was aimed at sequencing and comparing the genomes of three M. morganii strains isolated from the urine samples of patients with community-acquired urinary tract infections. Draft genome sequencing was conducted using the Illumina HiSeq platform. The genomes of MM 1, MM 4, and MM 190 strains have a size of 3.82–3.97 Mb and a GC content of 50.9–51%. Protein-coding sequences (CDS) represent 96.1% of the genomes, RNAs are encoded by 2.7% of genes and pseudogenes account for 1.2% of the genomes. The pan-genome containes 4,038 CDS, of which 3,279 represent core genes. Six to ten prophages and 21–33 genomic islands were identified in the genomes of MM 1, MM 4, and MM 190. More than 30 genes encode capsular biosynthesis proteins, an average of 60 genes encode motility and chemotaxis proteins, and about 70 genes are associated with fimbrial biogenesis and adhesion. We determined that all strains contained urease gene cluster ureABCEFGD and had a urease activity. Both MM 4 and MM 190 strains are capable of hemolysis and their activity correlates well with a cytotoxicity level on T-24 bladder carcinoma cells. These activities were associated with expression of RTX toxin gene hlyA, which was introduced into the genomes by a phage similar to Salmonella phage 118970_sal4.
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Affiliation(s)
- Leyla Minnullina
- Laboratory of Microbial Biotechnology, Institute of Fundamental Medicine and Biology, Kazan (Volga region) Federal University, Kazan, Russia
| | - Daria Pudova
- Laboratory of Microbial Biotechnology, Institute of Fundamental Medicine and Biology, Kazan (Volga region) Federal University, Kazan, Russia
| | - Elena Shagimardanova
- Laboratory of Extreme Biology, Institute of Fundamental Medicine and Biology, Kazan (Volga region) Federal University, Kazan, Russia
| | - Leyla Shigapova
- Laboratory of Extreme Biology, Institute of Fundamental Medicine and Biology, Kazan (Volga region) Federal University, Kazan, Russia
| | - Margarita Sharipova
- Laboratory of Microbial Biotechnology, Institute of Fundamental Medicine and Biology, Kazan (Volga region) Federal University, Kazan, Russia
| | - Ayslu Mardanova
- Laboratory of Microbial Biotechnology, Institute of Fundamental Medicine and Biology, Kazan (Volga region) Federal University, Kazan, Russia
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Krishnankutty SP, Muraleedharan M, Perumal RC, Michael S, Benny J, Balan B, Kumar P, Manazhi J, Kumar BD, Santhosh S, Thomas G, Gupta R, Zachariah A. Next-generation sequencing analysis reveals high bacterial diversity in wild venomous and non-venomous snakes from India. J Venom Anim Toxins Incl Trop Dis 2018; 24:41. [PMID: 30598660 PMCID: PMC6303853 DOI: 10.1186/s40409-018-0181-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 12/06/2018] [Indexed: 11/24/2022] Open
Abstract
Background The oral cavities of snakes are replete with various types of bacterial flora. Culture-dependent studies suggest that some of the bacterial species are responsible for secondary bacterial infection associated with snakebite. A complete profile of the ophidian oral bacterial community has been unreported until now. Therefore, in the present study, we determined the complete bacterial compositions in the oral cavity of some snakes from India. Methods Total DNA was isolated from oral swabs collected from three wild snake species (Indian Cobra, King Cobra and Indian Python). Next, the DNA was subjected to PCR amplification of microbial 16S rRNA gene using V3-region-specific primers. The amplicons were used for preparation of DNA libraries that were sequenced on an Illumina MiSeq platform. Results The cluster-based taxonomy analysis revealed that Proteobacteria and Actinobacteria were the most predominant phyla present in the oral cavities of snakes. This result indicates that snakes show more similarities to birds than mammals as to their oral bacterial communities. Furthermore, our study reports all the unique and common bacterial species (total: 147) found among the oral microbes of snakes studied, while the majority of commonly abundant species were pathogens or opportunistic pathogens to humans. A wide difference in ophidian oral bacterial flora suggests variation by individual, species and geographical region. Conclusion The present study would provide a foundation for further research on snakes to recognize the potential drugs/antibiotics for the different infectious diseases. Electronic supplementary material The online version of this article (10.1186/s40409-018-0181-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | - Saju Michael
- AgriGenome Labs Pvt. Ltd., SmartCity Kochi, Kakkanad, Kerala 682042 India
| | - Jubina Benny
- AgriGenome Labs Pvt. Ltd., SmartCity Kochi, Kakkanad, Kerala 682042 India
| | - Bipin Balan
- AgriGenome Labs Pvt. Ltd., SmartCity Kochi, Kakkanad, Kerala 682042 India
| | - Pramod Kumar
- AgriGenome Labs Pvt. Ltd., SmartCity Kochi, Kakkanad, Kerala 682042 India
| | - Jishnu Manazhi
- Department of Forests and Wildlife, Sulthan Batheri, Wayanad District, Kerala 673592 India
| | | | - Sam Santhosh
- AgriGenome Labs Pvt. Ltd., SmartCity Kochi, Kakkanad, Kerala 682042 India
| | - George Thomas
- SciGenom Research Foundation, Cheruthuruthy, Kerala 679531 India
| | - Ravi Gupta
- 4Medgenome Labs Pvt. Ltd., Narayana Health City, Bommasandra, Bengaluru, Karnataka 560099 India
| | - Arun Zachariah
- Department of Forests and Wildlife, Sulthan Batheri, Wayanad District, Kerala 673592 India
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Huang YT, Cheng JF, Liu YT, Mao YC, Wu MS, Liu PY. Genome-based analysis of virulence determinants of a Serratia marcescens strain from soft tissues following a snake bite. Future Microbiol 2017; 13:331-343. [PMID: 29105506 DOI: 10.2217/fmb-2017-0202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Serratia marcescens wound infection after snakebite is often associated with aggressive presentations. However, the virulence determinants remain understudied. MATERIALS & METHODS Whole-genome sequencing was performed on S. marcescens VGH107, an isolate from wound infection secondary to Trimeresurus mucrosquamatus bite. Comparative genomics approach coupled with multivirulent-locus sequencing typing was applied to systematically predict potential virulence factors. RESULTS Multivirulent-locus sequencing typing indicated VGH107 falls within the cluster of high pathogenic strains. Comparative analysis identified virulence genes unique in VGH107, including ecpD and ecpE genes for periplasmic chaperone-pilus subunit complex and cdiA and cdiB genes for contact-dependent growth inhibition system. CONCLUSION The data established here provide foundation for further research regarding the virulence and resistance of S. marcescens.
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Affiliation(s)
- Yao-Ting Huang
- Department of Computer Science & Information Engineering, National Chung Cheng University, Chia-Yi, Taiwan
| | - Jan-Fang Cheng
- Department of Energy, Joint Genome Institute, Walnut Creek, CA 94598, USA
| | - Yi-Ting Liu
- Department of Computer Science & Information Engineering, National Chung Cheng University, Chia-Yi, Taiwan
| | - Yan-Chiao Mao
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Meng-San Wu
- Division of Infection & Immunity, University College London, London, UK
| | - Po-Yu Liu
- Division of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Rong Hsing Research Center for Translational Medicine, College of Life Sciences, National Chung Hsing University, Taichung, Taiwan
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Mao YC, Liu PY, Chiang LC, Liao SC, Su HY, Hsieh SY, Yang CC. Bungarus multicinctus multicinctus Snakebite in Taiwan. Am J Trop Med Hyg 2017; 96:1497-1504. [PMID: 28719273 DOI: 10.4269/ajtmh.17-0005] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
AbstractAlthough specific antivenom is available in Taiwan, respiratory failure and general pain frequently accompany Bungarus multicinctus envenomation and there have been few reports on the management of B. multicinctus envenomation. We retrospectively analyzed 44 cases of B. multicinctus bite admitted to Taichung Veterans General Hospital (VGH) or to Taipei VGH. Demographic data, treatment, and outcome of patients with and without respiratory failure were compared. In this study, 20.5% patients had bites without noticeable signs or symptoms of significant envenoming, 27.3% developed respiratory failure, and 27.3% experienced general pain. Bivalent specific antivenom for B. multicinctus and N. atra was administered in all envenomed cases. Respiratory failure occurred 1.5-6.5 hours post-bite and general pain occurred 1-12 hours post-bite. Specific antivenom for B. multicinctus and N. atra at the recommended dose (i.e., 2-4 vials) might not effectively prevent respiratory failure and pain. Respiratory failure, general pain, and autonomic effects after B. multicinctus bite were probably caused, at least partly, by β-bungarotoxin. Although general weakness, ptosis, dysarthria, and dilated pupils were significantly associated with respiratory failure, their predictive value could not be accurately determined in such a retrospective study. Due to the rapid onset of respiratory failure, every suspected envenomed case thus should be closely monitored in the first few hours. We recommend the initial administration of four vials of antivenom in all envenomation cases, and a subsequent four vials be considered if the patient's condition is deteriorating. Prospective evaluation of the antivenom dosing regimen is urgently needed to improve B. multicinctus envenomation treatment.
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Affiliation(s)
- Yan-Chiao Mao
- Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Po-Yu Liu
- Division of Infection, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Liao-Chun Chiang
- National Health Research Institutes, National Institute of Infectious Diseases and Vaccinology, Miaoli, Taiwan.,National Tsing Hua University, College of Life Sciences, Hsinchu, Taiwan
| | - Shu-Chen Liao
- Department of Emergency Medicine, Chang Guang Memorial Hospital, Taipei, Taiwan.,Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hung-Yuan Su
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Szu-Yin Hsieh
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chen-Chang Yang
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Mao YC, Liu PY, Chiang LC, Lai CS, Lai KL, Ho CH, Wang TH, Yang CC. Naja atra snakebite in Taiwan. Clin Toxicol (Phila) 2017; 56:273-280. [PMID: 28830248 DOI: 10.1080/15563650.2017.1366502] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Naja atra snakebite is uncommon in Taiwan and causes distinct effects on its victims. Although the Taiwan government produces its own specific antivenom, little information on the management of N. atra snakebite is available. MATERIALS AND METHODS We retrospectively evaluated 183 patients admitted to two medical centers. Of these, 45 were identified as definite cases of N. atra snakebite, 86 as suspected cases, and 52 as clinical cases. Demographic data, symptomatology, and management were compared between these case groups. RESULTS Symptomatology and management were similar in the three groups. Among the 183 patients, 10 (5.5%) were asymptomatic and nine (4.9%) had transient and partial ptosis or body weakness. The principal effects were local tissue swelling and pain in 173 patients (94.5%), followed by clinically suspected wound infection in 148 (80.9%), skin necrosis in 120 (65.6%), necrotizing soft tissue infection in 77 (42.1%), fever in 59 (32.2%), and gastrointestinal effects in 53 (29%). The median total dose of specific antivenom needed to treat N. atra envenoming was 10 vials. In the envenomed patients, debridement was required in 74 patients (42.8%), fasciotomy/fasciectomy in 46 (26.6%), and finger or toe amputation in seven (4%). The first operation was performed at a median of 3.5 days after the bite. DISCUSSION AND CONCLUSIONS Based on these typical manifestations, clinical diagnosis of N. atra snakebites may be feasible and practical. In contrast to other snakes of Elapidae family, N. atra bite did not cause serious neurological effects. Early surgical consultation should be obtained because half of the patients underwent surgery due to infectious complications. Acute compartment syndrome was the surgical indication in rare cases; however, overestimation of the incidence may have occurred. This syndrome should be confirmed by serial intracompartmental pressure monitoring instead of only physical examination, and a sufficient dose of antivenom should be given prior to surgical decompression.
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Affiliation(s)
- Yan-Chiao Mao
- a Division of Clinical Toxicology, Department of Emergency Medicine , Taichung Veterans General Hospital , Taichung , Taiwan.,b Division of Clinical Toxicology and Occupational Medicine, Department of Medicine , Taipei Veterans General Hospital , Taipei , Taiwan.,c Institute of Environmental and Occupational Health Sciences , School of Medicine, National Yang-Ming University , Taipei , Taiwan.,d School of Medicine , National Defense Medical Center , Taipei , Taiwan
| | - Po-Yu Liu
- e Division of Infection, Department of Medicine , Taichung Veterans General Hospital , Taichung , Taiwan.,f Rong Hsing Research Center for Translational Medicine , National Chung Hsing University , Taichung , Taiwan
| | - Liao-Chun Chiang
- g College of Life Sciences , National Tsing Hua University , Hsinchu , Taiwan
| | - Chih-Sheng Lai
- h Division of Plastic and Reconstructive Surgery, Department of Surgery , Taichung Veterans General Hospital , Taichung , Taiwan
| | - Kuo-Lung Lai
- i Division of Allergy, Immunology and Rheumatology, Department of Medicine , Taichung Veterans General Hospital , Taichung , Taiwan
| | - Cheng-Hsuan Ho
- d School of Medicine , National Defense Medical Center , Taipei , Taiwan.,j Department of Emergency Medicine , Tri-Service General Hospital , Taipei , Taiwan
| | - Te-Huo Wang
- b Division of Clinical Toxicology and Occupational Medicine, Department of Medicine , Taipei Veterans General Hospital , Taipei , Taiwan.,k Department of Emergency Medicine , National Yang-Ming University Hospital , Yilan , Taiwan
| | - Chen-Chang Yang
- b Division of Clinical Toxicology and Occupational Medicine, Department of Medicine , Taipei Veterans General Hospital , Taipei , Taiwan.,c Institute of Environmental and Occupational Health Sciences , School of Medicine, National Yang-Ming University , Taipei , Taiwan
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