Ward round--crocodile bites in Malawi: microbiology and surgical management

An Assessment of Open Fracture Management in Hospitals in Malawi Before and Immediately After Implementing Open Fracture Guidelines

Background

Open fractures, a common consequence of road traffic collisions, are associated with a high risk of complications. The introduction of standard guidelines has been shown to improve patient care and reduce the risk of complications in several countries. In September 2021, the Malawi Orthopaedic Association/Arbeitsgemeinschaft für Osteosynthesefragen Alliance (MOA/AOA) guidelines and standards for open fracture management were introduced in Malawi. This study aimed to assess the management of open fractures in hospitals in Malawi, before and after implementing a training course on the MOA/AOA open fracture guidelines.

Methods

This was a descriptive and quantitative, before-and-after study that reviewed the medical files of patients with open fractures at Zomba Central Hospital and Mulanje, Salima, and Mangochi district hospitals over two 3-month periods. Variables included initial assessment; antibiotic prophylaxis; place of debridement; type of anesthesia; treatment of the open fracture in the emergency department, operating room, and wards; and short-term complications requiring hospital treatment.

Results

A total of 88 open-fracture case files were reviewed; 43 were prior and 45 were subsequent to the implementation of the open fracture guidelines. The overall median patient age was 36 years (interquartile range, 27 to 45 years), and 91% (80) were male. Limb neurovascular status assessment and documentation improved from 26% (11) of the patients before the guidelines to 62% (28) afterward (p = 0.0002). The percentage who underwent debridement in the operating room significantly increased from 19% (8) to 69% (31) (p = 0.01). The percentage who underwent debridement under general or spinal anesthesia significantly increased from 5% (2) to 38% (17) and from 12% (5) to 29% (13), respectively (p= 0.001). The wound infection rate decreased from 21% to 11%, but this was not significant, and there was no change in the overall complication rate (p = 0.152).

Conclusions

This study suggests that training on the MOA/AOA open fracture management guidelines followed by their implementation can lead to at least temporary improvement in the management of open fractures. Nevertheless, additional studies need to be performed to understand the effect on long-term patient outcomes.

Levels of Evidence

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Placing Locking Compression Plates as an External Fixator in Wild Animal (Crocodile) Bite Victim: A Case Report

Animal bites can cause severely contaminated open fractures, especially in the hand, wrist, and lower extremities, requiring expert orthopedic care. This case report emphasizes the unique issues posed by such injuries, particularly in low-income areas with limited access to comprehensive medical services. Pediatric examples, such as open tibiofibular fractures caused by animal encounters, highlight the significance of individualized treatment techniques. Crocodile bites, though infrequent, present an extreme peril and potential fatality. In Sri Lanka, where various crocodile species inhabit the waters, such incidents are rare but present. Long bone fractures caused by crocodile bites are significant and complicated injuries. The enormous force of a crocodile's jaw can cause substantial damage to bones, tendons, and surrounding tissues, often resulting in significant bone and soft tissue loss. Managing such injuries is extremely difficult, especially in low-resource settings. The use of a locking plate as an external fixator is a novel approach in the treatment of open fractures, nonunion, septic arthritis, and even as a distraction osteogenesis adjuvant. While it is not as common in typical fracture fixation textbooks, it is critical in specialized instances. This study describes a unique case of a 13-year-old boy with a Gustilo-Anderson Type IIIA crocodile bite who was treated in a low-income environment with a locking plate as an external fixator.

Drug-Resistant Aerobic Bacterial Pathogens in Patients with Crocodile Bite Wounds Attending at Arba Minch General Hospital, Southern Ethiopia

Background

A polymicrobial infection containing a diverse range of drug-resistant bacteria worsens the success of treatment for crocodile bite wound infection. However, there is a dearth of data in Ethiopia, where crocodile bite injuries are relatively common, particularly in the area around Lake Abaya and Lake Chamo in southern Ethiopia.

Methods

 A hospital-based cross-sectional study was conducted from May 1st, 2021, to April 30th, 2022, at Arba Minch General Hospital. Eleven consenting patients with crocodile bite wounds were enrolled in this study. Wound swabs were collected aseptically following microbiological procedures. The diversity and type of aerobic bacterial pathogens, and drug-resistant patterns were used to determine and characterize the nature of crocodile bite wound infections.

Results

Among 11 patients with crocodile bite wounds, 72.7% (8/11) of wound samples were found to be culture-positive, with a total of 21 aerobic bacterial isolates. Gram-negative bacterial isolates were found in 57.1% (12/21). Triple-bacterial isolates were found in 62.5% (5/8) of wound samples, followed by 37.5% (3/8) of double bacterial isolates. Pseudomonas aeruginosa (n = 5), followed by Citrobacter spp. (n = 4), and coagulase-negative Staphylococci (CoNS) (n = 4) were frequently isolated bacteria. Methicillin resistance (MR-CoNS) was found in 75% of isolated CoNS. 6.7% of the isolated Enterococcus faecalis was vancomycin-resistant (VRE), while 60% of the isolated P. aeruginosa were piperacillin-resistant. Overall, 85.7% (18/21) of the isolates were found to be multidrug-resistant (MDR), with 55.6% (10/18) of them being Gram-negative MDR bacterial isolates.

Conclusion

Numerous aerobic bacteria that are resistant to the majority of common antibiotics have been associated with infections in crocodile bite wounds. Thus, the key to providing empirical therapy for such wounds is detecting the drug-resistant pattern of bacterial isolates.

Surgical amputation of a limb 31,000 years ago in Borneo

The prevailing view regarding the evolution of medicine is that the emergence of settled agricultural societies around 10,000 years ago (the Neolithic Revolution) gave rise to a host of health problems that had previously been unknown among non-sedentary foraging populations, stimulating the first major innovations in prehistoric medical practices^1,2. Such changes included the development of more advanced surgical procedures, with the oldest known indication of an 'operation' formerly thought to have consisted of the skeletal remains of a European Neolithic farmer (found in Buthiers-Boulancourt, France) whose left forearm had been surgically removed and then partially healed³. Dating to around 7,000 years ago, this accepted case of amputation would have required comprehensive knowledge of human anatomy and considerable technical skill, and has thus been viewed as the earliest evidence of a complex medical act³. Here, however, we report the discovery of skeletal remains of a young individual from Borneo who had the distal third of their left lower leg surgically amputated, probably as a child, at least 31,000 years ago. The individual survived the procedure and lived for another 6-9 years, before their remains were intentionally buried in Liang Tebo cave, which is located in East Kalimantan, Indonesian Borneo, in a limestone karst area that contains some of the world's earliest dated rock art⁴. This unexpectedly early evidence of a successful limb amputation suggests that at least some modern human foraging groups in tropical Asia had developed sophisticated medical knowledge and skills long before the Neolithic farming transition.

A Rare Case of Limb-Threatening Injury Secondary to Extrinsic Vascular Compression Following Crocodile Bite

Crocodile bites lead to fatal and nonfatal outcomes in humans. Mugger crocodiles (Crocodylus palustris) and saltwater crocodiles (Crocodylus porosus) are common in India. Most crocodile bites can cause severe injuries, especially to the extremities, due to the substantial bite force of the crocodile, which typically leads to extensive tissue damage, fractures, amputations, and vascular injuries. We report the case of a crocodile bite victim who presented with features of acute limb ischemia, was found to have vascular thrombosis of the common femoral artery, and was experiencing complete compression of the femoral vein due to external vascular compression by a hematoma. We discuss various injury mechanisms sustained in crocodile bites and the roles of point-of-care ultrasound and continuous tomography angiography, which could help identify these injuries. After thrombectomy and hematoma evacuation the patient recovered and was discharged without any physical dysfunction.

Practical Review of the Management of Animal Bites

Animal bites are common worldwide. Due to the plethora of animals, there are diverse pathogens with specific associated risks and treatment algorithms. It is crucial to understand these to develop and execute appropriate management plans. This practical review was designed to amalgamate the most common bites worldwide and synthesize data to help guide treatment plans.

METHODS

A PubMed literature search was performed focusing on the major animal bites. High-level studies were preferred and analyzed but lower-level studies were also used if high-level studies did not exist.

RESULTS

The tables presented in this article cover the pertinent information regarding the incidence, common presentation, initial treatment, and potential complications associated with bites from dogs, cats, horses, rodents, snakes, marine life, and spiders. Many of the pathogens associated with the bites are treatable with various and somewhat common antimicrobials, though some are less easy to access. Basic irrigation, debridement, and wound culture are common to almost every animal and should be the first step in treatment.

CONCLUSIONS

Based on the current studies, the most important factor in treating animal bites is timely presentation to a medical facility and/or physician. It is critical that the offending animal be accurately identified to help guide medical and surgical algorithms, including specific antimicrobial treatment guided by the most commonly presenting pathogens specific to certain animals.

A study on the oral and cloacal bacterial flora of Mugger crocodiles (Crocodylus palustris) in the Negour protected area, Iran

Mugger crocodile is the only crocodile existing in Iran. The present study was aimed to investigate the bacterial flora in oral and cloacal cavities of wild Mugger crocodiles in Negour protected area, Iran. The isolation and molecular characterization of oral and cloacal bacterial flora were performed in 22 Mugger crocodiles captured in Negour protected area, Iran. Ten bacterial species from all oral samples and six bacterial species from all cloacal samples were recovered. The most commonly isolated bacteria in oral samples were Burkholderia contaminans and Lactococcus garvieae, respectively; whereas, in cloacal samples, it was Lactococcus lactis. It is likely that the isolated bacteria would pose a threat to both crocodiles and humans health. It can threaten crocodiles during stressful conditions; while, humans would be susceptible if they are bitten by crocodiles, consume their meat or spend time near their natural environment. This study provides useful information about bacterial diversity which could help to select the most appropriate anti-bacterial when dealing with infections caused by crocodiles.

A Case Report of a Bite From the Nile Crocodile (Crocodylus niloticus) Managed with Regional Anesthesia

Crocodile attack injuries plague communities near bodies of water and continue to be an infrequent but significant form of trauma encountered in our medical facility. Regional anesthesia techniques are a novel adjunct to treatment and may facilitate simplified definitive management and better utilization of constrained operating room resources. We report a case of an adult male who presented with a large lower extremity wound after a crocodile bite. The patient was managed with initial debridement and irrigation and serial wound care entirely under regional anesthesia at the bedside. The patient did not develop wound infection, eventually receiving a skin graft with good functional outcomes. Regional anesthesia techniques are increasingly being used in the trauma setting, and their versatility allows for their use in multiple settings, by practitioners with limited experience and in resource-limited environments. No specific guidelines exist for performance of neuraxial techniques in the setting of animal bite injuries, but concerns about infectious complications have been raised. Regional anesthesia techniques may be useful in the management of extremity trauma due to crocodile attacks without infectious complications. They may reduce utilization of theatre resources and reduce opioid requirements.

Domestication and large animal interactions: Skeletal trauma in northern Vietnam during the hunter-gatherer Da But period

The aim of this paper is to test the hypothesis that healed traumatic injuries in the pre-Neolithic assemblage of Con Co Ngua, northern Vietnam (c. 6800-6200 cal BP) are consistent with large wild animal interactions prior to their domestication. The core sample included 110 adult (aged ≥ 18 years) individuals, while comparisons are made with an additional six skeletal series from Neolithic through to Iron Age Vietnam, Thailand, and Mongolia. All post cranial skeletal elements were assessed for signs of healed trauma and identified cases were further x-rayed. Crude trauma prevalence (14/110, 12.7%) was not significantly different between males (8/52) and females (5/37) (χ2 = 0.061, p = 0.805). Nor were there significant differences in the prevalence of fractured limbs, although males displayed greater rates of lower limb bone trauma than females. Further, distinct from females, half the injured males suffered vertebral fractures, consistent with high-energy trauma. The first hypothesis is supported, while some support for the sexual divisions of labour was found. The prevalence and pattern of fractured limbs at CCN when compared with other Southeast and East Asian sites is most similar to the agropastoral site of Lamadong, China. The potential for skeletal trauma to assess animal trapping and herding practices prior to domestication in the past is discussed.

Task-shifting of orthopaedic surgery to non-physician clinicians in Malawi: effective and safe?

There is a shortage of orthopaedic surgeons in Malawi. Orthopaedic clinical officers (OCOs) treat trauma patients and occasionally perform major orthopaedic surgery. No studies have assessed the efficacy and safety of their work. The aim of this study was to evaluate their contribution to major orthopaedic surgery at Zomba Central Hospital. Data about orthopaedic procedures during 2006-2010 were collected from theatre books. We selected major amputations and open reductions and plating for outcome analysis and collected details from files. We compared patients operated by OCOs alone ('OCOs alone' group) and by surgeons or OCOs assisted by surgeons ('Surgeon present' group). OCOs performed 463/1010 major (45.8%) and 1600/1765 minor operations (90.7%) alone. There was no difference in perioperative outcome between both groups. OCOs carry out a large proportion of orthopaedic procedures with good clinical results. Shifting of clinical tasks including major orthopaedic surgery can be safe. Further prospective studies are recommended.

Dead or Alive? Factors Affecting the Survival of Victims during Attacks by Saltwater Crocodiles (Crocodylus porosus) in Australia

Conflicts between humans and crocodilians are a widespread conservation challenge and the number of crocodile attacks is increasing worldwide. We identified the factors that most effectively decide whether a victim is injured or killed in a crocodile attack by fitting generalized linear models to a 42-year dataset of 87 attacks (27 fatal and 60 non-fatal) by saltwater crocodiles (Crocodylus porosus) in Australia. The models showed that the most influential factors were the difference in body mass between crocodile and victim, and the position of victim in relation to the water at the time of an attack. In-water position (for diving, swimming, and wading) had a higher risk than on-water (boating) or on-land (fishing, and hunting near the water's edge) positions. In the in-water position a 75 kg person would have a relatively high probability of survival (0.81) if attacked by a 300 cm crocodile, but the probability becomes much lower (0.17) with a 400 cm crocodile. If attacked by a crocodile larger than 450 cm, the survival probability would be extremely low (<0.05) regardless of the victim's size. These results indicate that the main cause of death during a crocodile attack is drowning and larger crocodiles can drag a victim more easily into deeper water. A higher risk associated with a larger crocodile in relation to victim's size is highlighted by children's vulnerability to fatal attacks. Since the first recently recorded fatal attack involving a child in 2006, six out of nine fatal attacks (66.7%) involved children, and the average body size of crocodiles responsible for these fatal attacks was considerably smaller (384 cm, 223 kg) than that of crocodiles that killed adults (450 cm, 324 kg) during the same period (2006-2014). These results suggest that culling programs targeting larger crocodiles may not be an effective management option to improve safety for children.

Oral and cloacal microflora of wild crocodiles Crocodylus acutus and C. moreletii in the Mexican Caribbean

Bacterial cultures and chemical analyses were performed from cloacal and oral swabs taken from 43 American crocodiles Crocodylus acutus and 28 Morelet's crocodiles C. moreletii captured in Quintana Roo State, Mexico. We recovered 47 bacterial species (28 genera and 14 families) from all samples with 51.1% of these belonging to the family Enterobacteriaceae. Fourteen species (29.8%) were detected in both crocodile species and 18 (38.3%) and 15 (31.9%) species were only detected in American and Morelet's crocodiles, respectively. We recovered 35 bacterial species from all oral samples, of which 9 (25.8%) were detected in both crocodile species. From all cloacal samples, we recovered 21 bacterial species, of which 8 (38.1%) were detected in both crocodile species. The most commonly isolated bacteria in cloacal samples were Aeromonas hydrophila and Escherichia coli, whereas in oral samples the most common bacteria were A. hydrophila and Arcanobacterium pyogenes. The bacteria isolated represent a potential threat to crocodile health during conditions of stress and a threat to human health through crocodile bites, crocodile meat consumption or carrying out activities in crocodile habitat. We especially warn about the presence of Salmonella arizonae and S. typhi, which cause enteritis and septicemia in crocodiles and salmonellosis and typhoid fever in humans. The risk of bacterial contamination from crocodiles to humans could increase in the future because of the accelerated destruction of crocodile habitat, which could lead to an augmentation of human-crocodile interactions. Information on bacterial diversity reported here could help in the choice of antibacterial products in case of infections that are of crocodile origin.

Bush animal attacks: management of complex injuries in a resource-limited setting

INTRODUCTION

Though animal-related injuries and fatalities have been documented throughout the world, the variety of attacks by wild animals native to rural East Africa are less commonly described. Given the proximity of our northwestern Tanzania hospital to Lake Victoria, Lake Tanganyika, and the Serengeti National Park, and presentation of several patients attacked by bush animals and suffering a variety of complex injuries, we sought to report the pattern of attacks and surgical management in a resource-limited setting.

MATERIALS AND METHODS

Four patients who were admitted to the northwestern Tanzania tertiary referral hospital, Bugando Medical Centre (BMC), in 2010-2011 suffered attacks by different bush animals: hyena, elephant, crocodile, and vervet monkey. These patients were triaged as trauma patients in the Casualty Ward, then admitted for inpatient monitoring and treatment. Their outcomes were followed to discharge.

RESULTS

The age and gender of the patients attacked was variable, though all but the pediatric patient were participating in food gathering or guarding activities in rural locations at the time of the attacks. All patients required surgical management of their injuries, which included debridement and closure of wounds, chest tube insertion, amputation, and external fixation of an extremity fracture. All patients survived and were discharged home.

DISCUSSION

Though human injuries secondary to encounters with undomesticated animals such as cows, moose, and camel are reported, they often are indirect traumas resulting from road traffic collisions. Snake attacks are well documented and common. However, this series of unique bush animal attacks describes the initial and surgical management of human injuries in the resource-limited setting of the developing world.

CONCLUSION

Animal attacks are common throughout the world, but their pattern may vary in Africa throughout jungle and bush environmental settings. It is important to understand the management of these attacks in resource-limited health care environment. Further, the growing population and human encroachment on previously wild habitats such as the northwestern Tanzania bush argues for increased community awareness to assist in prevention of human injuries by animals.

Microbiology of animal bite wound infections

The microbiology of animal bite wound infections in humans is often polymicrobial, with a broad mixture of aerobic and anaerobic microorganisms. Bacteria recovered from infected bite wounds are most often reflective of the oral flora of the biting animal, which can also be influenced by the microbiome of their ingested prey and other foods. Bacteria may also originate from the victim's own skin or the physical environment at the time of injury. Our review has focused on bite wound infections in humans from dogs, cats, and a variety of other animals such as monkeys, bears, pigs, ferrets, horses, sheep, Tasmanian devils, snakes, Komodo dragons, monitor lizards, iguanas, alligators/crocodiles, rats, guinea pigs, hamsters, prairie dogs, swans, and sharks. The medical literature in this area has been made up mostly of small case series or case reports. Very few studies have been systematic and are often limited to dog or cat bite injuries. Limitations of studies include a lack of established or inconsistent criteria for an infected wound and a failure to utilize optimal techniques in pathogen isolation, especially for anaerobic organisms. There is also a lack of an understanding of the pathogenic significance of all cultured organisms. Gathering information and conducting research in a more systematic and methodical fashion through an organized research network, including zoos, veterinary practices, and rural clinics and hospitals, are needed to better define the microbiology of animal bite wound infections in humans.