Animal Bites: What to Do and What to Avoid Meg Fisher, MD Medical Director Disclosures I have no disclosures I do not plan to discuss off label uses of drugs Objectives Manage a child who is bitten Discuss the need for rabies vaccine following a bite Prescribe antibiotics for patients who have been bitten Consider This Case 13 yr Asian boy interrupted a dog and cat fight. He was bitten on his arm by his Yorkie. Wound is 1cm by 5 mm; he cleaned it at home. Immunizations: Boy all the usual; Dog all the usual; Cat - none Animal Bites: Epidemiology Accounts for 1% of emergency visits Often a pet: 90% dogs, 3 to 15% cats Inoculation of oral and skin flora Risk for infection: dog bite 3-18%, cat bite 30-80% Litwin. Pediatr Infect Dis J 2003;22:768 Rothe et al. Dtsch Arztebi Int 2015;112:433 Ellis et al. Am Fam Physician 2014;90:239 Consequences of Bites Damage to tissues, bone: crush injury Psychological injury: post-trauma stress Skin, soft tissue, skeletal infections Clenched fist injury: fractures, cuts Nail biting injury: newborn and infants, parent bites the child s nails Schalamon et al. Pediatrics 2006;117:e374 Peters et al. J Pediatr 2004;144:121
Acute Care Thoroughly clean the area with soap and water Anesthetize the area Debride damaged tissue Consider closure: worth the risk? Consider prophylactic antibiotics To Close or Not Cosmetic considerations Presence of sutures greatly increases risk for infection If wound is clean, closing is fine Wu et al. Pediatr Emerg Care 2011;27:801 Gurunluoglu et al. J Trauma Acute Care Surg. 2014;76:1294 Antibiotics or Not Risk for infection pretty high Antibiotics not always benign Cleaning the wound is most important Name the bug(s) to pick the drug(s) Mouth Flora Pasteurella multocida: cats and dogs Capnocytophaga canimorsus: dogs Oral anaerobes: all Streptobacillus moniliformis: rats Rabies: wild animals, bats Herpes simplex virus: people, Rabies American Academy of Pediatrics. Rabies. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of the Committee on Infectious Diseases American Academy of Pediatrics. Bite wounds. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of the Committee on Infectious Dis Skin and Other Flora Skin: Staphylococcus aureus, Streptococcus pyogenes Other: dirt, water, etc Antibiotic Prophylaxis Usual choice: amoxicillin/clavulanate What if you know the child carries methicillin resistant Staphylococcus aureus? What if the child is allergic to penicillin?
Tetanus Immunization Tetanus Clean, minor All other vaccine: prior Vaccine doses TIG Vaccine TIG <3, unknown Yes No Yes Yes 3 or more No* No No+ No, Tetanus Rabies Prophylaxis Animal Evaluation Prophylaxis? Dog, cat and ferrets Healthy, watch Not unless ill Rabid Yes Unknown Consult Yes Bat, skunk, etc Consider rabid Livestock, Consider each rodent, rabbit case, Rabies Consult; rare for rat, rabbit Rabies Prophylaxis Thoroughly wash and flush wound Rabies immune globulin: 20IU/kg infiltrated around the wound Rabies vaccine: 4 doses (days 0, 3, 7, and 14) 2015 Red Book. Rabies AAP. Pediatrics 2011;127:785 Complications of Bites Skin and soft tissue infection Skeletal infection: bone, joint, tendon Rat bite fever Rabies Monkeypox Rhea et al. Acad Emerg Med 2014;21:196 Skin, Soft Tissue, Skeletal Wound infection, cellulitis, tendon, bone and joint infection Warm, red, tender, swollen Foreign body increases risk: suture Lymphangiitis: group A streptococci Adenopathy: HSV, staphylococci Diagnosis Clinical Culture: especially for MRSA Gram stain Imaging
Antibiotics Route depends on illness Empiric: amoxicillin/clavulanate Specific: depends on infection and cause Clean and debride necrotic tissue Drain pus Remove sutures Herpetic Whitlow Example: Recurs at the same site Feder et al. Am j Dis Child 1983;137:861 Monkeypox Orthopox Cluster in Midwest, pet prairie dogs Vesicular lesion, Adenopathy West Africa rodents Reed et al. N Engl J Med 2004;350:342 Rat Bite Fever Streptobacillus moniliformis in the US Flu-like illness: chills, fever, myalgia, headache, vomiting Arthralgia or arthritis in half Complications: heart, CNS, lungs Relapsing course over about 3 weeks Zerbib et al. Clinical Pediatr 2013;52:96 Rabies Tingling at the bite site: first symptom Hydrophobia, encephalitis Paralysis to death Wild animals: bats, raccoons, foxes Incubation time depends on bite site Specific rabies therapy: 5 survivors www.mcw.edu/rabies 2015 Red Book. Rabies Prevention: Education Approach to animals: cautious Pets: avoid contact while pet eating Wild animals: avoid all contact Do not tease or provoke animals Dixon et al. J Pediatr 2012;160:337
Select A Pet Exotic animals generally not ideal pets Wild animals not good pets Reptiles, turtles carry risk of Salmonella Consider the child s developmental level Is the child immunocompromised? http://www.cdc.gov/healthypets/ Pickering et al. Pediatrics 2008;122:876 Considering The Case 13 yr Asian boy interrupted a dog and cat fight. Bad move but He was bitten on his arm by his Yorkie. Wound is 1cm by 5 mm; he cleaned it at home. Clean again; antibiotic maybe Immunizations: Boy all usual; Dog all usual; Cat none Cat needs a visit Take Home Messages Thoroughly clean bites with soap and water Consider suture risks and benefits Name the bugs to pick a drug Consider need for tetanus prophylaxis Consider need for rabies prophylaxis Prevention involves education about approaching animals, domestic and wild The End