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Capybara Bites: Report of Human Injury Caused by a Hydrochoerus hydrochaeris
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–4, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.08.007
Clinical Communications: Adults CAPYBARA BITES: REPORT OF HUMAN INJURY CAUSED BY A HYDROCHOERUS HYDROCHAERIS Camille de Oliveira Vieira, MD,* Fred Bernardes Filho, MD,*† and Luna Azulay-Abulafia, MD, PHD† *Emergency Department, Policlı´nica Regional do Largo da Batalha, Nitero´i (RJ), Brazil and †Instituto de Dermatologia Professor Rubem David Azulay, Santa Casa da Miserico´rdia do Rio de Janeiro, Rio de Janeiro, Brazil Reprint Address: Fred Bernardes Filho, MD, Arnaldo Victaliano, 971/152. Jd. Palma Travassos, Ribeira˜o Preto (SP) 14091-220, Brazil
, Abstract—Background: Health care demand due to animal bites is frequent, especially in the emergency department (ED). In addition to the physical trauma caused by bites, one should be concerned with infectious diseases that can be transmitted. The range of the lesions depends on the animal species. Bites of Hydrochoerus hydrochaeris (capybaras) in humans are relatively uncommon. Capybaras are docile animals; however, their large rodent incisive teeth could cause serious injury. Localized care, antibiotic therapy when necessary, careful examination of the structures, tetanus and rabies immunization as indicated, and followup are recommended for wild animal bites. The authors hereby describe and discuss the medical management of a case of multiple lesions from capybara bites on the right thigh of a man. Case Report: A 54-year-old male patient was admitted to the ED with a compression bandage soaked with blood after being bitten by a capybara. At the clinical examination, the patient had two lacerating wounds and multiple abrasions on the anterior face of the right thigh. Rabies prophylaxis was administered and the wounds were irrigated and closed with sterile dressings. Oral amoxicillin/clavulanate potassium for 7 days was administered to the patient. The patient was followed up; 3 months after the attack he returned to his previous level of activity without any complication. Why Should an Emergency Physician Be Aware of This?: We recommend that practitioners and physicians should provide prompt attention
due to potentially significant morbidities, particularly rabies. The adequate care of the wound will allow better aesthetic and functional results to victims of wild animal bites. Ó 2015 Elsevier Inc. , Keywords—rodents; bites and stings; capybara; wild animal attack; wild animal trauma
INTRODUCTION Skin lesions caused by animal bites are globally prevalent and account for a large proportion of the cases of physical injury observed in emergency departments (EDs) (1,2). Typically, bite lesions are lacerating or cut-contusion wounds, with distinctive characteristics. The wounds are more elongated and are frequently V-shaped, showing no traces of suction; they result in deeper lesions, which are caused by the canine teeth, and they show diastemata (the gaps between two consecutive teeth) patterns that are unique for each animal species (3,4). The perforating wounds are associated with a high degree of infection, and the bites of wild animals provoke various lesions according to the tooth and the pressure of the bite (2,4). Injuries to humans caused by Hydrochoerus hydrochaeris (capybaras) are rare because capybaras are generally docile animals; however, their large rodent incisor teeth could cause serious wounds (5). The authors hereby describe and discuss the medical management of a case of multiple lesions from capybara
Research was performed in Instituto de Dermatologia Professor Rubem David Azulay, Santa Casa da Miserico´rdia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil.
RECEIVED: 15 March 2015; FINAL SUBMISSION RECEIVED: 28 July 2015; ACCEPTED: 8 August 2015 1
2
C.d.o. Vieira et al.
bites (Hydrochoerus hydrochaeris) on the right thigh of a man who was reported to have been bitten while protecting his pets against a capybara attack. CASE REPORT A 54-year-old male patient was admitted to the ED 30 min after being bitten by a capybara, which he captured and took to the Health Unit (Figure 1). The patient reported that he was working on his farm when he witnessed two of his dogs struggling with a capybara; he tried to separate the wild animal from his pets. The attacker was a solitary capybara, and the farmer was bitten in the right thigh. He arrived at the ED with a compression bandage soaked with blood and was admitted. His leg was dirty and there was extensive foreign matter in the wounds. Despite the hemorrhage caused by the wound, the patient was conscious, oriented, and eupneic, although he walked with difficulty due to the pain. The patient was attended by the first author. At clinical examination, the patient had two lacerating wounds and multiple abrasions on the anterior face of the right thigh (Figure 2). Thigh and leg extension and flexion were not impaired, and the digital exploration of the lesions revealed that the muscle layer was preserved. The neurovascular examination was normal. The results of the laboratory tests (hematology and biochemistry profiles) were within the normal ranges. These laboratory tests were performed due to the bleeding. The wounds were repeatedly rinsed with saline solution and alcohol-free chlorhexidine. The bite wounds were closed with sterile dressings. The prophylactic protocol against human rabies was performed, and daily occlusive bandages were applied with 1% silver sulfadiazine cream. The patient received a prescription for sodium diclofenac in case of pain and for amoxicillin/ clavulanic acid (500/125 mg) three times a day for
Figure 1. Capybara (Hydrochoerus hydrochaeris) captured by the patient.
Figure 2. Lacerating wounds and multiple abrasions on the anterior face of the right thigh.
7 days. Fifteen days after the attack, the lesions looked much better; there was mild erythema on the edges (Figure 3). At the final follow-up, 3 months after the attack, the patient had returned to his previous level of activity without complications. DISCUSSION Despite numerous recommendations from the medical and veterinary professions, injuries resulting from contact with animals remain a significant public health concern (1). Although the bite wound treatment involves some specific aspects of the animal aggressor, the overarching principles, such as identification and treatment of serious injury, tetanus, and secondary contamination prophylaxis, are independent of the involved animal. A satisfactory cosmetic result must be a goal, whenever possible. It is necessary to perform and document a detailed physical examination to evaluate the patient as to the existence of possible nerve, tendon, joint, and
Figure 3. Lesions after 15 days of daily bandages.
Capybara Bites
blood vessel damage. Therefore, the anatomical location of the injury, as well as any deviations from the anatomical position in normal rest, sensibility, motor strength, range of motion, skin color, and capillary refill should be documented. The wound must be explored in search of foreign bodies, including teeth or tooth fragments. The washing of the bite wound with copious amounts of saline fluid, and the remaining nonviable tissue debridement are part of the recommendations to control local infection. Surgical closure of animalbite wounds is controversial, and an evidence-based approach is lacking (2,4,6,7). Early management of the bite wounds seems to be correlated with lower infection rates and improved cosmetic outcomes regardless of whether the wound is closed or not. In this case, the presence of an extensive amount of foreign matter in the wounds indicates a contamination risk and was the reason that the first author decided not to perform surgical closure on the injuries. A decision to close wounds should be made on a caseby-case basis. Additionally, the patient was fully vaccinated and his immunization for tetanus was up to date; therefore, he did not receive antitetanus prophylaxis. The presence of deep, multiple or large lesions in any part of the body indicates a serious injury. According to the Brazilian Guidelines on Human Rabies Prophylaxis, wild animals like bats, monkeys, marmosets, fox, raccoon, skunk, and wild rodents, among others, should be classified as
3
risk animals for rabies transmission, even if they are domiciled or domesticated, given that in these animals, rabies is not well known (8). Antimicrobial prophylaxis must be oriented to the bacteria of the animal’s oral microbiota (9,10). There is a lack of published knowledge regarding oral flora of capybaras. Antibiotic chemoprophylaxis should ideally begin in the 8 h immediately after the accident in the case of moderate to serious wounds, particularly if edema and laceration are present (4). The patient received amoxicillin/clavulanic acid (500/125 mg) three times a day for 7 days, and this drug was chosen because its wide spectrum ensures positive results against the aerobic and anaerobic bacteria that generally infect these types of wounds (in most cases they are producers of b-lactamases). The most striking feature of the capybara is its size; it weighs an average of 50 kg and is the world’s largest rodent (11). The dental structure of this species is upper 1.0.1.3/lower 1.0.1.13, for a total of 20 teeth. There is a marked diastema separating the sharp incisive and the premolar teeth (Figure 4); the huge incisor teeth are more than 1 cm wide each at the cutting surface, and could reach 7 cm if they are not worn down by the animal biting rocks and tree trunks (5,11). In general, capybaras flee when they see human beings, and it is extremely rare for a capybara to be aggressive toward humans (5). They are potentially dangerous animals due to their sharp incisive teeth, and they might cause serious injuries if aggression occurs. Male capybaras are typically more
Figure 4. View of a capybara’s head (anatomic preparation) showing the animal’s teeth. (A) Frontal view; (B) lateral view. Photograph by Department of Veterinary Medicine, Fabio Barreto Zoo/Ribeira˜o Preto-SP.
4
aggressive in their habitat, and in areas with human interference they tend to develop nocturnal habits. If these animals perceive a threat, they could attack human beings. The presence of Hydrochoerus hydrochaeris in urban areas should be taken seriously. In this case, the aggressive behavior of the capybara probably occurred due to a perceived threat by the patient’s dogs. The injuries caused by Hydrochoerus hydrochaeris in our patient were considered to result from an accident and not an assault. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? Obtaining the history of the bite event is of major importance, including home treatment of wounds, body parts involved, and other symptoms. Educating patients about the risk of infection despite proper wound care, antibiotics (if indicated), and close follow-up care is very important. Even bite wounds that have received the best care may become infected. Teach patients the signs of infection and the need for prompt attention if the wound should become infected. Wild animals, especially larger ones, should be respected and avoided. Although generally shy and docile, capybaras are strong and capable of inflicting bites with serious consequences. Proper wound care, careful examination of structures, tetanus immunization, rabies prevention, appropriate antibiotics, and follow-up form part of the proper management of victims of capybara attacks. We suggest that the dissemination of guidelines for treating bite and sting injuries might reduce the number of injuries treated in EDs.
C.d.o. Vieira et al.
REFERENCES 1. Langley R, Mack K, Haileyesus T, Proescholdbell S, Annest JL. National estimates of noncanine bite and sting injuries treated in US Hospital Emergency Departments, 2001–2010. Wilderness Environ Med 2014;25:14–23. 2. Brook I. Management of human and animal bite wound infection: an overview. Curr Infect Dis Rep 2009;11:389–95. 3. Vanrell JP. Odontologia Legal e Antropologia Forense [Portuguese]. 2nd edn. Rio de Janeiro, Brazil: Guanabara Koogan; 2009. 4. Porto GG, Souza BLM, Sampaio DO. Management of animal bite injuries: case reports [Portuguese]. Rev Cir Traumatol BucoMaxilo-Fac 2013;13:39–44. 5. Moreira JR, Ferraz KMPMB, Herrera EA, MacDonald DW. Capybara: biology, use and conservation of an exceptional neotropical species. New York: Springer Science; 2013. 6. Abrahamian FM, Goldstein EJ. Microbiology of animal bite wound infections. Clin Microbiol Rev 2011;24:231–46. 7. Stefanopoulos PK, Tarantzopoulou AD. Facial bite wounds: management update. Int J Oral Maxillofac Surg 2005;34: 464–72. 8. Brasil. Ministe´rio da Sau´de. Secretaria de Vigilaˆncia em Sau´de. Departamento de Vigilaˆncia Epidemiolo´gica. Normas te´cnicas de profilaxia da raiva humana / Ministe´rio da Sau´de, Secretaria de Vigilaˆncia em Sau´de, Departamento de Vigilaˆncia Epidemiolo´gica. – Brası´lia. Ministe´rio da Sau´de, 2011. 60 p. [Portuguese]. Available at: http://www.saude.sp.gov.br/resources/instituto-pasteur/pdf/aten dimentomedico/normas_tecnicas_profilaxia_raiva.pdf. Accessed December 5, 2014 9. Goldstein EJ. New horizons in the bacteriology, antimicrobial susceptibility and therapy of animal bite wounds. J Med Microbiol 1998;47:95–7. 10. Levin ASS, Campos AF, Rossi Junior A, et al. Guia de utilizac¸a˜o de anti-infecciosos e recomendac¸o˜es para a prevenc¸a˜o de infecc¸o˜es hospitalares [Portuguese]. 5th edn. Sa˜o Paulo, Brazil: Hospital das Clı´nicas; 2011. 11. Universidade Federal de Vic¸osa. Centro de Cieˆncias Agra´rias. Departamento de Engenharia Florestal. A capivara: uma ampla revisa˜o sobre este animal ta˜o importante [Portuguese]. Available at: http:// ciflorestas.com.br/arquivos/d_d_d_10906.pdf. Accessed December 5, 2014.
http://dx.doi.org/10.1016/j.jemermed.2015.08.007
Clinical Communications: Adults CAPYBARA BITES: REPORT OF HUMAN INJURY CAUSED BY A HYDROCHOERUS HYDROCHAERIS Camille de Oliveira Vieira, MD,* Fred Bernardes Filho, MD,*† and Luna Azulay-Abulafia, MD, PHD† *Emergency Department, Policlı´nica Regional do Largo da Batalha, Nitero´i (RJ), Brazil and †Instituto de Dermatologia Professor Rubem David Azulay, Santa Casa da Miserico´rdia do Rio de Janeiro, Rio de Janeiro, Brazil Reprint Address: Fred Bernardes Filho, MD, Arnaldo Victaliano, 971/152. Jd. Palma Travassos, Ribeira˜o Preto (SP) 14091-220, Brazil
, Abstract—Background: Health care demand due to animal bites is frequent, especially in the emergency department (ED). In addition to the physical trauma caused by bites, one should be concerned with infectious diseases that can be transmitted. The range of the lesions depends on the animal species. Bites of Hydrochoerus hydrochaeris (capybaras) in humans are relatively uncommon. Capybaras are docile animals; however, their large rodent incisive teeth could cause serious injury. Localized care, antibiotic therapy when necessary, careful examination of the structures, tetanus and rabies immunization as indicated, and followup are recommended for wild animal bites. The authors hereby describe and discuss the medical management of a case of multiple lesions from capybara bites on the right thigh of a man. Case Report: A 54-year-old male patient was admitted to the ED with a compression bandage soaked with blood after being bitten by a capybara. At the clinical examination, the patient had two lacerating wounds and multiple abrasions on the anterior face of the right thigh. Rabies prophylaxis was administered and the wounds were irrigated and closed with sterile dressings. Oral amoxicillin/clavulanate potassium for 7 days was administered to the patient. The patient was followed up; 3 months after the attack he returned to his previous level of activity without any complication. Why Should an Emergency Physician Be Aware of This?: We recommend that practitioners and physicians should provide prompt attention
due to potentially significant morbidities, particularly rabies. The adequate care of the wound will allow better aesthetic and functional results to victims of wild animal bites. Ó 2015 Elsevier Inc. , Keywords—rodents; bites and stings; capybara; wild animal attack; wild animal trauma
INTRODUCTION Skin lesions caused by animal bites are globally prevalent and account for a large proportion of the cases of physical injury observed in emergency departments (EDs) (1,2). Typically, bite lesions are lacerating or cut-contusion wounds, with distinctive characteristics. The wounds are more elongated and are frequently V-shaped, showing no traces of suction; they result in deeper lesions, which are caused by the canine teeth, and they show diastemata (the gaps between two consecutive teeth) patterns that are unique for each animal species (3,4). The perforating wounds are associated with a high degree of infection, and the bites of wild animals provoke various lesions according to the tooth and the pressure of the bite (2,4). Injuries to humans caused by Hydrochoerus hydrochaeris (capybaras) are rare because capybaras are generally docile animals; however, their large rodent incisor teeth could cause serious wounds (5). The authors hereby describe and discuss the medical management of a case of multiple lesions from capybara
Research was performed in Instituto de Dermatologia Professor Rubem David Azulay, Santa Casa da Miserico´rdia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil.
RECEIVED: 15 March 2015; FINAL SUBMISSION RECEIVED: 28 July 2015; ACCEPTED: 8 August 2015 1
2
C.d.o. Vieira et al.
bites (Hydrochoerus hydrochaeris) on the right thigh of a man who was reported to have been bitten while protecting his pets against a capybara attack. CASE REPORT A 54-year-old male patient was admitted to the ED 30 min after being bitten by a capybara, which he captured and took to the Health Unit (Figure 1). The patient reported that he was working on his farm when he witnessed two of his dogs struggling with a capybara; he tried to separate the wild animal from his pets. The attacker was a solitary capybara, and the farmer was bitten in the right thigh. He arrived at the ED with a compression bandage soaked with blood and was admitted. His leg was dirty and there was extensive foreign matter in the wounds. Despite the hemorrhage caused by the wound, the patient was conscious, oriented, and eupneic, although he walked with difficulty due to the pain. The patient was attended by the first author. At clinical examination, the patient had two lacerating wounds and multiple abrasions on the anterior face of the right thigh (Figure 2). Thigh and leg extension and flexion were not impaired, and the digital exploration of the lesions revealed that the muscle layer was preserved. The neurovascular examination was normal. The results of the laboratory tests (hematology and biochemistry profiles) were within the normal ranges. These laboratory tests were performed due to the bleeding. The wounds were repeatedly rinsed with saline solution and alcohol-free chlorhexidine. The bite wounds were closed with sterile dressings. The prophylactic protocol against human rabies was performed, and daily occlusive bandages were applied with 1% silver sulfadiazine cream. The patient received a prescription for sodium diclofenac in case of pain and for amoxicillin/ clavulanic acid (500/125 mg) three times a day for
Figure 1. Capybara (Hydrochoerus hydrochaeris) captured by the patient.
Figure 2. Lacerating wounds and multiple abrasions on the anterior face of the right thigh.
7 days. Fifteen days after the attack, the lesions looked much better; there was mild erythema on the edges (Figure 3). At the final follow-up, 3 months after the attack, the patient had returned to his previous level of activity without complications. DISCUSSION Despite numerous recommendations from the medical and veterinary professions, injuries resulting from contact with animals remain a significant public health concern (1). Although the bite wound treatment involves some specific aspects of the animal aggressor, the overarching principles, such as identification and treatment of serious injury, tetanus, and secondary contamination prophylaxis, are independent of the involved animal. A satisfactory cosmetic result must be a goal, whenever possible. It is necessary to perform and document a detailed physical examination to evaluate the patient as to the existence of possible nerve, tendon, joint, and
Figure 3. Lesions after 15 days of daily bandages.
Capybara Bites
blood vessel damage. Therefore, the anatomical location of the injury, as well as any deviations from the anatomical position in normal rest, sensibility, motor strength, range of motion, skin color, and capillary refill should be documented. The wound must be explored in search of foreign bodies, including teeth or tooth fragments. The washing of the bite wound with copious amounts of saline fluid, and the remaining nonviable tissue debridement are part of the recommendations to control local infection. Surgical closure of animalbite wounds is controversial, and an evidence-based approach is lacking (2,4,6,7). Early management of the bite wounds seems to be correlated with lower infection rates and improved cosmetic outcomes regardless of whether the wound is closed or not. In this case, the presence of an extensive amount of foreign matter in the wounds indicates a contamination risk and was the reason that the first author decided not to perform surgical closure on the injuries. A decision to close wounds should be made on a caseby-case basis. Additionally, the patient was fully vaccinated and his immunization for tetanus was up to date; therefore, he did not receive antitetanus prophylaxis. The presence of deep, multiple or large lesions in any part of the body indicates a serious injury. According to the Brazilian Guidelines on Human Rabies Prophylaxis, wild animals like bats, monkeys, marmosets, fox, raccoon, skunk, and wild rodents, among others, should be classified as
3
risk animals for rabies transmission, even if they are domiciled or domesticated, given that in these animals, rabies is not well known (8). Antimicrobial prophylaxis must be oriented to the bacteria of the animal’s oral microbiota (9,10). There is a lack of published knowledge regarding oral flora of capybaras. Antibiotic chemoprophylaxis should ideally begin in the 8 h immediately after the accident in the case of moderate to serious wounds, particularly if edema and laceration are present (4). The patient received amoxicillin/clavulanic acid (500/125 mg) three times a day for 7 days, and this drug was chosen because its wide spectrum ensures positive results against the aerobic and anaerobic bacteria that generally infect these types of wounds (in most cases they are producers of b-lactamases). The most striking feature of the capybara is its size; it weighs an average of 50 kg and is the world’s largest rodent (11). The dental structure of this species is upper 1.0.1.3/lower 1.0.1.13, for a total of 20 teeth. There is a marked diastema separating the sharp incisive and the premolar teeth (Figure 4); the huge incisor teeth are more than 1 cm wide each at the cutting surface, and could reach 7 cm if they are not worn down by the animal biting rocks and tree trunks (5,11). In general, capybaras flee when they see human beings, and it is extremely rare for a capybara to be aggressive toward humans (5). They are potentially dangerous animals due to their sharp incisive teeth, and they might cause serious injuries if aggression occurs. Male capybaras are typically more
Figure 4. View of a capybara’s head (anatomic preparation) showing the animal’s teeth. (A) Frontal view; (B) lateral view. Photograph by Department of Veterinary Medicine, Fabio Barreto Zoo/Ribeira˜o Preto-SP.
4
aggressive in their habitat, and in areas with human interference they tend to develop nocturnal habits. If these animals perceive a threat, they could attack human beings. The presence of Hydrochoerus hydrochaeris in urban areas should be taken seriously. In this case, the aggressive behavior of the capybara probably occurred due to a perceived threat by the patient’s dogs. The injuries caused by Hydrochoerus hydrochaeris in our patient were considered to result from an accident and not an assault. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? Obtaining the history of the bite event is of major importance, including home treatment of wounds, body parts involved, and other symptoms. Educating patients about the risk of infection despite proper wound care, antibiotics (if indicated), and close follow-up care is very important. Even bite wounds that have received the best care may become infected. Teach patients the signs of infection and the need for prompt attention if the wound should become infected. Wild animals, especially larger ones, should be respected and avoided. Although generally shy and docile, capybaras are strong and capable of inflicting bites with serious consequences. Proper wound care, careful examination of structures, tetanus immunization, rabies prevention, appropriate antibiotics, and follow-up form part of the proper management of victims of capybara attacks. We suggest that the dissemination of guidelines for treating bite and sting injuries might reduce the number of injuries treated in EDs.
C.d.o. Vieira et al.
REFERENCES 1. Langley R, Mack K, Haileyesus T, Proescholdbell S, Annest JL. National estimates of noncanine bite and sting injuries treated in US Hospital Emergency Departments, 2001–2010. Wilderness Environ Med 2014;25:14–23. 2. Brook I. Management of human and animal bite wound infection: an overview. Curr Infect Dis Rep 2009;11:389–95. 3. Vanrell JP. Odontologia Legal e Antropologia Forense [Portuguese]. 2nd edn. Rio de Janeiro, Brazil: Guanabara Koogan; 2009. 4. Porto GG, Souza BLM, Sampaio DO. Management of animal bite injuries: case reports [Portuguese]. Rev Cir Traumatol BucoMaxilo-Fac 2013;13:39–44. 5. Moreira JR, Ferraz KMPMB, Herrera EA, MacDonald DW. Capybara: biology, use and conservation of an exceptional neotropical species. New York: Springer Science; 2013. 6. Abrahamian FM, Goldstein EJ. Microbiology of animal bite wound infections. Clin Microbiol Rev 2011;24:231–46. 7. Stefanopoulos PK, Tarantzopoulou AD. Facial bite wounds: management update. Int J Oral Maxillofac Surg 2005;34: 464–72. 8. Brasil. Ministe´rio da Sau´de. Secretaria de Vigilaˆncia em Sau´de. Departamento de Vigilaˆncia Epidemiolo´gica. Normas te´cnicas de profilaxia da raiva humana / Ministe´rio da Sau´de, Secretaria de Vigilaˆncia em Sau´de, Departamento de Vigilaˆncia Epidemiolo´gica. – Brası´lia. Ministe´rio da Sau´de, 2011. 60 p. [Portuguese]. Available at: http://www.saude.sp.gov.br/resources/instituto-pasteur/pdf/aten dimentomedico/normas_tecnicas_profilaxia_raiva.pdf. Accessed December 5, 2014 9. Goldstein EJ. New horizons in the bacteriology, antimicrobial susceptibility and therapy of animal bite wounds. J Med Microbiol 1998;47:95–7. 10. Levin ASS, Campos AF, Rossi Junior A, et al. Guia de utilizac¸a˜o de anti-infecciosos e recomendac¸o˜es para a prevenc¸a˜o de infecc¸o˜es hospitalares [Portuguese]. 5th edn. Sa˜o Paulo, Brazil: Hospital das Clı´nicas; 2011. 11. Universidade Federal de Vic¸osa. Centro de Cieˆncias Agra´rias. Departamento de Engenharia Florestal. A capivara: uma ampla revisa˜o sobre este animal ta˜o importante [Portuguese]. Available at: http:// ciflorestas.com.br/arquivos/d_d_d_10906.pdf. Accessed December 5, 2014.