- Email: [email protected]
Epidemiologic and clinical aspects of animal bite injuries
ORIG INAL CONTRIBUTION
Epidemiologic and Clinical Aspects of Animal Bite Injuries Kenneth W. Kizer, MD, MPH Mililani Town, Hawaii
During 1975, 332 animal bite injuries accounted for 1.2% of all surgical problems treated at the UCLA Hospital Emergency Department. Data on 307 bite injuries were available and analyzed for environmental, animal, human, interaction, and clinical factors. More than half of the dog bites and almos( three fourths of the cat bites-scratches happened at or near the victims' homes. Dog bites were almost twice as common among men, while cat bites-scratches were twice as common among women. Of the incidents in which ownership information was a~aUable, 85% of dog bites and 80% of cat bites-scratches were from an animal belonging to the victim, his family or friends, or another known person. Fortythree percent of dog bites, and 52% of cat bites-scratches were provoked, that is, happened while the victim was interacting with the animal. Of bites of the head and/or neck, 38% injured the upper lip; 17% of dog bites injured the eye or adjacent tissues; 48% were in children less than ten-years-old. One fifth of cat bites-scratches involved the head and/or neck, 60% of these injured orbital or periorbital tissues. Over 2% of patients were hospitalized. Five percent of dog " bite victims and 29% of cat bite-scratch victims returned with complications, mostly cellulitis or lymphangitis. Pasteurella multocida was the most common pathogen cultured, as evidenced by the 50% and 800 culture-positive rates for dog and cat bite-scratches respectively in this series. Kizer KW: Epidemiologic and clinical aspects of animal bite injuries. JACEP 8:134-141, April 1979.
bites and stings epidemiology INTRODUCTION
The American pet population numbers over 100 million cats and dogs and many more million rodents, reptiles, birds, tropical fish, horses and exotics (Time, December 23, 1974, pp 57-62; US News and World Report, July 26, 1976, pp 48-49). The ecological, socioeconomic, and health problems imposed (Table 1) by a poorly controlled pet population are numerous (US News and World Report, July 26, 1976, pp 48-49). 1-11 Of these, animal bites and related injuries create a community medical problem because of their frequency, preventability, potential severity, and increasing number~, 12-2e seen as "medical emergencies" by family physicians, surgeons and emergency physicians, and, consequently, their impact as a health care expense. Animal bites have been studied by reviewing s u r v e i l l a n c e reports,12"16,2°, 23,~4 by surveys, 19-23 and by examining health care records of selected populations, eg, postmen.26, e9-32 However, few studies have investigated animal bite injuries presenting to emergency departments.~S,~9,2e, ss-s5 This study investigated the epidemiologic and clinical aspects of animal bites and related injuries treated at a university hospital emergency department. From the UCLA Hospital Emergency Department. Dr. Kizer is currently at the Naval Regional Medical Clinic, Pearl Harbor, Hawaii. Address for reprints: Kenneth W. Kizer, MD, MPH, 95-180 Ihuku Place, Mililani Town, Hawaii 96789. The opinions contained herein are the private ones of the author and are not to be construed as official or reflecting the view of the NaW Department or the Naval service at, large.
8:4 (Ap ri I) 1979
JACEP
134/17
Table 1 PROBLEMS OF UNCONTROLLED PET POPULATION
Zoonotic and parasitic hazards Bite, scratch and related injuries Personal property damage Wildlife and stock destruction Traffic accident causation Noise pollution E x c r e m e n t and other solid waste disposal problems
40
~
3O
OTAL DOG
!20 .= 10 0
~ AN
CAT
MISCELLANEOUS FEB
JUN JUL AUG
M A R APR MAY
All cases listed in the daily register at the U n i v e r s i t y of California, Los A n g e l e s H o s p i t a l E m e r g e n c y D e p a r t m e n t with a chief diagnosis of a n i m a l bites were identified for the year 1975. H u m a n , insect, reptile, a n d fish b i t e s a n d / o r s t i n g s were excluded. Information was extracted from the emergency records the inpatient chart,~and, in cases where it was included, the A n i m a l Bite Report F o r m from t h e Los A n g e l e s C o u n t y D e p a r t m e n t of H e a l t h Services. (The information obtained was not similar in every case). The data was a n a l y z e d on the b a s i s of env i r o n m e n t a l , a n i m a l , h u m a n , interaction and clinical factors.
Table 2 TIME OF DAY Time*
% 0001 0601 1201 1801 After
to 0600 to 1200 to 1800 to 2400 24 hours**
2 20 35
(1) (10) (18)
6 26 32
(2) (9) (11)
18 18
(6) (6)
(55)
18
(8)
13
(29)
27
(14)
%
Dog (#)
%
C at (#)
71
(36)
M isc ella neous % (#)
Near or in victim's home
51
(110)
Near or in friend's home
12
(27)
6
(3)
3
(1)
5
(11)
15
(8)
38
(13)
32
(70)
8
(4)
18
(6)
Public place
18/135
(4) (36) (98)
Cat (#)
25
Locatio n
Of the 50,791 p a t i e n t s seen at the UCLA Hospital Emergency Dep a r t m e n t d u r i n g 1975, 28,402 were surgical cases. There were 332 animal bite injuries, 1.2% of all the surgical problems treated. Information was o b t a i n e d on 93% (307) of the a n i m a l bite cases and these are the basis of this report.
dog and cat bites was i n August, but t h e r e was no c l e a r s e a s o n a l dist r i b u t i o n ( F i g u r e ) . I n j u r i e s were
2 16 44
Miscellaneous % (#)
%
Table 3 GEOGRAPHIC SITE
Work
S e a s o n a l a n d daily distribution. The peak _occurrence of b o t h
Dog (#)
* Times indicated according to the 24-hour convention.... **The patient presented more than 24 hours after the ir~jury, and the actual time of the accident was not determined. -~
RESULTS
Environmental Factors
DEC
Fig. Monthly distribution of bites.
Exorbitant resource consumption Governmental administrative costs for animal c o n t r o l measures Litigation stemming from any of the proble, ms
METHODS
OCT .NOV
MONTH
Hypersensitivity reactions Anxiety and fear of attack by roaming animals
SEP
r a n d o m l y distributed throughout the week. T i m e o f d a y . Most b i t e s occurred during the afternoon and e a r l y e v e n i n g , w i t h t h e p e a k bet w e e n 1600 and 2000 hours: 37% of dog bites, 29% of cat bites-scratches, and 32% of miscellaneous bites occurred between these hours (Table 2). Several of the miscellaneous bites seen more t h a n 24 hours after the inc i d e n t were w i l d a n i m a l b i t e s in travelers. JACEP
41
(14)
G e o g r a p h i c location. Information on where the incident occurred was a v a i l a b l e for 98% of the dog bites and 100% of the cat and other a n i m a l bites (Table 3). More than h a l f of the dog b i t e s o c c u r r e d in e i t h e r the v i c t i m ' s or a close relative's home, or in the vicinity of that household. A third of the dog bites h a p p e n e d i n a public location. Almost three fourths of the cat bitesscratches h a p p e n e d at or n e a r the v i c t i m ' s home. The m i s c e l l a n e o u s 8:4 (April) 1979
bites at work were m a i n l y laboratory rat bites, while those o c c u r r i n g in public areas were u s u a l l y those from Mld animals. The victims of dog or cot bites-scratches incurred at work v¢ere i n v e t e r i n a r y a s s i s t a n t s or laboratory workers, policemen, anireal control personnel, delivery m e n or others of s i m i l a r occupations.
Table 4 SEX FREQUENCY Dog (#)
Sex %
%
Cat (#)
Miscellaneous % (#)
Men
62_(137)
33
(17)
50
(17)
Women
38
67
(34)
50
(17)
(85)
Human Factors Sex. Dog bites were almost twice as c o m m o n a m o n g m e n , w h e r e a s among women the opposite was true for cat bites-scratches. (Table 4). Age. C h i l d r e n and adolescents were victims in only a third of the dog bites (Table 5). For all bite victims, the t w e n t i e s were the peak ages.
Animal Factors B r e e d o r t y p e o f a n i m a l . Presumed i d e n t i f i c a t i o n of the type of dog was available in 60% of the cases (Table 6). Mixed breeds and G e r m a n shepherds accounted for 59%. Working dogs ( G e r m a n shepherds, Doberman p i n s c h e r s , St. Bernards, Great Danes, collies, huskies, sheep dogs, etc) accounted for 50% of the bites, while sporting dogs (pointers, setters, retrievers, spaniels, etc) accounted for only 13%. The prevalence of the various breeds is u n k n o w n . Two of the 51 cat bite-scratch injuries were from other t h a n ordinary domestic cats; one was from a cougar and the other was from a margay. Both were household pets. There was a wide distribution of miscellaneous types of bites (Table 7).
Interaction Factors R e l a t i o n s h i p o f the a n i m a l to the v i c t i m . The relationship of the animal to the victim was d e t e r m i n e d in 85% of the dog bites, 65% of the cat bites-scratches, and 92% of the miscellaneous types. There were three types of relationships: 1) the a n i m a l b e l o n g e d to t h e v i c t i m or close family; 2) the a n i m a l belonged to a friend or some other known person (this i n c l u d e s l a b o r a t o r y a n i reals), or 3) the a n i m a l was stray or wild (Table 8). Some misclassification is likely, b u t it i s a s s u m e d to have occurred r a n d o m l y . A l t h o u g h data was available in only 67% of the cat b i t e - s c r a t c h i n c i d e n t s , because 71% happened at the victim's home or t h a t of his immediate family, more than the n u m b e r listed probably were from the victim's own pet. Circumstances surrounding the i n c i d e n t . Information on the cir8:4 (April) 1979
Table 5 AGE DISTRIBUTION Age (years)
%
0 -4 5 -9 10 - 14 15 - 19 20 - 29 30 - 39 40 - 49 5O+
Dog (#)
8 11 6
(18) (25) (13)
%
Cat (#)
5 0 0
9 (20)
8
(4)
23 (51) 18 (40) 9 (19). 16 (36)
31 24 8 24
(16) (12) (4) (12)
%
Mixed breed German shepherd Terrier Cocker-spaniel Doberman pinscher St. Bernard Great Dane Poodle Others
31 28 5 4 4 4 4 4 16
%
(#)
6 (2) 6 (2) 3 (1) 9 (3) 38 (13) 14 ( 5 ) 12 ( 4 ) 12 ( 4 )
Table 7 MISCELLANEOUS BITES BY SPECIES
Table 6 DOG BITES ACCORDING TO BREED Breed
(3)
Miscellaneous
(#) (41) (37) 7) 6) 6) 5) 5) 5) (23)
Species Rodent* Monkey Horse Bat Kinkajou Coyote Macaw
%
(#)
65
(22)
15
5)
6 6 3 3 3
2) 2) 1) 1) 1)
*Rat, mouse, hamster, squirrel, and rabbit.
Table 8 RELATIONSHIP TO THE VICTIM Relationship %
Dog (#)
%
Victim's or family's pet
30
(57)
60
Friend's or other known person's pet
55
(104)
Stray or wild animal
15
(28)
cumstances u n d e r which curred was available in dog b i t e s , 45% of t h e scratches and 65% of the
JACEP
the bite oc57% of the cat b i t e s miscellane-
Cat (#)
Miscellaneous
%
(#)
(20)
38
(12)
20
(7)
40
(13)
20
(7)
22
(7)
ous types. The precipitating e v e n t s were divided into four categories: 1) A "vicious" bite occurred w h e n the v i c t i m h a d no i n t e n t i o n a l a n i m a l
136/19
contact. 2) A ~sick a n i m a l " bite res u l t e d from efforts to help a n injured a n i m a l or from a t o t a l l y unprovoked a t t a c k by a n o b v i o u s l y sick or inj u r e d animal. 3) A bite from a "fighting" a n i m a l occurred when the vict i m t r i e d to s e p a r a t e two or more a n i m a l s who w e r e f i g h t i n g . 4) A "provoked" bite h a p p e n e d w h e n the victim was i n t e n t i o n a l l y i n t e r a c t i n g in some w a y w i t h the a n i m a l prior to t h e i n j u r y - - e g , p l a y i n g , feeding, conducting an e x p e r i m e n t (Table 9). About 35% of t h e provoked dog bites happened while playing with the a n i m a l and 19% h a p p e n e d after s t a r t l i n g it. One f o u r t h of t h e cat bite-scratch injuries occurred while playing with t h e animal. S i x t y - t h r e e percent of the provoked miscellaneous types of bites r e s u l t e d from rodent l a b o r a t o r y experiments. Clinical Aspects
A n a t o m i c d i s t r i b u t i o n (Table 10). More t h a n a t h i r d (36%) of the dog bites to the head and/or neck inj u r e d t h e upper !ip. Nine percent of all dog bites involved injury to the lips. Seventeen p e r c e n t of t h e head injuries involved e i t h e r the eye or adj a c e n t structures. F o r t y - e i g h t percent of facial dog bites were in children less t h a n tela-years-old; 58% of all dog bites s u s t a i n e d by children who were less t h a n ten-years-old involved the h e a d and/or neck (Table 11). More t h a n t h r e e fourths of the dog bites i n v o l v e d t h e e x t r e m i t i e s . A n a r m or a h a n d was i n j u r e d in 45%; 29% i n v g l v e d one o r b o t h hands. More bft~es o c c u r r e d on the r i g h t h a n d (27%) t h a n the left (20%). A single lower e x t r e m i t y was bitten in 29%; of the cases s l i g h t l y less t h a n one fourth involved t h e foot or ankle. One fifth of the cat bite-scratch injuries involved the h e a d or neck; 60% of these injured e i t h e r the orbital or p e r i o r b i t a l tissues, and 40% of the victims s u s t a i n e d corneal abrasions. M o r e t h a n 70% o f t h e c a t b i t e scratch incidents involved t h e upper e x t r e m i t i e s , a n d 43% of t h e s e involved the hands. More t h a n 90% of the miscellaneous t y p e s of bites were on the arms or hands. T r e a t m e n t ( T a b l e 12). T r e a t m e n t w a s d i v i d e d i n t o five c a t e gories: 1) none ( p a t i e n t left before being seen); 2) w o u n d d e b r i d e m e n t a n d p a t i e n t i n s t r u c t i o n in selfa d m i n i s t e r e d wound care; 3) wound d e b r i d e m e n t , p r e s c r i p t i o n for antibiotics and other supportive measures (eg, heat, elevation); 4) wound d e b r i d e m e n t , p r i m a r y closure w i t h sutures, and prescription for antibio20/137
Table 9 CIRCUMSTANCES SURROUNDING INJURY Circumstances
Dog (#)
%
Cat (#)
39 (50) 5 (7) 13 (16) 43 (54)
17 9 22 52
(4) (2) (5) (12)
% Vicious Sick animal Fighting Provoked
Miscellaneous %
(#)
9 5 0 86
(2) (1) (19)
Table 10 ANATOMIC DISTRIBUTION Site
% Head and neck Right arm Left arm Trunk Right leg Left leg Multiple bites
Dog (#)
21 20 14 3 14 15 13
(47) (45) (32) (6) (31) (33) (28)
Table 11 AGE DISTRIBUTION OF DOG BITES INVOLVING THE HEAD OR NECK Age (years)
0to 5 to 10 to 15 to 20 to 30 to 40 to 50+
Percent
4 9 14 19 29 39 49
67 56 8 25 12 18 16 11
tics and supportive m e a s u r e s , and 5) h o s p i t a l i z a t i o n for o p e r a t i v e deb r i d e m e n t a n d r e p a i r of t h e wound and/or intravenous antibiotics. T e t a n u s toxoid was given in all cases if the p a t i e n t ' s i m m u n i z a t i o n was not current. Of a l l b i t e wounds, 56% were t r e a t e d w i t h antibiotics. In 12% of patients, wounds were sutured. Over 2% w e r e hospitalized. The a v e r a g e hospitalization period was four days. In addition, s e v e r a l visits to one or more specialty clinics were required after discharge. A n t i b i o t i c s ( T a b l e 13). O r a l penicillin, combined with procaine
JACEP
% 20 27 33 0 2 8 10
Cat (#)
(10) (14) (17) (1) (4) (5)
Miscellaneous %
(#)
3 41 50 6 0 0 0
(1) (13) (16) (2)
penicillin in a few cases, was used in over 60% of bite injuries. The second most c o m m o n a n t i b i o t i c chosen for dog bites was an b r a l cephalosporin, a n d for cat bites-scratches a penicillin analogue (either ampicillin, oxacillin or dicl0xacillin). Number of emergency dep a r t m e n t v i s i t s (Table 14). These n u m b e r s considerably underestimate t h e a c t u a l a m o u n t of m e d i c a l care g i v e n to t h e i n j u r y b e c a u s e many p a t i e n t s were referred to a surgical clinic or to a p r i v a t e p h y s i c i a n for follow-up. In addition, follow-up visits ~ were n o t always logged. The average n u m b e r of e m e r g e n c y d e p a r t m e n t visits for dog bites w a s 1.4; for cat bites-scratches, 1.5; a n d for miscellaneous bites, 1.1. C o m p l i c a t i o n s . F i v e percent of t h e dog bite victims r e t u r n e d with a c o m p l i c a t i o n ; a l l h a d c e l l u l i t i s or l y m p h a n g i t i s e x c e p t for o n e drug r e a c t i o n . None w e r e i n i t i a l l y prescribed antibiotics. F o u r of t h e nine cases of ceUulitis h a d c u l t u r e s taken; t w o w e r e p o s i t i v e for Pasteurella multocida in addition to staphylococcus or streptococcus. Osteomyelitis or tenosynovitis was not seen in three cases that l~.d compound hand fractures. Of the cat b i t e - s c r a t c h injuries 29% r e t u r n e d w i t h e i t h e r cellulitis or l y m p h a n g i t i s w i t h or w i t h o u t single or m u l t i p l e abscesses. Of these, 60% h a d received initial medical evalua-
8:4 (April) 1979
tion more t h a n 24 hours after t h e accident. F i v e of t h e 15 c a s e s (33%) were cultured, four were positive for p. multocida alone or w i t h a n o t h e r organism. A t h i r d of these complicationS occurred in p e r s o n s o v e r 50years-old. Ten p e r c e n t of t h e r a t b i t e patients r e t u r n e d w i t h cellulitis; one required a d m i s s i o n for i n t r a v e n o u s a n t i b i o t i c s . No c u l t u r e d a t a w a s available. There were no known complications a m o n g t h e five m o n k e y bites. No f a t a l i t i e s occurred, nor were there any eases of sepsis or other disseminated disease. No eases of rabies occurred, and no a n t i r a b i e s prophylaxis was given. No i n f o r m a t i o n was available on t h e c o m p l i c a t i o n s not seen in t h e U C L A E m e r g e n c y Department for follow-up, w h i c h was known to have h a p p e n e d in a few instances.
Table 12 TREATMENT Treatment
%
Not seen Debridement and " self-care Debridement, antibiotics, and supportive care Debridement, suturing, antibiotics, and supportive care Admission to the hospital
8:4 (April) 1979
(#)
Cat
(#)
%
2 .-(4)
Miscellaneous % (#)
2 (1)
6
(2)
43 (95)
31
(16)
53 (18)
40 (88)
57 (29)
32 (11)
14 (32)
4
(2)
6 (2)
1 (3)
6
(3)
3
(I)
Table 13 ANTIBIOTICS
DISCUSSION More t h a n a m i l l i o n bite injuries are r e p o r t e d in t h e U n i t e d S t a t e s each year, and this p r o b a b l y represents only 25% to 50% of all such incidents (Time, December 23, 1974, pp 57-62; US News and World Report, J u l y 26, 1976, pp 4849).1°,12,21,29,31,8~, z7 In 1972, a n i m a l bites were the fourth most often volu n t a r i l y r e p o r t e d d i s e a s e to t h e Center for D i s e a s e C o n t r o l . 2° The overwhelming majority are from dogs, w i t h cats b e i n g t h e second leading o f f e n d e r . 1 4 - ] 6,2°-22,24,26, 33 A l t h o u g h t h e incidence of animal bites h a s r i s e n to epidemic proportions i n r e c e n t y e a r s , b i t e s are still not recognized as a significant health c a r e problem2°,12-~4,1%2°, 2~ The frequency of dog bites in large metropolitan a r e a s h a s been reported between 319 a n d 1,231 c a s e s p e r 100,000 population2,12,1a-15,19-21,2~ Certain a r e a s in west Texas report a bite r a t e of 2,059 per 100,000. 2~ If one a s s u m e s in u r b a n incidence of 775 bite i n j u r i e s per 100,000 population a n d a r e p o r t i n g r a t e of 50%, then the e s t i m a t e d a n n u a l US incidence of a n i m a l b i t e s is a b o u t 3.5 million. More t h a n 1% of all c h i l d r e n , perhaps as m a n y as 15%, are injured by dog bites each y e a r 12,22,a~ a7 Rice et al as c a l c u l a t e d t h a t a n i m a l bites were the fourth l e a d i n g cause of accidents in children. W h e n t h e cost of medical t r e a t m e n t , Suspect a n i m a l surveillance, public h e a l t h investigation of reported bites, and other associated expenses are totaled, a n i m a l
Dog
Antibiotic
Dog
None Penicillin Cephalosporin Erythromycin Tetracycline Penicillin analogues Miscellaneous combinations
%
(#)
46 36 8 3 2
(102) (79) (17) ( 6) ( 4)
%
Cat
(#)
33 (17)
2
1)
62 23 3 3 3
16
8)
6
6
3)
0
33 (17) 6 3) 4 2)
3(7) 3 (7)
Miscellaneous % (#) (21) (8) (1) (1) (1) 2)
Table 14 NUMBER OF VISITS Number %
Dog (#)
73 (161) 20 (45) 5 (10)
One
Two Three
Cat (#)
Miscellaneous % (#)
75 (38) 15 ( 8 ) 2 (1)
94 (32) 3 (1) 0
%
Four Five
2 (4) 0.5 ( 1 )
4 (2) o
3 (1) o
Six
0.5 ( 1 )
4 (2)
0
bites figure to be one of the more expensive childhood diseases. 21 A l t h o u g h not a l l a n i m a l bite and r e l a t e d i n j u r i e s a r e t r e a t e d in e m e r g e n c y m e d i c a l facilities, these incidents still cofi~stitute a significant
JACEP
proportion of t h e t r a u m a seen there. The n u m b e r of these injuries t r e a t e d at the UCLA Emergency Departm e n t is c o m p a r a b l e to t h a t reported by o t h e r s as b e i n g between 1% and 2% of all surgical problems. 27-29
138/21
Most s t u d i e s have s h o w n t h a t a n i m a l bites u s u a l l y happen d u r i n g the warm months. 1,13-16,22,24,25,2%34,a5 There was no clear seasonal distribution in this study, probably due to the good weather year around in southern California. A similar lack of seasonal variations was noted in northern Florida. 2s The peak occurrence of' a n i m a l bites in the late afternoon and early e v e n i n g correlates with the time of' day that people are most actively involved with their pets and has been ~bserved by others.~2,~a,22,25, 27 Dog bites are t r a d i t i o n a l l y considered a p r o b l e m of c h i l d r e n a n d certain occupational groups.'2,1'~-lS,20-22,24-,,7,2~ C h i l d r e n are at higher risk because of their interaction with household a n i m a l s , their more freq u e n t abuse of, and inexperience in, handling animals, their curiosity and recklessness, t h e i r relative ina b i l i t y to defend t h e m s e l v e s , a n d their proclivity for active and aggressive p a s t i m e s t h a t t e n d to excite animals. However, children accounted for only one fourth of the dog bite cases i n our study. The even distribution of dog bites with respect to age may' reflect the age structure of west Los Angeles or it may indicate that the problem is more widespread t h a n previously believed. The sex distribution of dog and cat bites in our cases is s i m i l a r to that reported elsewhere.S,12,~4,~6,~7, 2°21,24-28,'~1,39The propensity for men to be bitten by dogs may be due to the male preferenc@Lfbr dogs as pets, a tendency for m e n to be more daring and aggressive with dogs, and a greater likelihood for m e n to have oceupat i o n s t h a t expose t h e m to a n i m a l bites. The g r e a t e r incidence of cat bite-scratch injuries among w o m e n is probably related to their preference for cats as pets. The mixed breed and G e r m a n shepherd have been identified as the most f r e q u e n t o f f e n d e r s i n o t h e r studies.15,1s,25,26, 29.al,a° Undoubtedly, t h i s r e f l e c t s t h e v e r y l a r g e n u m b e r of mongrels in the dog popul a t i o n a n d t h e p o p u l a r i t y of the German shepherd. Despite this, the high frequency of reported G e r m a n shepherd bites can be partially attributed to t h e i r t e n d e n c y to react vic-iously in certain situations. The need for b e t t e r control of pets and safer a n i m a l h a n d l i n g pracrices is apparent. More t h a n twice as m a n y dog bites occurred i n public areas t h a n could be accounted for by stray animals. A significant n u m b e r happened on or in the immediate vic-
22/139
i n i t y of the victim's property by a dog owned by someone else. M a n y of the bites reported as b e i n g from stray a n i m a l s were probably also due to r o a m i n g pets. The high proportion of b i t i n g dogs w i t h k n o w n owners (85%) h a s b e e n n o t e d p r e v i ously. 12-14'20'21'27 The a n i m a l bites problem is not due to strays. Data on circumstances surrounding the injury m u s t be cautiously interpreted because of poor reporting a n d a n i n h e r e n t b i a s on the p a r t of some v i c t i m s to b l a m e the anim a l r e g a r d l e s s of t h e a c t u a l circumstances. However, the large n u m b e r of bites r e s u l t i n g from victim provocation or the victim t r y i n g to s e p a r a t e f i g h t i n g a n i m a l s indicates the need for better education on safe a n i m a l h a n d l i n g practices. This is especially t r u e fbr five- to nineyear-old children where a third of the b i t e s w e r e provoked. Y o u n g children's limited capacity to u n d e r s t a n d a n d a n t i c i p a t e the r e s u l t s of t h e i r b e h a v i o r u n d e r s c o r e s the need for better supervision when they are in the presence of animals. Conversely, the m a n y unprovoked dog bites emphasize the need for pet owners to a s s u m e r e s p o n s i b i l i t y for e n s u r i n g t h a t t h e i r a n i m a l s do n o t h a r m others. The anatomic d i s t r i b u t i o n of dog bites in this series is s i m i l a r to that found previously.* About three fourths of all bites involve the extremities with a roughly equal division b e t w e e n the u p p e r a n d lower limbs. People use their extremities to w a r d off a t t a c k i n g a n i m a l s , or to provoke them, and the limbs provide a better biting surface than the t r u n k . The p r e d i l e c t i o n of y o u n g children to suffer facial bites is due to their size, their heads being closer to the a n i m a l ' s head, a n d a greater tendency to place v u l n e r a b l e pieces of a n a t o m y a t r i s k . T h e l a r g e n u m b e r of upper lip bites is probably due to being bitten while k i s s i n g the animal. 2~ Because of the greater possibility of h a v i n g to give postexposure rabies prophylaxis as a result of facial bites,al,a6, 37 as well as their g r e a t e r p o t e n t i a l for c o s m e t i c s e q u e l a e , t h e i r h i g h i n c i d e n c e in children is disturbing. Similarly, the n u m b e r of cat scratches to the eyes has potential for serious outcome. T h e c o m p l i c a t i o n s of a n i m a l b i t e s are n u m e r o u s a n d i n c l u d e cosmetic disfigurement (scars,
* 13,15116118120-23,25~27128,33135139~43
JACEP
keloids), d e v e l o p m e n t of epidermal i n c l u s i o n cysts, f u n c t i o n a l impair. m e n t (eg, r e s u l t i n g from fractures or tendon damage), and psychologi. cal t r a u m a . However, the most con~. m o n postbite c o n c e r n is infection, which can take the form of cellulitis, lymphangitis, abscess formation, ten. osynovitis, osteomyelitis, sepsis or o t h e r d i s s e m i n a t e d infection. Well known diseases t r a n s m i t t e d by ani. mal bite-scratch injuries include pasteurellosis, leptospirosis, Erysipelo. thrix, bubonic plague, rat bite fever, sporotrichosis, t u l a r e m i a , cat scratch d i s e a s e , t e t a n u s , gas gangrene, rabies, and B a c t e r o i d e s a n d other g r a m - n e g a t i v e a n a e r o b i c infee. tions 17,35-37,41,43-59 The cosmopolitan n a t u r e of the west Los Angeles popu. lation necessitates t h a t the physician consider exotic zoonoses. Appropriate i m m u n i z a t i o n s and m e d i c a l treat. m e n t minimizes the risk of sequelae. However, the possible occurrence of a n y of s e v e r a l of t h e s e infectious complications make each bite injury potentially life-threatening. To most, though, rabies is the d r e a d e d c o n s e q u e n c e of an animal bite. Although the likelihood of being exposed to rabies from a household a n i m a l has decreased m a r k e d l y over the past 25 years, b i t e - s c r a t c h inj u r i e s from r o a n / i n g dogs and cats r e m a i n the p r i m a r y reason for giving a n t i r a b i e s ~treatment2°, 61 More than 30,000 persons undergo postexposure rabies t r e a t m e n t each year because of a n i m a l bites, m a n y unnecessarily (US News and World Report, July 26, 1976, pp 48-49). 4,s,9,aG,as,~l-sa Several factors d e t e r m i n e the need for prophylactic treatment.S,9,a6,aT,39,41,42,60-62 Although wild a n i m a l s are now the most likely source of rabies for both h u m a n s and domestic animals in the United States, the s.poradic c a s e s of r a b i e s r e s u l t i n g from domestic a n i m a F bites requires that the possibility be considered2 °,~,64 T h e p r o x i m i t y of Los A n g e l e s to Mexican border towns, the mobility of its population, and the Occurrence of epizootic canine rabies along the USM e x i c a n border requires physicians in southern California to m a i n t a i n an appropriate index of suspicion in all anirnal bite cases. ~5-67 The recent dev e l o p m e n t of H u m a n Diploid Cell Rabies Vaccine appears to represent a s u b s t a n t i a l i m p r o v e m e n t in poste x p o s u r e t r e a t m e n t of s u s p e c t e d rabies exposure. 2%6%6s The dog bite complication rate of 5% seen in this series is comparable to others ls,19,29,ax,aa and supports the belief t h a t dog bites m a y be closed
8:4 (April) 1979
p er 15,18 i m~19~25,28-33,43 aa frt eir lgood y
local wound
car The high rate of infection complicating cat bites is s i m il a r to t h a t ~oted by D o u g l a s , 33 and is p a r t l y due to d e l a y e d m e d i c a l a t t e n t i o n . More important, however, is the nature of t h e typical cat bite injury: a puncture wo u n d in which infective organisms are d e p o s it e d deep into tissues. This allows small abscesses to d e v e l o p t h a t c a n p r o g r e s s to tenosynovitis or other disseminated infection. 18,1 9,3 3 The 2% hospitalization rate for bite injuries in this study is similar to previous observation, as is the average length of hospitalization, is,22,29,a' In a d d i t i o n to s t a p h y l o c o c c i , streptococci, d i p h t h e r o i d s , pseudomonas, p r o t e u s species, coliforms, clostridia, and N e i s s e r i a which can be cultured from a n i m a l bite wounds, p m u l t o c i d a is a common pathogen, as ev i d en ced by th e 50% and 80% c u l t u r e - p o s i t i v e r a t e s for dog a n d cat bites, r e s p e c t i v e l y , seen in our series. A l t h o u g h P r n u l t o c i d a is part of the n o r m a l flora of the upper respiratory t r a c t of m a n y ' d o m e s t i c animals and m o s t c o m m o n l y p r e s e n t s as an infected a n i m a l bite, it has a variety of manifestations in man.lS,4~, 44,46-51,5~-57,71 p rnultocida is not often identified as t h e infecting agent because it is not suspected, not cultured, or not identified since t h e r e is nothing distinctive abou~ its'Clinical presentation. Penicillin is universally considered the d r u g of c h o i c e to t r e a t t h i s pathogen. A cephalosporin is generally c o n s i d e r e d t h e drug of second choice, a l t h o u g h t e t r a c y c l i n e is so c o n s i d e r e d by s o m e . 2 7 , 3 9 , 4 s , 5 5 , 5 7 T r e a t m e n t failures with erythromycin have been noted. 4s The f r e q u e n t use of antibiotics o b s e r v e d in o u r c a s e s t y p i f i e s the concern for infec£ious complications. Recent reports of sepsis with a Bact e r o i d s species f o l l o w i n g dog b i t e s and associated with r e n a l failure and disseminated i n t r a v a s c u l a r coagulation, e m p h a s i z e t h e p o t e n t i a l seriousness of these injuries.52, 53 The use of p e n i c i l l i n or o t h e r a n t i b i o t i c prophylaxis, in all but t r i v i a l bite injuries, should be considered. BeCause of the difficulty t h a t m a y be involved in i d e n t i f y i n g t h e p a t h o g e n i c organism from infected bite wounds, it seems p r u d e n t to o b t a i n anaerobic cultures early. CONCLUSION Pet a n i m a l bites r e p r e s e n t a significant proportion of the accidental i n j u r i e s t r e a t e d in e m e r g e n c y de-
8:4 (April) 1979
p a r t m e n t s an d t h e y a c c o u n t for a s u b s t a n t i a l e x p e n d i t u r e of h e a l t h care resources. The physical, e m o : t i o n a l an d socioeconomic m o r b i d i t y r e s u l t i n g from these injuries can be reduced by control of t h e pet population explosion, by more responsible pet ownership, by b e t t e r education about household a n i m a l s and by e f . fective an d uniform s u r v e i l l a n c e of a n i m a l bite injuries. The physician's office, t h e e m e r g e n c y d e p a r t m e n t , and local medical societies can play a role in e d u c a t i o n . In addition, the h e a l t h care c o m m u n i t y needs to give its full support to local agencies concerned w i t h a n i m a l r e g u l a t i o n and control. To be successful, any educational p r o g r am on this problem will have to enlist t h e support of law enforcement agencies, local g o v e r n m e n t and the g e n e r a l public. It will have to promote a full u n d e r s t a n d i n g of the pet population problem in all segments of the community. A n y antibite prog r a m must be p r o h u m a n , especially prochild, and not anticanine or antipet. It m u s t stress both the benefits and the dangers of pets, and the importance of informed and i n t e l l i g e n t h u m a n - a n i m a l interaction.
REFERENCES 1. Klein D: Friendly dog syndrome. N Y State J IVied 66:2306-2309, 1966. 2. Cohen D: Community health and animal populations. A r c h E n v i r o n Health 17:1-3, 1968. 3. Beck AM: The public health implications of urban dogs. A m J Public Health 65:1315-1318, 1975, 4. Feldman BM, Carding TH: Freeroaming urban pets. Health Services Reports 88:956-962, 1973. 5. Robinson D: Canis familiaris. N Engl J Med 290:1378-1379, 1974. 6. Sheridan JP: Dogs, cats and other pets. Practitioner 215:172-177, 1975. 7. Carithers HA: Pets in the home: Incidence and significance. P e d i a t r i c s 21:840-848, 1958. 8. Currier RW, McCroan JE, Dreesen DW, et ah Epidemiology of antirabies treatment in Georgia, 1967-71. Public Health Rep 90:435-439, 1975. 9. Schnurrenberger PR, Martin RJ, Meerdink GL, et al: Epidemiology of human exposure to rabid animals in Illinois. Public Health Rep 84:1078-1084, 1969. 10. Bennett JS: Man's best friend? Can Med Assoc J 116:126, 1977. 11. Seah SKK, Hucal G, Law C: Dogs and intestinal parasites: a public health problem. C a n , M e d Assoc J 112:11911194, 1975.
JACEP
12. Beck AM, Loring H, Lockwood R: The ecology of dog bite injury in St. Louis, Missouri. Public Health Rep 90:262-267, 1975. 13. Harris D, Imperato PJ, Oken B: Dog bites - - an unrecognized epidemic. Bull N Y Acad IVied 50:981-1000, 1974. 14. Berzon DR, Farber RE, Gordon J, et " a[: Animal bites in a large city - - A report on Baltimore, Maryland. A m Public Health 62:422-426, 1972. 15. Morton C: Dog bites in Norfolk, Va. Health Services Reports 88:59-64, 1973. 16. Mayers SP, Beachley RG: A survey of dog bites in Arlington. Va Med 82:317319, 1955. 17. Berzon DR, DeHoffJB: Medical costs and other aspects of dog bites in Baltimore. P u b l i c H e a l t h Re]) 89:377-381, 1974. 18. Graham WP, Calabretta AM, Miller SH: Dog bites. A m Faro Physician 15: 132-137, 1977. °
19. Callaham ML: Treatment of common dog bites: Infection risk factors. J A C E P 7:83-87, 1978. 20. Moore RM, Zehmer RB, Moulthrop Ji, et al: Surveillance of animal bite cases in the United States, 1971-1972. A r c h Environ Health 34:267-270, 1977. 21. Newman EC: Animal bites as a public health disease. Tex M e d 73:49-52, 1977. 22. Hervey E: Incidence of bites due to dogs and other animals in Leeds. Br Med J 3:53-54, 1977. 23. Scarcella JV: Management of bites. Ohio State Med J 65:25-31, 1969. 24. Olsen CD: Epidemiology of animal exposures. Nebr Med J 46:143-145, 1961. 25. Parrish HM, Clark FB, Brobst D, et al: Epidemiology of dog bites. P u b l i c Health Rep 74:891-903, 1959. 26. Lockwood R, Beck AM: Dog bites among letter carriers in St. Louis. Public Health Rep 90:267-269, 1975. 27. Brobst D, Parrish HM, Clark FB: The animal bite problem. Vet Med 54:251-256, 1959. 28. Carithers HA: Mammalian bites of children. A m J Dis C h i l d 95:150-156, 1958. 29. Schultz RC, McMaster WC: The treatment of dog bite injuries, especially of the face. Plast Reconstr Surg. 49:494500, 1972. 30. Barclay TL: Dog bites of the face. B r J Plast Surg 9:34-37, 1956-57. 31. Chair LA, Spitz L: Dog bite injuries in children. S A f r M e d J 49:718-720, 1975. 32. Thompson HG, Svitek V: Small animal bites: The role of primary closure. J Trauma 13:20-23, 1973. 33. Douglas LG: Bite wounds. A m Faro Physician 11:93-99, 1975.
140/23
34. Sokol AB, Houser RG: Dog bites: prev e n t i o n and t r e a t m e n t . Clin Pediatr 10:336-338, 1971.
47. Tindall JP, Harrison CM: Pasteurella multocida infections following animal injuries, especially cat bites. Arch Dermatol
35. Ford WJA: The t r e a t m e n t of dog bites and t h e r a b i e s p r o b l e m . A m J Surg 93:678-681, 1957.
105:412-416, 1972.
36. Kaplan C (ed): Rabies - - T h e Facts. Oxford University Press, 1977. 37. Arena JM: Bites, zoonoses and rabies. Clin Pediatr 6:259-260, 1967. 38. Rice RG, Starbuck GW, Reed: Accidental injuries to children. N Engl J Med 255:1212-1219, 1956. 39. M a r t i n RJ, S c h n u r r e n b e r g e r PR, Rose NJ: Epidemiology of rabies vaccinations of persons in Illinois, 1967-68. Public Health Rep 84:1069-1077, 1969. 40. Berson DR: The animal bite epidemic in Baltimore, Maryland: Review and update. A m J Pub Health 68:593-595, 1978. 41. S h a h U, J a s w a l GS: V i c t i m s of a rabid wolf: Effects of severity and location of bites on development of rabies. J Infec Dis 134:25-29, 1976. 42. E l l e n b o g e n C: P o s t e x p o s u r e ant i r a b i e s t h e r a p y . A m F a m Physician 15:138-145, 1977. 43. Lee MLH, Buhr AJ: Dog bites and local infections with Pasteurella septica. Br Med J 1:169-1711 1960. 44. Hubbert WT, McCulloch WF, Schnurrenberger RP: Diseases Transmitted From Animals To Man, ed 6. Springfield, Illinois, Charles C. Thomas Publishers, 1975. 45. Plague - - United States. Morbidity and Mortality Weekly Report 26:337, 1977.
48. S w a r t z MN, Kunz LJ: Pasteurella multocida infections in man. N Engl J Med 261:889-893, 1959. 49. Henderson A: Pasteurella multocida infections in man: a review of the literature. Antonie van Leewenhock 29:359-367, 1963. 50. Holmes MA, Brandon G: Pasteurella multocida i n f e c t i o n s in 16 p e r s o n s in Oregon. Public Health Rep 80:1107-1112, 1965. 51. Torphy DE, Ray CG: Pasteurella multocida in dog and c a t bite infections. Pediatrics 43:295-297, 1969. 52. Butler T, Weaver RE, Ramani TKV, et al: Unidentified Gram-negative rod infection: a new disease of man. Ann Intern Med 86:1-5, 1977. 53. Fiala M, Bauer H, Khaleeli M, et al: Dog bite, Bacteroides infection, coagulopathy, renal microangiopathy. Ann intern Med 87:248-249, 1977. 54. Meyers BR, Hirschman SZ, Sloan W: G e n e r a l i z e d S c h w a r t z m a n r e a c t i o n in m a n a f t e r dog bite. A n n Intern Med 73:433-438, 1970. 55. Allott EN, C r i c k s h a n k R, CyrlasWilliams R, et al: Infection of cat-bite and dog-bite wounds with Pasteurella septica. J Pathol 56:411-415, 1944. 56. Holloway WJ, Scott EG, Adams VB:
Pasteurella multocida infections in man. A m J Clin Pathol 51:705-708, 1969.
domestic animal bites and scratches.
57. Johnson RH, Rumans LW: Unusual infections c a u s e d by Pasteurella multocida. J A M A 237:146-147, 1977.
J A M A 233:42-45~. 1975.
58. Quenzen RW, Mostow SR, Emerson
46. Francis DP, Holmes MA, Brandon G:
Pasteurella multocida infections after
24/141
JACEP
JK: Cat-bite tularemia. J A M A 238:1845, 1977. 59. T u l a r e m i a - - Colorado. Morbidity and Mortality Weekly Report 26:117, 1977. 60. Public H e a l t h S e r v i c e Advisory Committee on I m m u n i z a t i o n Practices: Rabies. Morbidity and Mortality Weekly Report 25:403-406, 1976. 61. Postexposure Rabies T r e a t m e n t Georgia. Morbidity and Mortality Weekly Report 26:92, 1977. 62. Changes in Rabies Control. Morbidity and Mortality Weekly Report 24:82, 1975. 63. Center for Disease Control: Rodent rabies in the United States. J Infec Dis 126:565-567, 1972. 64. Rabies - - Minnesota. Morbidity and Mortality Weekly Report 24:59, 1975. 65. Animal rabies - - Worldwide. Morbidity and Mortality Weekly Report 25:317, 1976. 66. C a n i n e Rabies - - Laredo, Texas.
Morbidity and Mortality Weekly Report 26:8, 1977. 67. Follow-up on canine rabies - - Laredo, Texas, Nuevo Laredo, Mexico. Morbidity and Mortality Weekly Report 26:59, 1977. 68. H u m a n rabies - - Texas. Morbidity and Mortality Weekly Report 26:31-32, 1977. 69. Bahmanyar M, Fayaz A, Nour-Salehi S, et al: Successful protection of humans e x p o s e d to r a b i e s i n f e c t i o n . J A M A 236:2751-27'54, 1976. 70. A ne~y rabies vaccine. The Medical
Letter 19:43-44, 1977. 71. Milder JE, Hall NK, Pinley RA: Pasteurella multocida pneumonia and bact e r e m i a . S o u t h Med J 70:1123-1124, 1977.
8:4 (April) 1979
Epidemiologic and Clinical Aspects of Animal Bite Injuries Kenneth W. Kizer, MD, MPH Mililani Town, Hawaii
During 1975, 332 animal bite injuries accounted for 1.2% of all surgical problems treated at the UCLA Hospital Emergency Department. Data on 307 bite injuries were available and analyzed for environmental, animal, human, interaction, and clinical factors. More than half of the dog bites and almos( three fourths of the cat bites-scratches happened at or near the victims' homes. Dog bites were almost twice as common among men, while cat bites-scratches were twice as common among women. Of the incidents in which ownership information was a~aUable, 85% of dog bites and 80% of cat bites-scratches were from an animal belonging to the victim, his family or friends, or another known person. Fortythree percent of dog bites, and 52% of cat bites-scratches were provoked, that is, happened while the victim was interacting with the animal. Of bites of the head and/or neck, 38% injured the upper lip; 17% of dog bites injured the eye or adjacent tissues; 48% were in children less than ten-years-old. One fifth of cat bites-scratches involved the head and/or neck, 60% of these injured orbital or periorbital tissues. Over 2% of patients were hospitalized. Five percent of dog " bite victims and 29% of cat bite-scratch victims returned with complications, mostly cellulitis or lymphangitis. Pasteurella multocida was the most common pathogen cultured, as evidenced by the 50% and 800 culture-positive rates for dog and cat bite-scratches respectively in this series. Kizer KW: Epidemiologic and clinical aspects of animal bite injuries. JACEP 8:134-141, April 1979.
bites and stings epidemiology INTRODUCTION
The American pet population numbers over 100 million cats and dogs and many more million rodents, reptiles, birds, tropical fish, horses and exotics (Time, December 23, 1974, pp 57-62; US News and World Report, July 26, 1976, pp 48-49). The ecological, socioeconomic, and health problems imposed (Table 1) by a poorly controlled pet population are numerous (US News and World Report, July 26, 1976, pp 48-49). 1-11 Of these, animal bites and related injuries create a community medical problem because of their frequency, preventability, potential severity, and increasing number~, 12-2e seen as "medical emergencies" by family physicians, surgeons and emergency physicians, and, consequently, their impact as a health care expense. Animal bites have been studied by reviewing s u r v e i l l a n c e reports,12"16,2°, 23,~4 by surveys, 19-23 and by examining health care records of selected populations, eg, postmen.26, e9-32 However, few studies have investigated animal bite injuries presenting to emergency departments.~S,~9,2e, ss-s5 This study investigated the epidemiologic and clinical aspects of animal bites and related injuries treated at a university hospital emergency department. From the UCLA Hospital Emergency Department. Dr. Kizer is currently at the Naval Regional Medical Clinic, Pearl Harbor, Hawaii. Address for reprints: Kenneth W. Kizer, MD, MPH, 95-180 Ihuku Place, Mililani Town, Hawaii 96789. The opinions contained herein are the private ones of the author and are not to be construed as official or reflecting the view of the NaW Department or the Naval service at, large.
8:4 (Ap ri I) 1979
JACEP
134/17
Table 1 PROBLEMS OF UNCONTROLLED PET POPULATION
Zoonotic and parasitic hazards Bite, scratch and related injuries Personal property damage Wildlife and stock destruction Traffic accident causation Noise pollution E x c r e m e n t and other solid waste disposal problems
40
~
3O
OTAL DOG
!20 .= 10 0
~ AN
CAT
MISCELLANEOUS FEB
JUN JUL AUG
M A R APR MAY
All cases listed in the daily register at the U n i v e r s i t y of California, Los A n g e l e s H o s p i t a l E m e r g e n c y D e p a r t m e n t with a chief diagnosis of a n i m a l bites were identified for the year 1975. H u m a n , insect, reptile, a n d fish b i t e s a n d / o r s t i n g s were excluded. Information was extracted from the emergency records the inpatient chart,~and, in cases where it was included, the A n i m a l Bite Report F o r m from t h e Los A n g e l e s C o u n t y D e p a r t m e n t of H e a l t h Services. (The information obtained was not similar in every case). The data was a n a l y z e d on the b a s i s of env i r o n m e n t a l , a n i m a l , h u m a n , interaction and clinical factors.
Table 2 TIME OF DAY Time*
% 0001 0601 1201 1801 After
to 0600 to 1200 to 1800 to 2400 24 hours**
2 20 35
(1) (10) (18)
6 26 32
(2) (9) (11)
18 18
(6) (6)
(55)
18
(8)
13
(29)
27
(14)
%
Dog (#)
%
C at (#)
71
(36)
M isc ella neous % (#)
Near or in victim's home
51
(110)
Near or in friend's home
12
(27)
6
(3)
3
(1)
5
(11)
15
(8)
38
(13)
32
(70)
8
(4)
18
(6)
Public place
18/135
(4) (36) (98)
Cat (#)
25
Locatio n
Of the 50,791 p a t i e n t s seen at the UCLA Hospital Emergency Dep a r t m e n t d u r i n g 1975, 28,402 were surgical cases. There were 332 animal bite injuries, 1.2% of all the surgical problems treated. Information was o b t a i n e d on 93% (307) of the a n i m a l bite cases and these are the basis of this report.
dog and cat bites was i n August, but t h e r e was no c l e a r s e a s o n a l dist r i b u t i o n ( F i g u r e ) . I n j u r i e s were
2 16 44
Miscellaneous % (#)
%
Table 3 GEOGRAPHIC SITE
Work
S e a s o n a l a n d daily distribution. The peak _occurrence of b o t h
Dog (#)
* Times indicated according to the 24-hour convention.... **The patient presented more than 24 hours after the ir~jury, and the actual time of the accident was not determined. -~
RESULTS
Environmental Factors
DEC
Fig. Monthly distribution of bites.
Exorbitant resource consumption Governmental administrative costs for animal c o n t r o l measures Litigation stemming from any of the proble, ms
METHODS
OCT .NOV
MONTH
Hypersensitivity reactions Anxiety and fear of attack by roaming animals
SEP
r a n d o m l y distributed throughout the week. T i m e o f d a y . Most b i t e s occurred during the afternoon and e a r l y e v e n i n g , w i t h t h e p e a k bet w e e n 1600 and 2000 hours: 37% of dog bites, 29% of cat bites-scratches, and 32% of miscellaneous bites occurred between these hours (Table 2). Several of the miscellaneous bites seen more t h a n 24 hours after the inc i d e n t were w i l d a n i m a l b i t e s in travelers. JACEP
41
(14)
G e o g r a p h i c location. Information on where the incident occurred was a v a i l a b l e for 98% of the dog bites and 100% of the cat and other a n i m a l bites (Table 3). More than h a l f of the dog b i t e s o c c u r r e d in e i t h e r the v i c t i m ' s or a close relative's home, or in the vicinity of that household. A third of the dog bites h a p p e n e d i n a public location. Almost three fourths of the cat bitesscratches h a p p e n e d at or n e a r the v i c t i m ' s home. The m i s c e l l a n e o u s 8:4 (April) 1979
bites at work were m a i n l y laboratory rat bites, while those o c c u r r i n g in public areas were u s u a l l y those from Mld animals. The victims of dog or cot bites-scratches incurred at work v¢ere i n v e t e r i n a r y a s s i s t a n t s or laboratory workers, policemen, anireal control personnel, delivery m e n or others of s i m i l a r occupations.
Table 4 SEX FREQUENCY Dog (#)
Sex %
%
Cat (#)
Miscellaneous % (#)
Men
62_(137)
33
(17)
50
(17)
Women
38
67
(34)
50
(17)
(85)
Human Factors Sex. Dog bites were almost twice as c o m m o n a m o n g m e n , w h e r e a s among women the opposite was true for cat bites-scratches. (Table 4). Age. C h i l d r e n and adolescents were victims in only a third of the dog bites (Table 5). For all bite victims, the t w e n t i e s were the peak ages.
Animal Factors B r e e d o r t y p e o f a n i m a l . Presumed i d e n t i f i c a t i o n of the type of dog was available in 60% of the cases (Table 6). Mixed breeds and G e r m a n shepherds accounted for 59%. Working dogs ( G e r m a n shepherds, Doberman p i n s c h e r s , St. Bernards, Great Danes, collies, huskies, sheep dogs, etc) accounted for 50% of the bites, while sporting dogs (pointers, setters, retrievers, spaniels, etc) accounted for only 13%. The prevalence of the various breeds is u n k n o w n . Two of the 51 cat bite-scratch injuries were from other t h a n ordinary domestic cats; one was from a cougar and the other was from a margay. Both were household pets. There was a wide distribution of miscellaneous types of bites (Table 7).
Interaction Factors R e l a t i o n s h i p o f the a n i m a l to the v i c t i m . The relationship of the animal to the victim was d e t e r m i n e d in 85% of the dog bites, 65% of the cat bites-scratches, and 92% of the miscellaneous types. There were three types of relationships: 1) the a n i m a l b e l o n g e d to t h e v i c t i m or close family; 2) the a n i m a l belonged to a friend or some other known person (this i n c l u d e s l a b o r a t o r y a n i reals), or 3) the a n i m a l was stray or wild (Table 8). Some misclassification is likely, b u t it i s a s s u m e d to have occurred r a n d o m l y . A l t h o u g h data was available in only 67% of the cat b i t e - s c r a t c h i n c i d e n t s , because 71% happened at the victim's home or t h a t of his immediate family, more than the n u m b e r listed probably were from the victim's own pet. Circumstances surrounding the i n c i d e n t . Information on the cir8:4 (April) 1979
Table 5 AGE DISTRIBUTION Age (years)
%
0 -4 5 -9 10 - 14 15 - 19 20 - 29 30 - 39 40 - 49 5O+
Dog (#)
8 11 6
(18) (25) (13)
%
Cat (#)
5 0 0
9 (20)
8
(4)
23 (51) 18 (40) 9 (19). 16 (36)
31 24 8 24
(16) (12) (4) (12)
%
Mixed breed German shepherd Terrier Cocker-spaniel Doberman pinscher St. Bernard Great Dane Poodle Others
31 28 5 4 4 4 4 4 16
%
(#)
6 (2) 6 (2) 3 (1) 9 (3) 38 (13) 14 ( 5 ) 12 ( 4 ) 12 ( 4 )
Table 7 MISCELLANEOUS BITES BY SPECIES
Table 6 DOG BITES ACCORDING TO BREED Breed
(3)
Miscellaneous
(#) (41) (37) 7) 6) 6) 5) 5) 5) (23)
Species Rodent* Monkey Horse Bat Kinkajou Coyote Macaw
%
(#)
65
(22)
15
5)
6 6 3 3 3
2) 2) 1) 1) 1)
*Rat, mouse, hamster, squirrel, and rabbit.
Table 8 RELATIONSHIP TO THE VICTIM Relationship %
Dog (#)
%
Victim's or family's pet
30
(57)
60
Friend's or other known person's pet
55
(104)
Stray or wild animal
15
(28)
cumstances u n d e r which curred was available in dog b i t e s , 45% of t h e scratches and 65% of the
JACEP
the bite oc57% of the cat b i t e s miscellane-
Cat (#)
Miscellaneous
%
(#)
(20)
38
(12)
20
(7)
40
(13)
20
(7)
22
(7)
ous types. The precipitating e v e n t s were divided into four categories: 1) A "vicious" bite occurred w h e n the v i c t i m h a d no i n t e n t i o n a l a n i m a l
136/19
contact. 2) A ~sick a n i m a l " bite res u l t e d from efforts to help a n injured a n i m a l or from a t o t a l l y unprovoked a t t a c k by a n o b v i o u s l y sick or inj u r e d animal. 3) A bite from a "fighting" a n i m a l occurred when the vict i m t r i e d to s e p a r a t e two or more a n i m a l s who w e r e f i g h t i n g . 4) A "provoked" bite h a p p e n e d w h e n the victim was i n t e n t i o n a l l y i n t e r a c t i n g in some w a y w i t h the a n i m a l prior to t h e i n j u r y - - e g , p l a y i n g , feeding, conducting an e x p e r i m e n t (Table 9). About 35% of t h e provoked dog bites happened while playing with the a n i m a l and 19% h a p p e n e d after s t a r t l i n g it. One f o u r t h of t h e cat bite-scratch injuries occurred while playing with t h e animal. S i x t y - t h r e e percent of the provoked miscellaneous types of bites r e s u l t e d from rodent l a b o r a t o r y experiments. Clinical Aspects
A n a t o m i c d i s t r i b u t i o n (Table 10). More t h a n a t h i r d (36%) of the dog bites to the head and/or neck inj u r e d t h e upper !ip. Nine percent of all dog bites involved injury to the lips. Seventeen p e r c e n t of t h e head injuries involved e i t h e r the eye or adj a c e n t structures. F o r t y - e i g h t percent of facial dog bites were in children less t h a n tela-years-old; 58% of all dog bites s u s t a i n e d by children who were less t h a n ten-years-old involved the h e a d and/or neck (Table 11). More t h a n t h r e e fourths of the dog bites i n v o l v e d t h e e x t r e m i t i e s . A n a r m or a h a n d was i n j u r e d in 45%; 29% i n v g l v e d one o r b o t h hands. More bft~es o c c u r r e d on the r i g h t h a n d (27%) t h a n the left (20%). A single lower e x t r e m i t y was bitten in 29%; of the cases s l i g h t l y less t h a n one fourth involved t h e foot or ankle. One fifth of the cat bite-scratch injuries involved the h e a d or neck; 60% of these injured e i t h e r the orbital or p e r i o r b i t a l tissues, and 40% of the victims s u s t a i n e d corneal abrasions. M o r e t h a n 70% o f t h e c a t b i t e scratch incidents involved t h e upper e x t r e m i t i e s , a n d 43% of t h e s e involved the hands. More t h a n 90% of the miscellaneous t y p e s of bites were on the arms or hands. T r e a t m e n t ( T a b l e 12). T r e a t m e n t w a s d i v i d e d i n t o five c a t e gories: 1) none ( p a t i e n t left before being seen); 2) w o u n d d e b r i d e m e n t a n d p a t i e n t i n s t r u c t i o n in selfa d m i n i s t e r e d wound care; 3) wound d e b r i d e m e n t , p r e s c r i p t i o n for antibiotics and other supportive measures (eg, heat, elevation); 4) wound d e b r i d e m e n t , p r i m a r y closure w i t h sutures, and prescription for antibio20/137
Table 9 CIRCUMSTANCES SURROUNDING INJURY Circumstances
Dog (#)
%
Cat (#)
39 (50) 5 (7) 13 (16) 43 (54)
17 9 22 52
(4) (2) (5) (12)
% Vicious Sick animal Fighting Provoked
Miscellaneous %
(#)
9 5 0 86
(2) (1) (19)
Table 10 ANATOMIC DISTRIBUTION Site
% Head and neck Right arm Left arm Trunk Right leg Left leg Multiple bites
Dog (#)
21 20 14 3 14 15 13
(47) (45) (32) (6) (31) (33) (28)
Table 11 AGE DISTRIBUTION OF DOG BITES INVOLVING THE HEAD OR NECK Age (years)
0to 5 to 10 to 15 to 20 to 30 to 40 to 50+
Percent
4 9 14 19 29 39 49
67 56 8 25 12 18 16 11
tics and supportive m e a s u r e s , and 5) h o s p i t a l i z a t i o n for o p e r a t i v e deb r i d e m e n t a n d r e p a i r of t h e wound and/or intravenous antibiotics. T e t a n u s toxoid was given in all cases if the p a t i e n t ' s i m m u n i z a t i o n was not current. Of a l l b i t e wounds, 56% were t r e a t e d w i t h antibiotics. In 12% of patients, wounds were sutured. Over 2% w e r e hospitalized. The a v e r a g e hospitalization period was four days. In addition, s e v e r a l visits to one or more specialty clinics were required after discharge. A n t i b i o t i c s ( T a b l e 13). O r a l penicillin, combined with procaine
JACEP
% 20 27 33 0 2 8 10
Cat (#)
(10) (14) (17) (1) (4) (5)
Miscellaneous %
(#)
3 41 50 6 0 0 0
(1) (13) (16) (2)
penicillin in a few cases, was used in over 60% of bite injuries. The second most c o m m o n a n t i b i o t i c chosen for dog bites was an b r a l cephalosporin, a n d for cat bites-scratches a penicillin analogue (either ampicillin, oxacillin or dicl0xacillin). Number of emergency dep a r t m e n t v i s i t s (Table 14). These n u m b e r s considerably underestimate t h e a c t u a l a m o u n t of m e d i c a l care g i v e n to t h e i n j u r y b e c a u s e many p a t i e n t s were referred to a surgical clinic or to a p r i v a t e p h y s i c i a n for follow-up. In addition, follow-up visits ~ were n o t always logged. The average n u m b e r of e m e r g e n c y d e p a r t m e n t visits for dog bites w a s 1.4; for cat bites-scratches, 1.5; a n d for miscellaneous bites, 1.1. C o m p l i c a t i o n s . F i v e percent of t h e dog bite victims r e t u r n e d with a c o m p l i c a t i o n ; a l l h a d c e l l u l i t i s or l y m p h a n g i t i s e x c e p t for o n e drug r e a c t i o n . None w e r e i n i t i a l l y prescribed antibiotics. F o u r of t h e nine cases of ceUulitis h a d c u l t u r e s taken; t w o w e r e p o s i t i v e for Pasteurella multocida in addition to staphylococcus or streptococcus. Osteomyelitis or tenosynovitis was not seen in three cases that l~.d compound hand fractures. Of the cat b i t e - s c r a t c h injuries 29% r e t u r n e d w i t h e i t h e r cellulitis or l y m p h a n g i t i s w i t h or w i t h o u t single or m u l t i p l e abscesses. Of these, 60% h a d received initial medical evalua-
8:4 (April) 1979
tion more t h a n 24 hours after t h e accident. F i v e of t h e 15 c a s e s (33%) were cultured, four were positive for p. multocida alone or w i t h a n o t h e r organism. A t h i r d of these complicationS occurred in p e r s o n s o v e r 50years-old. Ten p e r c e n t of t h e r a t b i t e patients r e t u r n e d w i t h cellulitis; one required a d m i s s i o n for i n t r a v e n o u s a n t i b i o t i c s . No c u l t u r e d a t a w a s available. There were no known complications a m o n g t h e five m o n k e y bites. No f a t a l i t i e s occurred, nor were there any eases of sepsis or other disseminated disease. No eases of rabies occurred, and no a n t i r a b i e s prophylaxis was given. No i n f o r m a t i o n was available on t h e c o m p l i c a t i o n s not seen in t h e U C L A E m e r g e n c y Department for follow-up, w h i c h was known to have h a p p e n e d in a few instances.
Table 12 TREATMENT Treatment
%
Not seen Debridement and " self-care Debridement, antibiotics, and supportive care Debridement, suturing, antibiotics, and supportive care Admission to the hospital
8:4 (April) 1979
(#)
Cat
(#)
%
2 .-(4)
Miscellaneous % (#)
2 (1)
6
(2)
43 (95)
31
(16)
53 (18)
40 (88)
57 (29)
32 (11)
14 (32)
4
(2)
6 (2)
1 (3)
6
(3)
3
(I)
Table 13 ANTIBIOTICS
DISCUSSION More t h a n a m i l l i o n bite injuries are r e p o r t e d in t h e U n i t e d S t a t e s each year, and this p r o b a b l y represents only 25% to 50% of all such incidents (Time, December 23, 1974, pp 57-62; US News and World Report, J u l y 26, 1976, pp 4849).1°,12,21,29,31,8~, z7 In 1972, a n i m a l bites were the fourth most often volu n t a r i l y r e p o r t e d d i s e a s e to t h e Center for D i s e a s e C o n t r o l . 2° The overwhelming majority are from dogs, w i t h cats b e i n g t h e second leading o f f e n d e r . 1 4 - ] 6,2°-22,24,26, 33 A l t h o u g h t h e incidence of animal bites h a s r i s e n to epidemic proportions i n r e c e n t y e a r s , b i t e s are still not recognized as a significant health c a r e problem2°,12-~4,1%2°, 2~ The frequency of dog bites in large metropolitan a r e a s h a s been reported between 319 a n d 1,231 c a s e s p e r 100,000 population2,12,1a-15,19-21,2~ Certain a r e a s in west Texas report a bite r a t e of 2,059 per 100,000. 2~ If one a s s u m e s in u r b a n incidence of 775 bite i n j u r i e s per 100,000 population a n d a r e p o r t i n g r a t e of 50%, then the e s t i m a t e d a n n u a l US incidence of a n i m a l b i t e s is a b o u t 3.5 million. More t h a n 1% of all c h i l d r e n , perhaps as m a n y as 15%, are injured by dog bites each y e a r 12,22,a~ a7 Rice et al as c a l c u l a t e d t h a t a n i m a l bites were the fourth l e a d i n g cause of accidents in children. W h e n t h e cost of medical t r e a t m e n t , Suspect a n i m a l surveillance, public h e a l t h investigation of reported bites, and other associated expenses are totaled, a n i m a l
Dog
Antibiotic
Dog
None Penicillin Cephalosporin Erythromycin Tetracycline Penicillin analogues Miscellaneous combinations
%
(#)
46 36 8 3 2
(102) (79) (17) ( 6) ( 4)
%
Cat
(#)
33 (17)
2
1)
62 23 3 3 3
16
8)
6
6
3)
0
33 (17) 6 3) 4 2)
3(7) 3 (7)
Miscellaneous % (#) (21) (8) (1) (1) (1) 2)
Table 14 NUMBER OF VISITS Number %
Dog (#)
73 (161) 20 (45) 5 (10)
One
Two Three
Cat (#)
Miscellaneous % (#)
75 (38) 15 ( 8 ) 2 (1)
94 (32) 3 (1) 0
%
Four Five
2 (4) 0.5 ( 1 )
4 (2) o
3 (1) o
Six
0.5 ( 1 )
4 (2)
0
bites figure to be one of the more expensive childhood diseases. 21 A l t h o u g h not a l l a n i m a l bite and r e l a t e d i n j u r i e s a r e t r e a t e d in e m e r g e n c y m e d i c a l facilities, these incidents still cofi~stitute a significant
JACEP
proportion of t h e t r a u m a seen there. The n u m b e r of these injuries t r e a t e d at the UCLA Emergency Departm e n t is c o m p a r a b l e to t h a t reported by o t h e r s as b e i n g between 1% and 2% of all surgical problems. 27-29
138/21
Most s t u d i e s have s h o w n t h a t a n i m a l bites u s u a l l y happen d u r i n g the warm months. 1,13-16,22,24,25,2%34,a5 There was no clear seasonal distribution in this study, probably due to the good weather year around in southern California. A similar lack of seasonal variations was noted in northern Florida. 2s The peak occurrence of' a n i m a l bites in the late afternoon and early e v e n i n g correlates with the time of' day that people are most actively involved with their pets and has been ~bserved by others.~2,~a,22,25, 27 Dog bites are t r a d i t i o n a l l y considered a p r o b l e m of c h i l d r e n a n d certain occupational groups.'2,1'~-lS,20-22,24-,,7,2~ C h i l d r e n are at higher risk because of their interaction with household a n i m a l s , their more freq u e n t abuse of, and inexperience in, handling animals, their curiosity and recklessness, t h e i r relative ina b i l i t y to defend t h e m s e l v e s , a n d their proclivity for active and aggressive p a s t i m e s t h a t t e n d to excite animals. However, children accounted for only one fourth of the dog bite cases i n our study. The even distribution of dog bites with respect to age may' reflect the age structure of west Los Angeles or it may indicate that the problem is more widespread t h a n previously believed. The sex distribution of dog and cat bites in our cases is s i m i l a r to that reported elsewhere.S,12,~4,~6,~7, 2°21,24-28,'~1,39The propensity for men to be bitten by dogs may be due to the male preferenc@Lfbr dogs as pets, a tendency for m e n to be more daring and aggressive with dogs, and a greater likelihood for m e n to have oceupat i o n s t h a t expose t h e m to a n i m a l bites. The g r e a t e r incidence of cat bite-scratch injuries among w o m e n is probably related to their preference for cats as pets. The mixed breed and G e r m a n shepherd have been identified as the most f r e q u e n t o f f e n d e r s i n o t h e r studies.15,1s,25,26, 29.al,a° Undoubtedly, t h i s r e f l e c t s t h e v e r y l a r g e n u m b e r of mongrels in the dog popul a t i o n a n d t h e p o p u l a r i t y of the German shepherd. Despite this, the high frequency of reported G e r m a n shepherd bites can be partially attributed to t h e i r t e n d e n c y to react vic-iously in certain situations. The need for b e t t e r control of pets and safer a n i m a l h a n d l i n g pracrices is apparent. More t h a n twice as m a n y dog bites occurred i n public areas t h a n could be accounted for by stray animals. A significant n u m b e r happened on or in the immediate vic-
22/139
i n i t y of the victim's property by a dog owned by someone else. M a n y of the bites reported as b e i n g from stray a n i m a l s were probably also due to r o a m i n g pets. The high proportion of b i t i n g dogs w i t h k n o w n owners (85%) h a s b e e n n o t e d p r e v i ously. 12-14'20'21'27 The a n i m a l bites problem is not due to strays. Data on circumstances surrounding the injury m u s t be cautiously interpreted because of poor reporting a n d a n i n h e r e n t b i a s on the p a r t of some v i c t i m s to b l a m e the anim a l r e g a r d l e s s of t h e a c t u a l circumstances. However, the large n u m b e r of bites r e s u l t i n g from victim provocation or the victim t r y i n g to s e p a r a t e f i g h t i n g a n i m a l s indicates the need for better education on safe a n i m a l h a n d l i n g practices. This is especially t r u e fbr five- to nineyear-old children where a third of the b i t e s w e r e provoked. Y o u n g children's limited capacity to u n d e r s t a n d a n d a n t i c i p a t e the r e s u l t s of t h e i r b e h a v i o r u n d e r s c o r e s the need for better supervision when they are in the presence of animals. Conversely, the m a n y unprovoked dog bites emphasize the need for pet owners to a s s u m e r e s p o n s i b i l i t y for e n s u r i n g t h a t t h e i r a n i m a l s do n o t h a r m others. The anatomic d i s t r i b u t i o n of dog bites in this series is s i m i l a r to that found previously.* About three fourths of all bites involve the extremities with a roughly equal division b e t w e e n the u p p e r a n d lower limbs. People use their extremities to w a r d off a t t a c k i n g a n i m a l s , or to provoke them, and the limbs provide a better biting surface than the t r u n k . The p r e d i l e c t i o n of y o u n g children to suffer facial bites is due to their size, their heads being closer to the a n i m a l ' s head, a n d a greater tendency to place v u l n e r a b l e pieces of a n a t o m y a t r i s k . T h e l a r g e n u m b e r of upper lip bites is probably due to being bitten while k i s s i n g the animal. 2~ Because of the greater possibility of h a v i n g to give postexposure rabies prophylaxis as a result of facial bites,al,a6, 37 as well as their g r e a t e r p o t e n t i a l for c o s m e t i c s e q u e l a e , t h e i r h i g h i n c i d e n c e in children is disturbing. Similarly, the n u m b e r of cat scratches to the eyes has potential for serious outcome. T h e c o m p l i c a t i o n s of a n i m a l b i t e s are n u m e r o u s a n d i n c l u d e cosmetic disfigurement (scars,
* 13,15116118120-23,25~27128,33135139~43
JACEP
keloids), d e v e l o p m e n t of epidermal i n c l u s i o n cysts, f u n c t i o n a l impair. m e n t (eg, r e s u l t i n g from fractures or tendon damage), and psychologi. cal t r a u m a . However, the most con~. m o n postbite c o n c e r n is infection, which can take the form of cellulitis, lymphangitis, abscess formation, ten. osynovitis, osteomyelitis, sepsis or o t h e r d i s s e m i n a t e d infection. Well known diseases t r a n s m i t t e d by ani. mal bite-scratch injuries include pasteurellosis, leptospirosis, Erysipelo. thrix, bubonic plague, rat bite fever, sporotrichosis, t u l a r e m i a , cat scratch d i s e a s e , t e t a n u s , gas gangrene, rabies, and B a c t e r o i d e s a n d other g r a m - n e g a t i v e a n a e r o b i c infee. tions 17,35-37,41,43-59 The cosmopolitan n a t u r e of the west Los Angeles popu. lation necessitates t h a t the physician consider exotic zoonoses. Appropriate i m m u n i z a t i o n s and m e d i c a l treat. m e n t minimizes the risk of sequelae. However, the possible occurrence of a n y of s e v e r a l of t h e s e infectious complications make each bite injury potentially life-threatening. To most, though, rabies is the d r e a d e d c o n s e q u e n c e of an animal bite. Although the likelihood of being exposed to rabies from a household a n i m a l has decreased m a r k e d l y over the past 25 years, b i t e - s c r a t c h inj u r i e s from r o a n / i n g dogs and cats r e m a i n the p r i m a r y reason for giving a n t i r a b i e s ~treatment2°, 61 More than 30,000 persons undergo postexposure rabies t r e a t m e n t each year because of a n i m a l bites, m a n y unnecessarily (US News and World Report, July 26, 1976, pp 48-49). 4,s,9,aG,as,~l-sa Several factors d e t e r m i n e the need for prophylactic treatment.S,9,a6,aT,39,41,42,60-62 Although wild a n i m a l s are now the most likely source of rabies for both h u m a n s and domestic animals in the United States, the s.poradic c a s e s of r a b i e s r e s u l t i n g from domestic a n i m a F bites requires that the possibility be considered2 °,~,64 T h e p r o x i m i t y of Los A n g e l e s to Mexican border towns, the mobility of its population, and the Occurrence of epizootic canine rabies along the USM e x i c a n border requires physicians in southern California to m a i n t a i n an appropriate index of suspicion in all anirnal bite cases. ~5-67 The recent dev e l o p m e n t of H u m a n Diploid Cell Rabies Vaccine appears to represent a s u b s t a n t i a l i m p r o v e m e n t in poste x p o s u r e t r e a t m e n t of s u s p e c t e d rabies exposure. 2%6%6s The dog bite complication rate of 5% seen in this series is comparable to others ls,19,29,ax,aa and supports the belief t h a t dog bites m a y be closed
8:4 (April) 1979
p er 15,18 i m~19~25,28-33,43 aa frt eir lgood y
local wound
car The high rate of infection complicating cat bites is s i m il a r to t h a t ~oted by D o u g l a s , 33 and is p a r t l y due to d e l a y e d m e d i c a l a t t e n t i o n . More important, however, is the nature of t h e typical cat bite injury: a puncture wo u n d in which infective organisms are d e p o s it e d deep into tissues. This allows small abscesses to d e v e l o p t h a t c a n p r o g r e s s to tenosynovitis or other disseminated infection. 18,1 9,3 3 The 2% hospitalization rate for bite injuries in this study is similar to previous observation, as is the average length of hospitalization, is,22,29,a' In a d d i t i o n to s t a p h y l o c o c c i , streptococci, d i p h t h e r o i d s , pseudomonas, p r o t e u s species, coliforms, clostridia, and N e i s s e r i a which can be cultured from a n i m a l bite wounds, p m u l t o c i d a is a common pathogen, as ev i d en ced by th e 50% and 80% c u l t u r e - p o s i t i v e r a t e s for dog a n d cat bites, r e s p e c t i v e l y , seen in our series. A l t h o u g h P r n u l t o c i d a is part of the n o r m a l flora of the upper respiratory t r a c t of m a n y ' d o m e s t i c animals and m o s t c o m m o n l y p r e s e n t s as an infected a n i m a l bite, it has a variety of manifestations in man.lS,4~, 44,46-51,5~-57,71 p rnultocida is not often identified as t h e infecting agent because it is not suspected, not cultured, or not identified since t h e r e is nothing distinctive abou~ its'Clinical presentation. Penicillin is universally considered the d r u g of c h o i c e to t r e a t t h i s pathogen. A cephalosporin is generally c o n s i d e r e d t h e drug of second choice, a l t h o u g h t e t r a c y c l i n e is so c o n s i d e r e d by s o m e . 2 7 , 3 9 , 4 s , 5 5 , 5 7 T r e a t m e n t failures with erythromycin have been noted. 4s The f r e q u e n t use of antibiotics o b s e r v e d in o u r c a s e s t y p i f i e s the concern for infec£ious complications. Recent reports of sepsis with a Bact e r o i d s species f o l l o w i n g dog b i t e s and associated with r e n a l failure and disseminated i n t r a v a s c u l a r coagulation, e m p h a s i z e t h e p o t e n t i a l seriousness of these injuries.52, 53 The use of p e n i c i l l i n or o t h e r a n t i b i o t i c prophylaxis, in all but t r i v i a l bite injuries, should be considered. BeCause of the difficulty t h a t m a y be involved in i d e n t i f y i n g t h e p a t h o g e n i c organism from infected bite wounds, it seems p r u d e n t to o b t a i n anaerobic cultures early. CONCLUSION Pet a n i m a l bites r e p r e s e n t a significant proportion of the accidental i n j u r i e s t r e a t e d in e m e r g e n c y de-
8:4 (April) 1979
p a r t m e n t s an d t h e y a c c o u n t for a s u b s t a n t i a l e x p e n d i t u r e of h e a l t h care resources. The physical, e m o : t i o n a l an d socioeconomic m o r b i d i t y r e s u l t i n g from these injuries can be reduced by control of t h e pet population explosion, by more responsible pet ownership, by b e t t e r education about household a n i m a l s and by e f . fective an d uniform s u r v e i l l a n c e of a n i m a l bite injuries. The physician's office, t h e e m e r g e n c y d e p a r t m e n t , and local medical societies can play a role in e d u c a t i o n . In addition, the h e a l t h care c o m m u n i t y needs to give its full support to local agencies concerned w i t h a n i m a l r e g u l a t i o n and control. To be successful, any educational p r o g r am on this problem will have to enlist t h e support of law enforcement agencies, local g o v e r n m e n t and the g e n e r a l public. It will have to promote a full u n d e r s t a n d i n g of the pet population problem in all segments of the community. A n y antibite prog r a m must be p r o h u m a n , especially prochild, and not anticanine or antipet. It m u s t stress both the benefits and the dangers of pets, and the importance of informed and i n t e l l i g e n t h u m a n - a n i m a l interaction.
REFERENCES 1. Klein D: Friendly dog syndrome. N Y State J IVied 66:2306-2309, 1966. 2. Cohen D: Community health and animal populations. A r c h E n v i r o n Health 17:1-3, 1968. 3. Beck AM: The public health implications of urban dogs. A m J Public Health 65:1315-1318, 1975, 4. Feldman BM, Carding TH: Freeroaming urban pets. Health Services Reports 88:956-962, 1973. 5. Robinson D: Canis familiaris. N Engl J Med 290:1378-1379, 1974. 6. Sheridan JP: Dogs, cats and other pets. Practitioner 215:172-177, 1975. 7. Carithers HA: Pets in the home: Incidence and significance. P e d i a t r i c s 21:840-848, 1958. 8. Currier RW, McCroan JE, Dreesen DW, et ah Epidemiology of antirabies treatment in Georgia, 1967-71. Public Health Rep 90:435-439, 1975. 9. Schnurrenberger PR, Martin RJ, Meerdink GL, et al: Epidemiology of human exposure to rabid animals in Illinois. Public Health Rep 84:1078-1084, 1969. 10. Bennett JS: Man's best friend? Can Med Assoc J 116:126, 1977. 11. Seah SKK, Hucal G, Law C: Dogs and intestinal parasites: a public health problem. C a n , M e d Assoc J 112:11911194, 1975.
JACEP
12. Beck AM, Loring H, Lockwood R: The ecology of dog bite injury in St. Louis, Missouri. Public Health Rep 90:262-267, 1975. 13. Harris D, Imperato PJ, Oken B: Dog bites - - an unrecognized epidemic. Bull N Y Acad IVied 50:981-1000, 1974. 14. Berzon DR, Farber RE, Gordon J, et " a[: Animal bites in a large city - - A report on Baltimore, Maryland. A m Public Health 62:422-426, 1972. 15. Morton C: Dog bites in Norfolk, Va. Health Services Reports 88:59-64, 1973. 16. Mayers SP, Beachley RG: A survey of dog bites in Arlington. Va Med 82:317319, 1955. 17. Berzon DR, DeHoffJB: Medical costs and other aspects of dog bites in Baltimore. P u b l i c H e a l t h Re]) 89:377-381, 1974. 18. Graham WP, Calabretta AM, Miller SH: Dog bites. A m Faro Physician 15: 132-137, 1977. °
19. Callaham ML: Treatment of common dog bites: Infection risk factors. J A C E P 7:83-87, 1978. 20. Moore RM, Zehmer RB, Moulthrop Ji, et al: Surveillance of animal bite cases in the United States, 1971-1972. A r c h Environ Health 34:267-270, 1977. 21. Newman EC: Animal bites as a public health disease. Tex M e d 73:49-52, 1977. 22. Hervey E: Incidence of bites due to dogs and other animals in Leeds. Br Med J 3:53-54, 1977. 23. Scarcella JV: Management of bites. Ohio State Med J 65:25-31, 1969. 24. Olsen CD: Epidemiology of animal exposures. Nebr Med J 46:143-145, 1961. 25. Parrish HM, Clark FB, Brobst D, et al: Epidemiology of dog bites. P u b l i c Health Rep 74:891-903, 1959. 26. Lockwood R, Beck AM: Dog bites among letter carriers in St. Louis. Public Health Rep 90:267-269, 1975. 27. Brobst D, Parrish HM, Clark FB: The animal bite problem. Vet Med 54:251-256, 1959. 28. Carithers HA: Mammalian bites of children. A m J Dis C h i l d 95:150-156, 1958. 29. Schultz RC, McMaster WC: The treatment of dog bite injuries, especially of the face. Plast Reconstr Surg. 49:494500, 1972. 30. Barclay TL: Dog bites of the face. B r J Plast Surg 9:34-37, 1956-57. 31. Chair LA, Spitz L: Dog bite injuries in children. S A f r M e d J 49:718-720, 1975. 32. Thompson HG, Svitek V: Small animal bites: The role of primary closure. J Trauma 13:20-23, 1973. 33. Douglas LG: Bite wounds. A m Faro Physician 11:93-99, 1975.
140/23
34. Sokol AB, Houser RG: Dog bites: prev e n t i o n and t r e a t m e n t . Clin Pediatr 10:336-338, 1971.
47. Tindall JP, Harrison CM: Pasteurella multocida infections following animal injuries, especially cat bites. Arch Dermatol
35. Ford WJA: The t r e a t m e n t of dog bites and t h e r a b i e s p r o b l e m . A m J Surg 93:678-681, 1957.
105:412-416, 1972.
36. Kaplan C (ed): Rabies - - T h e Facts. Oxford University Press, 1977. 37. Arena JM: Bites, zoonoses and rabies. Clin Pediatr 6:259-260, 1967. 38. Rice RG, Starbuck GW, Reed: Accidental injuries to children. N Engl J Med 255:1212-1219, 1956. 39. M a r t i n RJ, S c h n u r r e n b e r g e r PR, Rose NJ: Epidemiology of rabies vaccinations of persons in Illinois, 1967-68. Public Health Rep 84:1069-1077, 1969. 40. Berson DR: The animal bite epidemic in Baltimore, Maryland: Review and update. A m J Pub Health 68:593-595, 1978. 41. S h a h U, J a s w a l GS: V i c t i m s of a rabid wolf: Effects of severity and location of bites on development of rabies. J Infec Dis 134:25-29, 1976. 42. E l l e n b o g e n C: P o s t e x p o s u r e ant i r a b i e s t h e r a p y . A m F a m Physician 15:138-145, 1977. 43. Lee MLH, Buhr AJ: Dog bites and local infections with Pasteurella septica. Br Med J 1:169-1711 1960. 44. Hubbert WT, McCulloch WF, Schnurrenberger RP: Diseases Transmitted From Animals To Man, ed 6. Springfield, Illinois, Charles C. Thomas Publishers, 1975. 45. Plague - - United States. Morbidity and Mortality Weekly Report 26:337, 1977.
48. S w a r t z MN, Kunz LJ: Pasteurella multocida infections in man. N Engl J Med 261:889-893, 1959. 49. Henderson A: Pasteurella multocida infections in man: a review of the literature. Antonie van Leewenhock 29:359-367, 1963. 50. Holmes MA, Brandon G: Pasteurella multocida i n f e c t i o n s in 16 p e r s o n s in Oregon. Public Health Rep 80:1107-1112, 1965. 51. Torphy DE, Ray CG: Pasteurella multocida in dog and c a t bite infections. Pediatrics 43:295-297, 1969. 52. Butler T, Weaver RE, Ramani TKV, et al: Unidentified Gram-negative rod infection: a new disease of man. Ann Intern Med 86:1-5, 1977. 53. Fiala M, Bauer H, Khaleeli M, et al: Dog bite, Bacteroides infection, coagulopathy, renal microangiopathy. Ann intern Med 87:248-249, 1977. 54. Meyers BR, Hirschman SZ, Sloan W: G e n e r a l i z e d S c h w a r t z m a n r e a c t i o n in m a n a f t e r dog bite. A n n Intern Med 73:433-438, 1970. 55. Allott EN, C r i c k s h a n k R, CyrlasWilliams R, et al: Infection of cat-bite and dog-bite wounds with Pasteurella septica. J Pathol 56:411-415, 1944. 56. Holloway WJ, Scott EG, Adams VB:
Pasteurella multocida infections in man. A m J Clin Pathol 51:705-708, 1969.
domestic animal bites and scratches.
57. Johnson RH, Rumans LW: Unusual infections c a u s e d by Pasteurella multocida. J A M A 237:146-147, 1977.
J A M A 233:42-45~. 1975.
58. Quenzen RW, Mostow SR, Emerson
46. Francis DP, Holmes MA, Brandon G:
Pasteurella multocida infections after
24/141
JACEP
JK: Cat-bite tularemia. J A M A 238:1845, 1977. 59. T u l a r e m i a - - Colorado. Morbidity and Mortality Weekly Report 26:117, 1977. 60. Public H e a l t h S e r v i c e Advisory Committee on I m m u n i z a t i o n Practices: Rabies. Morbidity and Mortality Weekly Report 25:403-406, 1976. 61. Postexposure Rabies T r e a t m e n t Georgia. Morbidity and Mortality Weekly Report 26:92, 1977. 62. Changes in Rabies Control. Morbidity and Mortality Weekly Report 24:82, 1975. 63. Center for Disease Control: Rodent rabies in the United States. J Infec Dis 126:565-567, 1972. 64. Rabies - - Minnesota. Morbidity and Mortality Weekly Report 24:59, 1975. 65. Animal rabies - - Worldwide. Morbidity and Mortality Weekly Report 25:317, 1976. 66. C a n i n e Rabies - - Laredo, Texas.
Morbidity and Mortality Weekly Report 26:8, 1977. 67. Follow-up on canine rabies - - Laredo, Texas, Nuevo Laredo, Mexico. Morbidity and Mortality Weekly Report 26:59, 1977. 68. H u m a n rabies - - Texas. Morbidity and Mortality Weekly Report 26:31-32, 1977. 69. Bahmanyar M, Fayaz A, Nour-Salehi S, et al: Successful protection of humans e x p o s e d to r a b i e s i n f e c t i o n . J A M A 236:2751-27'54, 1976. 70. A ne~y rabies vaccine. The Medical
Letter 19:43-44, 1977. 71. Milder JE, Hall NK, Pinley RA: Pasteurella multocida pneumonia and bact e r e m i a . S o u t h Med J 70:1123-1124, 1977.
8:4 (April) 1979