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Mammalian bite wounds
ORIGINAL CONTRIBUTION
Mammalian Bite Wounds Richard V. Aghababian, MD John E. Conte, Jr, MD San Francisco, California
Clinical data were collected prospectively from a series of 160 patients presenting with mammalian bite wounds. Anaerobic and aerobic cultures were prepared from sterile swabs placed in 65 bite wounds prior to cleansing. Infection was noted in 11 of 22 cat bites, six of 37 human bites, three of 80 dog bites, and in none of the 21 bites caused by other mammals. Pasteurella multocida was recovered from six infected cat and dog bites, all of which developed infection within 24 hours of injury. Staphylococcus aureus and Streptococcus viridans were the principal pathogens isolated from the remaining infected cat, dog, and human bites. Infection most commonly followed puncture wounds caused by cats (10/19) and lacerations into subcutaneous tissue of the hand caused by humans (4/17). None of the 10 sutured wounds became infected. All infected bite wounds responded to antibiotic therapy. No conclusions regarding the value of prophylactic antibiotics could be made. A g h a b a b i a n RV, Conte JE Jr: M a m m a l i a n bite wounds. Ann
Emerg Med 9:79-83, February 1980. bites, mammalian, epidemiology INTRODUCTION Individuals with m a m m a l i a n bite wounds account for about 1% of emergency d e p a r t m e n t visits,I, 2 although the true incidence is not k n o w n because m a n y patients with such wounds never seek professional care.3, 4 E s t i m a t e s of approximately 500,000 domestic a n i m a l bites per year have been put forth. 3-5 Public h e a l t h statistics compiled i n three major A m e r i c a n cities from 1951 to 1972 demonstrated a range from 300 to more t h a n 700 reported a n i m a l bites per 100,000 population, suggesting t h a t a n i m a l s may account for more t h a n 1 million bite wounds a n n u a l l y 2 , 7 The incidence of h u m a n bite injuries is u n k n o w n . Most clinical studies of m a m m a l i a n bite wounds h a v e b e e n retrospective.l,2, s-l° Cases often are selected for the presence of gross infection or extensive tissue damage. Other reports have been limited to selected complications, p a r t i c u l a r areas of the body, specific infecting organisms, or b i t i n g a n i m a l s 2 ~-22 Our study was designed to investigate, prospectively, the epidemiologic, microbiologic, and clinical characteristics of bite wound injuries to facilitate a rational approach to the m a n a g e m e n t of this common problem.
MATERIALS AND METHODS The study population included all persons p r e s e n t i n g to the Moffitt Hospital Emergency D e p a r t m e n t with wounds r e s u l t i n g from m a m m a l i a n bites from December 1, 1976 to December 31, 1977. Records were reviewed daily to insure t h a t all bite wounds were included. A bite wound was defined as any wound p e n e t r a t i n g the epidermis and inflicted by the teeth of the attacker. Wound seFrom the Division of Emergency Medicine and the Division of Infectious Disease, Department of Medicine, School of Medicine, University of California, San Francisco, California. Supported by Grant No 1229 from the Robert Wood Johnson Foundation. Address for reprints: John E. Conte, Jr, MD, Division of Emergency Medicine, 131 Moffitt Hospital, University of California, Third and Parnassus, San Francisco, California 94143.
9:2 (February) 1980
Ann Emerg Med
79/39
verity ranged from superficial abrasions to large lacerations with tendon injury or bone fracture. Clinical i n f e c t i o n w a s d e f i n e d as localized pain, erythema, swelling, and purul e n t discharge. P a t i e n t s with bite wounds t h a t had undergone p a r t i a l h e a l i n g prior to p r e s e n t a t i o n were included for epidemiologic purposes. Swabs for bacterial culture were o b t a i n e d before t h e wounds were cleansed with povidone-iodine solution; they were placed in t r a n s p o r t media (Amies modification) and processed within three hours. Samples were inoculated on blood agar w i t h a Staphylococcus dot and on eosin methylene blue for aerobic culture. Direct anaerobic p l a t i n g was done using pre-reduced brucella agar with 5% sheep blood. Brucella agar with 5% sheep blood plus kanamycin was used for a n a e r o b i c c u l t u r e . Aerobic organisms were processed for antibiotic sensitivity. Wound swab m a t e r i a l was also g r a m - s t a i n e d using Hucker's modification. Aerobic plates were examined at 24 and 48 hours. Some wounds were not cult u r e d b e c a u s e of p a r t i a l h e a l i n g , p r i o r c l e a n s i n g with a n t i b a c t e r i a l material, superficiality, or because of failure to follow the study protocol. Although no attempt was made to influence the i n i t i a l t r e a t m e n t , most were aware of the study protocol. Physicians were asked to comp l e t e a d a t a s h e e t which i n c l u d ed epidemiologic, d e s c r i p t i v e , and t r e a t m e n t information. If a follow-up visit was considered necessary, the p a t i e n t was asked to return to the g e n e r a l s u r g e r y c l i n i c or to t h e e m e r g e n c y d e p a r t m e n t . Follow-up information was obtained from the p a t i e n t ' s m e d i c a l record, by telephone, or by letter. RESULTS Epidemiologic Data
One hundred sixty patients were included in the study. This repres e n t e d 0.7% of all e m e r g e n c y dep a r t m e n t visits. Dogs accounted for 80 wounds (50%); h u m a n s , 37 (23%); cats, 22 (14%); a n d six o t h e r m a m m a l i a n species (rat, rabbit, squirrel, gopher, fox, peccary) for the r e m a i n i n g 21 wounds (13%). Of the 123 nonhuman bites, 119 (97%) were inflicted by pet, laboratory, or zoo m a m m a l s . Four wounds were inflicted by wild animals (two squirrels, one gopher, one rat). Eighty-five wounds occurred w h i l e t h e v i c t i m was p l a y i n g or
40/8o
AGE AND SEX DISTRIBUTION
70:
Y/a MALE
60
V~] FEMALE
50 40 30 20
0-10
11-20 21-30
31-40
41-50
51-60
61-70
71 +
Fig. 1. Age and sex distribution. fighting (53%). Eleven (7%) occurred while feeding. Ten (6%) occurred during m a n i p u l a t i o n of a l a b o r a t o r y a n i m a l . Twelve of the h u m a n bite wounds were self-inflicted: five occurred in the course of nursing care; 21 were described as unprovoked; and the interaction of assailant and v i c t i m was not d e t e r m i n e d for the remaining 16. The age and sex of patients are summarized (Figure 1). Bite wounds occurred as frequently in women as in men. Of the victims, 41% were between the ages of 21 and 30, perhaps due to the youthful composition of the community as well as the large number of persons in this age group who were involved in r e s e a r c h or professional training. One h u n d r e d e i g h t p a t i e n t s (68%) presented for t r e a t m e n t within six h o u r s of i n j u r y . T w e n t y - n i n e (18%) presented between six and 24 hours and 17 (11%) presented more t h a n 24 hours after injury. The int e r v a l from i n j u r y to e v a l u a t i o n could not be determined for six patients (4%). The incidence of infection was not significantly different among patients in these groups (Figure 2). The number of cases per month for the 13-month period varied from eight to 18 with an average of 12.3. Clinical Data
Fourteen patients presented initially with evidence of infection and six patients subsequently developed
Ann Emerg Med
infection. Infection, t h e r e f o r e , occ u r r e d in 12.5% of p a t i e n t s with m a m m a l i a n bites. Wound infection developed at some point in 50% of cat bites, 16% of human bites, 4% of dog bites, and in none of the bites by other m a m m a l i a n species (P < 001). More h u m a n bites of the hand became infected (4/17) than did human bites elsewhere (2/20). However, this difference did not achieve statistical s i g n i f i c a n c e b e c a u s e of the small numbers (Figure 3). Of 60 wounds described as lacerations into subcutaneous tissue, 36 (60%) were caused by dogs; 23 (38%) by humans, and one (2%) by a cat. Nine of these wounds (two dog, six human, one cat) became infected. Of 36 wounds described as punctures p e n e t r a t i n g to subcutaneous tissue, 10 were caused by dogs, t h r e e by humans, 19 by cats, two by rats, and two by other m a m m a l s . Eleven of these wounds became infected: 10 of these were cat bites and one was a dog bite. The remaining 64 wounds, considered superficial, did not become infected. O v e r a l l , p u n c t u r e wounds caused by cat bites and large lacerations caused by h u m a n bites were most likely to become infected. Bacteriologic Data
Wound cultures were obtained from 65 patients. Bacteria were isolated from 35 cultures (54%) and 30 cultures (46%) had no growth. Of the 35 positive cultures, 24 (69%) cont a i n e d more t h a n one o r g a n i s m . 9:2 (February) 1980
mucosa, three were facial lacerations, and one was a h a n d laceration. N o n e of t h e s e w o u n d s b e c a m e infected; five of the p a t i e n t s were given prophylactic antibiotics. N o n e of our p a t i e n t s r e c e i v e d rabies immunization because San Francisco is considered a rabies-free a r e a . N o n e of t h e c a s e s m e t a n y o t h e r r e c o m m e n d a t i o n s for r a b i e s prophylaxis as described by the Advisory C o m m i t t e e on I m m u n i z a t i o n P r a c t i c e s (ACIP). 23 T e t a n u s toxoid was a d m i n i s t e r e d to 91 p a t i e n t s who r e q u i r e d i m m u n i z a t i o n according to A C I P recommendations. 24
T I M E I N T E R V A L F R O M BITE T O I N I T I A L V I S I T 60INFECTIONS
I
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30
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m
LwlJlJllJllJllJ Up to 1 hour
1-6
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H O U R S (bite to 1st visit)
Fig. 2. Time interval from bite to initial visit.
Wound cultures were obtained in 14 of 20 p a t i e n t s who p r e s e n t e d with, or subsequently developed, infection. Of the six c l i n i c a l l y i n f e c t e d w o u n d s w h i c h w e r e n o t c u l t u r e d , two p a tients h a d scrubbed the wound with antiseptic, one h a d t a k e n penicillin for more t h a n 24 hours, a n d t h r e e w e r e t r e a t e d e m p i r i c a l l y with an antibiotic w i t h o u t culture. P multocida was t h e p r e d o m i n a n t o r g a n i s m in six of e i g h t c u l t u r e d bites which developed infection within 24 hours of injury. S viridans was t h e p r e d o m i n a n t o r g a n i s m in t h e r e m a i n i n g two cultured bites which developed infection w i t h i n 24 hours. P multocida was not noted in a n y wounds which developed infection a f t e r 24 hours. Of t h e six infected wounds containing the organism, five were cat bites and one was a dog bite. All six c u l t u r e d wounds which d e v e l o p e d i n f e c t i o n a f t e r 24 h o u r s contained S aureus, S viridans or both as the p r e d o m i n a n t organism. Three of six h a n d wounds resulti n g from a blow to a n o p p o n e n t ' s teeth became infected with S aureus and/or S viridans. Osteomyelitis att r i b u t e d to the l a t t e r o r g a n i s m developed in one of four bites inflicted d u r i n g the course of n u r s i n g care.
9:2 (February) 1980
I n five of six p a t i e n t s w i t h P multocida infection, g r a m - n e g a t i v e rods were seen on g r a m stain. In five of seven p a t i e n t s w i t h S aureus, S viridans, or both, g r a m - p o s i t i v e cocci were seen on g r a m stain. Organisms other than those m e n t i o n e d were isolated in s m a l l e r numbers. Gram-positive organisms i n c l u d e d S epidermidis, Group G streptococcus, a n d Corynebacter. G r a m - n e g a t i v e o r g a n i s m s included P antipestifer, Moraxella osloensis, N e i s s e r i a species, CDC group EF-4, CDC group H-J, CDC group II-R ( t y p e I), Eikenella corrodens, Fusobacterium, Bacillus species, Enterobacter aerogenes, E cloacae, and Flavobacterium. Treatment
E l e v e n p a t i e n t s were a d m i t t e d for t r e a t m e n t with i n t r a v e n o u s (IV) a n t i b i o t i c s b e c a u s e of c e l l u l i t i s , p u r u l e n t d r a i n a g e , a n d t e n s e fluid a c c u m u l a ' t i o n in t i s s u e c o m p a r t m e n t s of the hand. Two p a t i e n t s with extensive soft tissue wounds suffered s h o r t l y b e f o r e a r r i v a l w e r e hospitalized because of the e x t e n t of injury. Ten bite wounds were closed w i t h s u t u r e s : six involved the oral
Ann Emerg Med
Follow-up d a t a were obtained for 144 p a t i e n t s (90%). Of t h e 144 wounds with complete data, 133 h a d healed p r o m p t l y without significant complications. N i n e t e e n of 20 wounds were in this category. The following t r a u m a t i c problems complicated the r e m a i n i n g 11 b i t e wounds: four f r a c t u r e s (one of which developed osteomyelitis), boutonniere deformity, p a r t i a l avuls i o n of t h e f i n g e r t i p , p e r m a n e n t n u m b n e s s over a portion of the digit, and, in four cases, extensive tissue injury. DISCUSSION Of the m a m m a l i a n bite wounds included in this study, 12.5% became infected. The s u b s t a n t i a l l y h i g h e r incidence of infection following cat a n d h u m a n bites has also been noted by others.I, 9 Dog bites of any severi t y seldom developed infection (3/80) in our series, confirming the results of others.I, lo Numerous bacterial and viral p a t h o g e n s h a v e been cultured from m a m m a l i a n bite wounds.S-l°,16,17,19, 22-37 p multocida is frequently an orop h a r y n g e a l i n h a b i t a n t of m a m m a l s to which m a n is exposed.5,9,29,31-36, 3s Much has been written about the p a t h o g e n i c i t y and errors in diagnosis associated with this organism.~,9, 2936,3s-4o Some authors have a l l u d e d to the t e n d e n c y o f P multocida infections to develop soon after the wound occurs. 5,3°,31 O u r s t u d y confirms t h e p a t h o g e n i c i t y of P multocida as well as the tendency for the o r g a n i s m inf e s t a t i o n to d e v e l o p e a r l y in t h e course of a bite wound. Our findings confirm previous reports t h a t S aureus and S viridans a r e i m p o r t a n t pathogens in the etiology of bite wound infection.S,l°,l~, 17, 26,41-43
T h a t infection was not noted in a n y of t h e s u t u r e d w o u n d s in t h i s
81/41
eus, or mixed infection. These infec-
WOUND LOCATION 80
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Dog 31 Human 17 Cat 17 Other 0
ug g~
7= 3o 2(10 ~ ' ~ [ ~
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Dog 14 Cat 2 Dog 6 Human 1
Hand to wrist Arm above wrist
Face, head and neck
Lower extramit'
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Fig. 3. W o u n d location.
tions should be managed with a peni c i l l i n a s e - r e s i s t a n t penicillin.16,17,42 In penicillin-allergic patients, erythromycin would be more appropriate for infected human bites. A cephalos p o r i n Could be used for human, dog, or cat bites.5,16, ~7 Cephalosporins, however, should not be used in pat i e n t s with a history of immediate allergic reactions to penicillin. Patients with serious bite wound infections should be admitted to the hospital and treated with parenteral antibiotic therapy. An increased incidence of bite injuries during spring and summer months has been reported, while we, and others, have noted little seasonal variation.2-s,45,4s Local climate may influence seasonal variation. Since 96 of 144 (67%) bites occurred while p l a y i n g , f i g h t i n g , or f e e d i n g , attempts to improve public awareness of the potential for injury while interacting with animals seems necessary. Careful patient instruction regarding wound care, signs of infection, elevation, and immobilization m a y prevent some of the wound complications. CONCLUSION
study confirms the findings of Callaham, ~° Douglas, 1 and Sokol. 2 Others, however, have noticed an increase in the incidence of infection following closure of dog bites.l, s,2e Some suggest that lacerations of the face a n d o r a l mucosa m a y be s u t u r e d after meticulous cleansing and irrigation,~,13,44, 45 while others t h i n k t h a t bite wounds of the hand should not be Sutured. le,~7,27 Emphasis is placed on antiseptic cleansing and irr i g a t i o n with sterile saline. ~,2,4~,46 E l e v a t i o n , w a r m s o a k s , a n d immobilization of extremity injuries in a position of function are appropriate steps in treating bite wounds. 46,47 In our investigation, changes in antibiotic therapy were based on culture and antibiotic sensitivities in six of 20 p a t i e n t s with infections. Wound culture and antibiotic sensitivities may yield useful information for subsequent management of infected bite wounds and wounds for which the risk of infection is great. Our data suggest t h a t gram stains are useful in the initial evaluation of infected bites; however, the absence of bacteria on g r a m stain does not rule out infection. No conclusion can be drawn from t h e s e d a t a r e g a r d i n g t h e use of prophylactic antibiotics in the management o f bite wounds. 42/B2
Goldstein et al ts recommend the use of penicillin and debridement for p a t i e n t s with dog bites p r e s e n t i n g within 12 hours. In their series of 80 prospectively studied dog bites, 64 were seen within 12 hours. Of these, two were infected, one on presentation and one 48 hours later despite penicillin prophylaxis therapy. In the l a t t e r p a t i e n t wound infection was due to gram-negative rods requiring a c h a n g e in a n t i b i o t i c t h e r a p y . Sixty-two of the 64 patients did not develop infection. In this group of 62 patients, 19 received a prophylactic antibiotic and 43 did not. Therefore, firm recommendations regarding antibiotic prophylaxis for p a t i e n t s in the above category must await further data. Most investigatorsh,~°,29,3~, 33, 34,47 agree t h a t antibiotic therapy is indicated when clinical infection occurring within 24 hours of a cat or dog bite is likely due to P multocida. This suspicion can be confirmed by the presence of g r a m - n e g a t i v e rods on g r a m stain. Penicillin is the antibiotic of choice for this organism. Tetracycline or a cephalosporin appear to be acceptable alternatives for outpat i e n t management.5,9,29,34, 38,47 Infected dog, human, or cat bites presenting after 24 hours have elapsed are likely to exhibit S viridans, S aur-
Ann Emerg Med
We have confirmed the high rate of wound infection following certain bite wound injuries. Fifty percent of cat bites, 16% of human bites, and 4% of dog bites became infected. P multocida is a common pathogen in this setting, particularly following cat bites, and infection with this organism usually becomes manifest within 24 hours of injury. S aureus and S viridans are i m p o r t a n t pathogens involved in bite wound infection, as are a wide variety of other aerobic a n d a n a e r o b i c o r g a n i s m s . Most infections yield mixtures of organisms. Gram stains and anaerobic and aerobic culture are important in determining appropriate antibiotic therapy and are recommended in the m a n a g e m e n t of these patients. Until further data are available, firm recommendations regarding the use of prophylactic antibiotic therapy cannot be made. Because of the high rate of infection in patients with cat bites or h u m a n bites or those with extensive lacerations, the potential value of prophylactic antibiotic adm i n i s t r a t i o n should be s t u d i e d in these groups. REFERENCES 1. Douglas LC: Bite wounds. A m Fam Physician 11:93-99, 1975.
9:2 (February) 1980
2. Sokol AB, Houser RG: Dog bites: prevention and t r e a t m e n t . C l i n P e d i a t r 10:.336-338, 1971.
Public Health Rep 92:425-429, 1977.
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34. Holloway WJ, Scott EG, Adams YB: Pasteurella multocida infection in man. A m J Clin Pathol 51:705-708, 1969.
4. Carithers HA: M a m m a l i a n bites of children. A m J Dis C h i l d 95:150-156, 1958.
20. Graham WP III, Calabretta AM, Miller SH: Dog bites. A m F a m P h y s i c i a n 15:132-137, 1977.
5. Francis DP, Holmes MA, Braidon G: Pasteurella multocida. J A M A 233:42-46, 1975.
21. Diwan R, Sen DK, Sood GC: Rat bite orbital cellulitis. B r J Ophthalmol 54:211, 1970.
35. Olson JR, Meadows TR: Pasteurella pneumotropica infection resulting from a cat bite. A m J Clin Pathol 51-'709-710, 1969.
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22. Klein DM, Cohen ME: Pasteurella multocida brain abscess following perforating cranial dog bite. J P e d i a t 92: 588-589, 1978.
7. Berzon DR, Farber RE, Gordon J, et ah Animal bites in a large city - - a report on Baltimore, Maryland. A m J Public Health 62:422-426, 1972.
23. Public H e a l t h S e r v i c e A d v i s o r y Committee on Immunization Practices: Rabies. Morbidity and Mortality Weekly Report 25:403-406, 1976.
8. Lee MH, Buhr AJ: Dog bites and local infection with P a s t e u r e l l a septica. B r Med J 1:169-171, 1960.
24. P u b l i c H e a l t h S e r v i c e A d v i s o r y Committee on Immunization Practices: Diphtheria and tetanus toxoids and pertussis vaccine. Morbidity and Mortality Weekly Report 21(25 suppl):5-7, 1972.
9. Tindall JP, Harrison CM: Pasteurella multocida infections following animal injuries, especially cat bites. Arch Dermatol 105:412-416, 1972. 10. Callaham ML: Treatment of common dog bites. Infection risk factors. J A C E P 7:83-87, 1978. 11. Macquarrie MB, Forghani B, Wolochow DA: Hepatitis B transmitted by a human bite. J A M A 230:723-724, 1974.
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43. Guba AM Jr, Mulliken JB, Hoopes JE: The selection of antibiotics for human bites of the hand. Plast Reconstr S u r g 56:538-541, 1975.
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12. Ford WJA: The treatment of dog bites and the rabies problem. A m J S u r g 93:676-681, 1957. 13. Crikelair GF, Bates GS: Human bites of head and neck. A m J S u r g 80:645-648, 1950. 14. Boyce FF: Human bites. South Med J 35:631-638, 1942. 15. Biggar RJ, Woodall JP, Walter PD, et al: Lymphocytic chloriomeningitis outbreak a s s o c i a t e d w i t h pet h a m s t e r s . J A M A 232:449-450, 1975. 16. Shields S, Patzakis MJ, Meyers MH, et ah H a n d infections secondary to human bites. J Trauma 15:235-236, 1975.
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Ann Emerg Med
49. Mayers SP, Beachley RG: A survey of dog bites in Arlington. Va Med 82:317319, 1955.
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Mammalian Bite Wounds Richard V. Aghababian, MD John E. Conte, Jr, MD San Francisco, California
Clinical data were collected prospectively from a series of 160 patients presenting with mammalian bite wounds. Anaerobic and aerobic cultures were prepared from sterile swabs placed in 65 bite wounds prior to cleansing. Infection was noted in 11 of 22 cat bites, six of 37 human bites, three of 80 dog bites, and in none of the 21 bites caused by other mammals. Pasteurella multocida was recovered from six infected cat and dog bites, all of which developed infection within 24 hours of injury. Staphylococcus aureus and Streptococcus viridans were the principal pathogens isolated from the remaining infected cat, dog, and human bites. Infection most commonly followed puncture wounds caused by cats (10/19) and lacerations into subcutaneous tissue of the hand caused by humans (4/17). None of the 10 sutured wounds became infected. All infected bite wounds responded to antibiotic therapy. No conclusions regarding the value of prophylactic antibiotics could be made. A g h a b a b i a n RV, Conte JE Jr: M a m m a l i a n bite wounds. Ann
Emerg Med 9:79-83, February 1980. bites, mammalian, epidemiology INTRODUCTION Individuals with m a m m a l i a n bite wounds account for about 1% of emergency d e p a r t m e n t visits,I, 2 although the true incidence is not k n o w n because m a n y patients with such wounds never seek professional care.3, 4 E s t i m a t e s of approximately 500,000 domestic a n i m a l bites per year have been put forth. 3-5 Public h e a l t h statistics compiled i n three major A m e r i c a n cities from 1951 to 1972 demonstrated a range from 300 to more t h a n 700 reported a n i m a l bites per 100,000 population, suggesting t h a t a n i m a l s may account for more t h a n 1 million bite wounds a n n u a l l y 2 , 7 The incidence of h u m a n bite injuries is u n k n o w n . Most clinical studies of m a m m a l i a n bite wounds h a v e b e e n retrospective.l,2, s-l° Cases often are selected for the presence of gross infection or extensive tissue damage. Other reports have been limited to selected complications, p a r t i c u l a r areas of the body, specific infecting organisms, or b i t i n g a n i m a l s 2 ~-22 Our study was designed to investigate, prospectively, the epidemiologic, microbiologic, and clinical characteristics of bite wound injuries to facilitate a rational approach to the m a n a g e m e n t of this common problem.
MATERIALS AND METHODS The study population included all persons p r e s e n t i n g to the Moffitt Hospital Emergency D e p a r t m e n t with wounds r e s u l t i n g from m a m m a l i a n bites from December 1, 1976 to December 31, 1977. Records were reviewed daily to insure t h a t all bite wounds were included. A bite wound was defined as any wound p e n e t r a t i n g the epidermis and inflicted by the teeth of the attacker. Wound seFrom the Division of Emergency Medicine and the Division of Infectious Disease, Department of Medicine, School of Medicine, University of California, San Francisco, California. Supported by Grant No 1229 from the Robert Wood Johnson Foundation. Address for reprints: John E. Conte, Jr, MD, Division of Emergency Medicine, 131 Moffitt Hospital, University of California, Third and Parnassus, San Francisco, California 94143.
9:2 (February) 1980
Ann Emerg Med
79/39
verity ranged from superficial abrasions to large lacerations with tendon injury or bone fracture. Clinical i n f e c t i o n w a s d e f i n e d as localized pain, erythema, swelling, and purul e n t discharge. P a t i e n t s with bite wounds t h a t had undergone p a r t i a l h e a l i n g prior to p r e s e n t a t i o n were included for epidemiologic purposes. Swabs for bacterial culture were o b t a i n e d before t h e wounds were cleansed with povidone-iodine solution; they were placed in t r a n s p o r t media (Amies modification) and processed within three hours. Samples were inoculated on blood agar w i t h a Staphylococcus dot and on eosin methylene blue for aerobic culture. Direct anaerobic p l a t i n g was done using pre-reduced brucella agar with 5% sheep blood. Brucella agar with 5% sheep blood plus kanamycin was used for a n a e r o b i c c u l t u r e . Aerobic organisms were processed for antibiotic sensitivity. Wound swab m a t e r i a l was also g r a m - s t a i n e d using Hucker's modification. Aerobic plates were examined at 24 and 48 hours. Some wounds were not cult u r e d b e c a u s e of p a r t i a l h e a l i n g , p r i o r c l e a n s i n g with a n t i b a c t e r i a l material, superficiality, or because of failure to follow the study protocol. Although no attempt was made to influence the i n i t i a l t r e a t m e n t , most were aware of the study protocol. Physicians were asked to comp l e t e a d a t a s h e e t which i n c l u d ed epidemiologic, d e s c r i p t i v e , and t r e a t m e n t information. If a follow-up visit was considered necessary, the p a t i e n t was asked to return to the g e n e r a l s u r g e r y c l i n i c or to t h e e m e r g e n c y d e p a r t m e n t . Follow-up information was obtained from the p a t i e n t ' s m e d i c a l record, by telephone, or by letter. RESULTS Epidemiologic Data
One hundred sixty patients were included in the study. This repres e n t e d 0.7% of all e m e r g e n c y dep a r t m e n t visits. Dogs accounted for 80 wounds (50%); h u m a n s , 37 (23%); cats, 22 (14%); a n d six o t h e r m a m m a l i a n species (rat, rabbit, squirrel, gopher, fox, peccary) for the r e m a i n i n g 21 wounds (13%). Of the 123 nonhuman bites, 119 (97%) were inflicted by pet, laboratory, or zoo m a m m a l s . Four wounds were inflicted by wild animals (two squirrels, one gopher, one rat). Eighty-five wounds occurred w h i l e t h e v i c t i m was p l a y i n g or
40/8o
AGE AND SEX DISTRIBUTION
70:
Y/a MALE
60
V~] FEMALE
50 40 30 20
0-10
11-20 21-30
31-40
41-50
51-60
61-70
71 +
Fig. 1. Age and sex distribution. fighting (53%). Eleven (7%) occurred while feeding. Ten (6%) occurred during m a n i p u l a t i o n of a l a b o r a t o r y a n i m a l . Twelve of the h u m a n bite wounds were self-inflicted: five occurred in the course of nursing care; 21 were described as unprovoked; and the interaction of assailant and v i c t i m was not d e t e r m i n e d for the remaining 16. The age and sex of patients are summarized (Figure 1). Bite wounds occurred as frequently in women as in men. Of the victims, 41% were between the ages of 21 and 30, perhaps due to the youthful composition of the community as well as the large number of persons in this age group who were involved in r e s e a r c h or professional training. One h u n d r e d e i g h t p a t i e n t s (68%) presented for t r e a t m e n t within six h o u r s of i n j u r y . T w e n t y - n i n e (18%) presented between six and 24 hours and 17 (11%) presented more t h a n 24 hours after injury. The int e r v a l from i n j u r y to e v a l u a t i o n could not be determined for six patients (4%). The incidence of infection was not significantly different among patients in these groups (Figure 2). The number of cases per month for the 13-month period varied from eight to 18 with an average of 12.3. Clinical Data
Fourteen patients presented initially with evidence of infection and six patients subsequently developed
Ann Emerg Med
infection. Infection, t h e r e f o r e , occ u r r e d in 12.5% of p a t i e n t s with m a m m a l i a n bites. Wound infection developed at some point in 50% of cat bites, 16% of human bites, 4% of dog bites, and in none of the bites by other m a m m a l i a n species (P < 001). More h u m a n bites of the hand became infected (4/17) than did human bites elsewhere (2/20). However, this difference did not achieve statistical s i g n i f i c a n c e b e c a u s e of the small numbers (Figure 3). Of 60 wounds described as lacerations into subcutaneous tissue, 36 (60%) were caused by dogs; 23 (38%) by humans, and one (2%) by a cat. Nine of these wounds (two dog, six human, one cat) became infected. Of 36 wounds described as punctures p e n e t r a t i n g to subcutaneous tissue, 10 were caused by dogs, t h r e e by humans, 19 by cats, two by rats, and two by other m a m m a l s . Eleven of these wounds became infected: 10 of these were cat bites and one was a dog bite. The remaining 64 wounds, considered superficial, did not become infected. O v e r a l l , p u n c t u r e wounds caused by cat bites and large lacerations caused by h u m a n bites were most likely to become infected. Bacteriologic Data
Wound cultures were obtained from 65 patients. Bacteria were isolated from 35 cultures (54%) and 30 cultures (46%) had no growth. Of the 35 positive cultures, 24 (69%) cont a i n e d more t h a n one o r g a n i s m . 9:2 (February) 1980
mucosa, three were facial lacerations, and one was a h a n d laceration. N o n e of t h e s e w o u n d s b e c a m e infected; five of the p a t i e n t s were given prophylactic antibiotics. N o n e of our p a t i e n t s r e c e i v e d rabies immunization because San Francisco is considered a rabies-free a r e a . N o n e of t h e c a s e s m e t a n y o t h e r r e c o m m e n d a t i o n s for r a b i e s prophylaxis as described by the Advisory C o m m i t t e e on I m m u n i z a t i o n P r a c t i c e s (ACIP). 23 T e t a n u s toxoid was a d m i n i s t e r e d to 91 p a t i e n t s who r e q u i r e d i m m u n i z a t i o n according to A C I P recommendations. 24
T I M E I N T E R V A L F R O M BITE T O I N I T I A L V I S I T 60INFECTIONS
I
f,J7 I-Z
soi
UJ
4C Q.. LL.
O
tv. LU C0
30
Z
2C
1C
Follow-up
m
LwlJlJllJllJllJ Up to 1 hour
1-6
6-12
12-24
24-48
;>48
L
Unknown
H O U R S (bite to 1st visit)
Fig. 2. Time interval from bite to initial visit.
Wound cultures were obtained in 14 of 20 p a t i e n t s who p r e s e n t e d with, or subsequently developed, infection. Of the six c l i n i c a l l y i n f e c t e d w o u n d s w h i c h w e r e n o t c u l t u r e d , two p a tients h a d scrubbed the wound with antiseptic, one h a d t a k e n penicillin for more t h a n 24 hours, a n d t h r e e w e r e t r e a t e d e m p i r i c a l l y with an antibiotic w i t h o u t culture. P multocida was t h e p r e d o m i n a n t o r g a n i s m in six of e i g h t c u l t u r e d bites which developed infection within 24 hours of injury. S viridans was t h e p r e d o m i n a n t o r g a n i s m in t h e r e m a i n i n g two cultured bites which developed infection w i t h i n 24 hours. P multocida was not noted in a n y wounds which developed infection a f t e r 24 hours. Of t h e six infected wounds containing the organism, five were cat bites and one was a dog bite. All six c u l t u r e d wounds which d e v e l o p e d i n f e c t i o n a f t e r 24 h o u r s contained S aureus, S viridans or both as the p r e d o m i n a n t organism. Three of six h a n d wounds resulti n g from a blow to a n o p p o n e n t ' s teeth became infected with S aureus and/or S viridans. Osteomyelitis att r i b u t e d to the l a t t e r o r g a n i s m developed in one of four bites inflicted d u r i n g the course of n u r s i n g care.
9:2 (February) 1980
I n five of six p a t i e n t s w i t h P multocida infection, g r a m - n e g a t i v e rods were seen on g r a m stain. In five of seven p a t i e n t s w i t h S aureus, S viridans, or both, g r a m - p o s i t i v e cocci were seen on g r a m stain. Organisms other than those m e n t i o n e d were isolated in s m a l l e r numbers. Gram-positive organisms i n c l u d e d S epidermidis, Group G streptococcus, a n d Corynebacter. G r a m - n e g a t i v e o r g a n i s m s included P antipestifer, Moraxella osloensis, N e i s s e r i a species, CDC group EF-4, CDC group H-J, CDC group II-R ( t y p e I), Eikenella corrodens, Fusobacterium, Bacillus species, Enterobacter aerogenes, E cloacae, and Flavobacterium. Treatment
E l e v e n p a t i e n t s were a d m i t t e d for t r e a t m e n t with i n t r a v e n o u s (IV) a n t i b i o t i c s b e c a u s e of c e l l u l i t i s , p u r u l e n t d r a i n a g e , a n d t e n s e fluid a c c u m u l a ' t i o n in t i s s u e c o m p a r t m e n t s of the hand. Two p a t i e n t s with extensive soft tissue wounds suffered s h o r t l y b e f o r e a r r i v a l w e r e hospitalized because of the e x t e n t of injury. Ten bite wounds were closed w i t h s u t u r e s : six involved the oral
Ann Emerg Med
Follow-up d a t a were obtained for 144 p a t i e n t s (90%). Of t h e 144 wounds with complete data, 133 h a d healed p r o m p t l y without significant complications. N i n e t e e n of 20 wounds were in this category. The following t r a u m a t i c problems complicated the r e m a i n i n g 11 b i t e wounds: four f r a c t u r e s (one of which developed osteomyelitis), boutonniere deformity, p a r t i a l avuls i o n of t h e f i n g e r t i p , p e r m a n e n t n u m b n e s s over a portion of the digit, and, in four cases, extensive tissue injury. DISCUSSION Of the m a m m a l i a n bite wounds included in this study, 12.5% became infected. The s u b s t a n t i a l l y h i g h e r incidence of infection following cat a n d h u m a n bites has also been noted by others.I, 9 Dog bites of any severi t y seldom developed infection (3/80) in our series, confirming the results of others.I, lo Numerous bacterial and viral p a t h o g e n s h a v e been cultured from m a m m a l i a n bite wounds.S-l°,16,17,19, 22-37 p multocida is frequently an orop h a r y n g e a l i n h a b i t a n t of m a m m a l s to which m a n is exposed.5,9,29,31-36, 3s Much has been written about the p a t h o g e n i c i t y and errors in diagnosis associated with this organism.~,9, 2936,3s-4o Some authors have a l l u d e d to the t e n d e n c y o f P multocida infections to develop soon after the wound occurs. 5,3°,31 O u r s t u d y confirms t h e p a t h o g e n i c i t y of P multocida as well as the tendency for the o r g a n i s m inf e s t a t i o n to d e v e l o p e a r l y in t h e course of a bite wound. Our findings confirm previous reports t h a t S aureus and S viridans a r e i m p o r t a n t pathogens in the etiology of bite wound infection.S,l°,l~, 17, 26,41-43
T h a t infection was not noted in a n y of t h e s u t u r e d w o u n d s in t h i s
81/41
eus, or mixed infection. These infec-
WOUND LOCATION 80
m ,.,.¢.o.s
70 6O m
so -LI.
O
40 -
Dog 31 Human 17 Cat 17 Other 0
ug g~
7= 3o 2(10 ~ ' ~ [ ~
Dog 15 Human 5 Cat 2 Other !
Dog 16 Human 14 Cat I
Dog 14 Cat 2 Dog 6 Human 1
Hand to wrist Arm above wrist
Face, head and neck
Lower extramit'
]
Trunk
Fig. 3. W o u n d location.
tions should be managed with a peni c i l l i n a s e - r e s i s t a n t penicillin.16,17,42 In penicillin-allergic patients, erythromycin would be more appropriate for infected human bites. A cephalos p o r i n Could be used for human, dog, or cat bites.5,16, ~7 Cephalosporins, however, should not be used in pat i e n t s with a history of immediate allergic reactions to penicillin. Patients with serious bite wound infections should be admitted to the hospital and treated with parenteral antibiotic therapy. An increased incidence of bite injuries during spring and summer months has been reported, while we, and others, have noted little seasonal variation.2-s,45,4s Local climate may influence seasonal variation. Since 96 of 144 (67%) bites occurred while p l a y i n g , f i g h t i n g , or f e e d i n g , attempts to improve public awareness of the potential for injury while interacting with animals seems necessary. Careful patient instruction regarding wound care, signs of infection, elevation, and immobilization m a y prevent some of the wound complications. CONCLUSION
study confirms the findings of Callaham, ~° Douglas, 1 and Sokol. 2 Others, however, have noticed an increase in the incidence of infection following closure of dog bites.l, s,2e Some suggest that lacerations of the face a n d o r a l mucosa m a y be s u t u r e d after meticulous cleansing and irrigation,~,13,44, 45 while others t h i n k t h a t bite wounds of the hand should not be Sutured. le,~7,27 Emphasis is placed on antiseptic cleansing and irr i g a t i o n with sterile saline. ~,2,4~,46 E l e v a t i o n , w a r m s o a k s , a n d immobilization of extremity injuries in a position of function are appropriate steps in treating bite wounds. 46,47 In our investigation, changes in antibiotic therapy were based on culture and antibiotic sensitivities in six of 20 p a t i e n t s with infections. Wound culture and antibiotic sensitivities may yield useful information for subsequent management of infected bite wounds and wounds for which the risk of infection is great. Our data suggest t h a t gram stains are useful in the initial evaluation of infected bites; however, the absence of bacteria on g r a m stain does not rule out infection. No conclusion can be drawn from t h e s e d a t a r e g a r d i n g t h e use of prophylactic antibiotics in the management o f bite wounds. 42/B2
Goldstein et al ts recommend the use of penicillin and debridement for p a t i e n t s with dog bites p r e s e n t i n g within 12 hours. In their series of 80 prospectively studied dog bites, 64 were seen within 12 hours. Of these, two were infected, one on presentation and one 48 hours later despite penicillin prophylaxis therapy. In the l a t t e r p a t i e n t wound infection was due to gram-negative rods requiring a c h a n g e in a n t i b i o t i c t h e r a p y . Sixty-two of the 64 patients did not develop infection. In this group of 62 patients, 19 received a prophylactic antibiotic and 43 did not. Therefore, firm recommendations regarding antibiotic prophylaxis for p a t i e n t s in the above category must await further data. Most investigatorsh,~°,29,3~, 33, 34,47 agree t h a t antibiotic therapy is indicated when clinical infection occurring within 24 hours of a cat or dog bite is likely due to P multocida. This suspicion can be confirmed by the presence of g r a m - n e g a t i v e rods on g r a m stain. Penicillin is the antibiotic of choice for this organism. Tetracycline or a cephalosporin appear to be acceptable alternatives for outpat i e n t management.5,9,29,34, 38,47 Infected dog, human, or cat bites presenting after 24 hours have elapsed are likely to exhibit S viridans, S aur-
Ann Emerg Med
We have confirmed the high rate of wound infection following certain bite wound injuries. Fifty percent of cat bites, 16% of human bites, and 4% of dog bites became infected. P multocida is a common pathogen in this setting, particularly following cat bites, and infection with this organism usually becomes manifest within 24 hours of injury. S aureus and S viridans are i m p o r t a n t pathogens involved in bite wound infection, as are a wide variety of other aerobic a n d a n a e r o b i c o r g a n i s m s . Most infections yield mixtures of organisms. Gram stains and anaerobic and aerobic culture are important in determining appropriate antibiotic therapy and are recommended in the m a n a g e m e n t of these patients. Until further data are available, firm recommendations regarding the use of prophylactic antibiotic therapy cannot be made. Because of the high rate of infection in patients with cat bites or h u m a n bites or those with extensive lacerations, the potential value of prophylactic antibiotic adm i n i s t r a t i o n should be s t u d i e d in these groups. REFERENCES 1. Douglas LC: Bite wounds. A m Fam Physician 11:93-99, 1975.
9:2 (February) 1980
2. Sokol AB, Houser RG: Dog bites: prevention and t r e a t m e n t . C l i n P e d i a t r 10:.336-338, 1971.
Public Health Rep 92:425-429, 1977.
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3. Klein D: Friendly dog syndrome. N Y State Med J 66:2306-2309, 1966.
19. Fiala M, Bauer H, Khaleeli M, et al: Dog bite, Bacteriodes infection, coagulopathy, renal microangiopathy. A n n Intern M e d 87:248-249, 1977.
34. Holloway WJ, Scott EG, Adams YB: Pasteurella multocida infection in man. A m J Clin Pathol 51:705-708, 1969.
4. Carithers HA: M a m m a l i a n bites of children. A m J Dis C h i l d 95:150-156, 1958.
20. Graham WP III, Calabretta AM, Miller SH: Dog bites. A m F a m P h y s i c i a n 15:132-137, 1977.
5. Francis DP, Holmes MA, Braidon G: Pasteurella multocida. J A M A 233:42-46, 1975.
21. Diwan R, Sen DK, Sood GC: Rat bite orbital cellulitis. B r J Ophthalmol 54:211, 1970.
35. Olson JR, Meadows TR: Pasteurella pneumotropica infection resulting from a cat bite. A m J Clin Pathol 51-'709-710, 1969.
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22. Klein DM, Cohen ME: Pasteurella multocida brain abscess following perforating cranial dog bite. J P e d i a t 92: 588-589, 1978.
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23. Public H e a l t h S e r v i c e A d v i s o r y Committee on Immunization Practices: Rabies. Morbidity and Mortality Weekly Report 25:403-406, 1976.
8. Lee MH, Buhr AJ: Dog bites and local infection with P a s t e u r e l l a septica. B r Med J 1:169-171, 1960.
24. P u b l i c H e a l t h S e r v i c e A d v i s o r y Committee on Immunization Practices: Diphtheria and tetanus toxoids and pertussis vaccine. Morbidity and Mortality Weekly Report 21(25 suppl):5-7, 1972.
9. Tindall JP, Harrison CM: Pasteurella multocida infections following animal injuries, especially cat bites. Arch Dermatol 105:412-416, 1972. 10. Callaham ML: Treatment of common dog bites. Infection risk factors. J A C E P 7:83-87, 1978. 11. Macquarrie MB, Forghani B, Wolochow DA: Hepatitis B transmitted by a human bite. J A M A 230:723-724, 1974.
25. Fuller CR, Cottrell JC: Infection with organisms of Vincent's angina following human bite. J A M A 92:2017, 1929. 26. Chambers GH, Payne JF: Treatment of dog bite wounds. M i n n Med 52:427-430, 1969. 27. Levin IA, Longacre AB: Antibacterial t h e r a p y in infections r e s u l t i n g from human bites. J A M A 147:815-817, 1951.
36. H u b b e r t WT, Rosen MN: I. Pasteurella multocida infection due to animal bite. A m J Public Health 60:11031108, 1970. 37. Saphir DA, Carter GR: Gingival flora of the dog with special reference to bacteria associated with bites. J Clin Microbiol 3:344-349, 1976. 38. Branson D, Bunkfeldt F: Pasteurella multocida in animal bites of humans. A m J Clin Pathol 48:552-555, 1967. 39. Bell DB, Marks MI, EickhoffTC: Past e u r e l l a m u l t o c i d a a r t h r i t i s and osteomyelitis. J A M A 210:343-345, 1969. 40. Gump DW, Holden RA: Endocarditis caused by a new species of Pasteurella. A n n Intern M e d 76:275-278, 1972. 41. Farmer CB, Mann RJ: Human bite infections of t h e hand. S o u t h M e d J 59:515-518, 1966. 42. Eaton R G , Butsch DP: Antibiotic g u i d e l i n e s for hand infections. S u r g Gynecol Obstet 130:119-122, 1970.
28. Polk LD: Human rabies. Clin Pediatr 9:697-698, 1970.
43. Guba AM Jr, Mulliken JB, Hoopes JE: The selection of antibiotics for human bites of the hand. Plast Reconstr S u r g 56:538-541, 1975.
29. Swartz MN, Kunz LJ: Pasteurella multocida infections in man. N E n g l J M e d 261:889-893, 1959.
44. C u r t i n JW, G r e e l e y PW: H u m a n bites of the face. P l a s t R e c o n s t r S u r g 28:394-404, 1961.
30. Szalay GC, Sommerstein A: Inoculation osteomyelitis secondary to animal bites. The clinical course differs from acute hematogenous osteomyelitis. Clin Pediatr 11:687-689, 1972.
45. Scarcella JV: Management of bites. Ohio State Med J 65:25-31, 1969. 46. P a t o n BC: Bites - - h u m a n , dog, spider and snake. S u r g Clin North A m 43:537-554, 1963.
31. Torphy DR, Ray CG: P a s t e u r e l l a multocida in dog and cat bite infections. Pediatrics 43:295-297, 1969.
47. Hawkins LG: Local pasteurella multocida infections. J Bone J o i n t S u r g 51A:363-366, 1969.
17. C h u i n a r d RG, D ' A m b r o s i a RD: H u m a n bite infections of the hand. J Bone Joint S u r g 59A:416-418, 1977.
32. Boisvert PL, Fousek MD: Human infection with Pasteurella lepiseptica following a rabbit bite. J A M A 116:19021903, 1941.
48. Goldstein EJC, Baraff LJ, Meislin H, et ah A n i m a l bites, correspondence. J A C E P 7:417, 1978.
18. Winkler WG: Human deaths induced by dog bites, United States, 1974-1975.
33. Henderson A: Pastourella multocida infection in man: a review of the litera-
12. Ford WJA: The treatment of dog bites and the rabies problem. A m J S u r g 93:676-681, 1957. 13. Crikelair GF, Bates GS: Human bites of head and neck. A m J S u r g 80:645-648, 1950. 14. Boyce FF: Human bites. South Med J 35:631-638, 1942. 15. Biggar RJ, Woodall JP, Walter PD, et al: Lymphocytic chloriomeningitis outbreak a s s o c i a t e d w i t h pet h a m s t e r s . J A M A 232:449-450, 1975. 16. Shields S, Patzakis MJ, Meyers MH, et ah H a n d infections secondary to human bites. J Trauma 15:235-236, 1975.
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Ann Emerg Med
49. Mayers SP, Beachley RG: A survey of dog bites in Arlington. Va Med 82:317319, 1955.
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