Approach to Animal Bites

Animal Bites and Prophylaxis

Dr. Vedat Turhan , MD., Infectious Diseases and Clinical Microbiology Gulhane School of Medicine Haydarpasa Training Hospital, Uskudar-Istanbul/ TURKIYE © by author ESCMID Online Lecture Library

VT-1 Planning & Overview

I. Common pathogens associated with bites from specific animals

II. Principles on animal bite management

III. Prophylactic or therapeutic AB

IV. Tetanus px © by author V. Rabies px ESCMID Online Lecture Library VI. Other animal bite & ID management

2 VT-2 I. PATHOGENS ASSOCIATED WITH BITES FROM SPECIFIC ANIMALS

Animal Pathogen Any vertebrate *Clostridium tetani Mammal * Rabies Lyssaviruse

Dog *Capnocytophaga canimorsus Cat *Bartonella henselae *Pasteurella multocida *Francisella tularensis

Rat *Streptobacilus moniliformis © by author*Spirillum minus

Fresh-water species Aeromonas hydrophila ESCMID Online LectureMycobacterium marinumLibrary Salt-water species Vibrio vulnificus Mycobacterium marinum

3 Macaque Herpesvirus simiae (B virus) VT-3 II. General principles on animal bite management

VT-4 Anamnesis & History taking • Provoked or unprovoked • Type of animal involved • Current location of the animals/ ownership/ vaccination status • Patient’s underlying medical conditions © by author • Drug allergy • TetanusESCMID immunization Online Lecturestatus Library

VT-5 Physical exam

• Location/type/depth of wound • Range of motion, neurovascular function • Signs of infection • Lymph node • X-ray if wound near joint or bone © by author ESCMID Online Lecture Library

VT-6 Principle of wound management

Followed by Dilute irrigation Clean with povidone- with copious 25% soap iodine normal solution or solution, saline with © by authorsyringe

ESCMID Online Lecturemay diminish developmentLibrary risk of Rabies and/or wound infections 90%

VT-7 Principle of wound management

• Take Cx- after topical decont (if infection suspected) • Remove foreign bodies and necrotic tissue. • Delayed suturing for contaminated, large or deep wounds and hand wounds (is advised) • Orthopedic/ surgical ©consultation by author • (as appropriate) • ElevationESCMID and immobilization Online Lecture of wound Library

VT-8

Bacteria commonly isolated from Dog/Cat bite wounds (Often Polymicrobial) Aerobes Anaerobes Streptococci spp. Actinomyces:

 S. aureus and other spp. Bacteroides

 Pasteurella multocida Fusobacterium  Moraxella spp. Peptostreptococcus  Corynebacterium ©spp. by authorPrevotella 

Neisseria spp. Capnocytophaga spp. ESCMID Online Lecture Library Eikenella corrodens

VT-9 Prophylactic Antibiotics

Empirical Rx:

Oral Amox-Clav

©Duration by author 5-7 ds

ESCMID Online Lecture Library

VT-10 Puncture-style bite: the possibility of infection and abscess development MORE

Make no mistake about it, cat bites can be very serious. © by author ESCMID Online Lecture Library

“Those thin sharp teeth …bite infections are serious and a high percentage of cat bites go deep into the flesh”. will become infected so you will likely be prescribed an AB. VT-11 III. Prophylactic Antibiotics Regimens for animal bite wounds

For pt with allergy hx of non-life For pt with allergy hx of life threatening rxs to pen: threatening rxs to pen: • Oral clindamycin +  • Oral cefuroxime + Fluoroquinolone metronidazole  Tetracycline  Septrin (paediatric)

ESCMID Online Lecture Library

VT-12

Indications for Antibiotic Pxs: *****

I. Severe wounds involving significant edema and “crush injury” in first 8 hrs, II. Probable penetrations to the bone or joint, III. Wounds closer to the Prosthetic joint, IV. Bites involving Hand & Face, Genital regio, V. All wounds immunocompromised© by author individuals

Pts with Lymphedema at Limbs ESCMID• SLE Online Lecture Library • Immunosuppressed pts • Asplenic pts

• Liver Failure pts VT-13 Tx of established bite wound infection

• Tx after wound swab for Cx/Ab-ST

• Depends on the progress; usually 7-14 ds; extend if there are joint/ bone involvement

14 VT-14 Tx of established bite wound infection

– Parenteral therapy preferred for admitted pt with infected bites • IV/Oral amoxicillin-clavulanic acid • Other alternatives: second /third generation cephalosporin + antianaerobic agents • OR carbapenems

– Life threatening rx to penicillin: • Oral clindamycin + fluoroquinolone/tetracycline/TMS ( paediatric) © by author – Non-life threatening rx to penicillin: ESCMID• Oral cefuroxime Online + metronidazole Lecture Library

VT-15 Pts with Penicillin allergy Contraindicated • Pregnant Children: women : tetracycline and • Tetracycline, Fluoroquinolones • TMS, • metronidazole © by author • May consider Macrolide e.g. azithromycin 250mg – 500mg per day under such situation ESCMID• Patient observed Online closely Lecture for tx failure Library

VT-16 TETANUS (Lockjaw)

– Tetanus only occurs when spores of C. tetani gain access into tissues. – usual mode of entry is through puncture wound or laceration. Injury itself is often trivial and in 20% of cases there is no evidence of wound. – spores germinate from© woundby author and toxin tetanospasmin is releasedESCMID into blood Online stream. LectureIt is Library then taken up into motor nerve endings and transported into 17 CNS. VT-17 TETANUS PROPHYLAXIS Vaccination in Last 10 yrs

Simple Wounds (Non Tetanus-prone) Tetanus –prone wound: ***** Vac <= 5 years: wound cleanliness Vac <= 1 year: wound cleanliness Vac > 5 years: wound cleanliness+ 0.5 ml Vac > 1 year: wound cleanliness+ 0.5 ml booster Vac booster Vac

No Vaccination in Last 10 yrs Simple Wounds Tetanus –prone wound: (Non Tetanus-prone) 250 U HTIG + wound cleanliness wound cleanliness & booster Vac + procain penicillin + Every 10 yrs rapel Vac +Every 10 yrs rapel Vac No Tetanus© by Vaccination author Lifelong Simple Wounds (Non Tetanus-prone) Tetanus –prone wound:

WoundESCMID cleanliness+ Full course Online vac (0.5 ml x 3, LectureWound cleanliness Library monthly) + Every10 yrs rapel Vac + 250 U HTIG Or 3000-5000 U heterolog serum +Full course vac (0.5 ml x 3, monthly) + Every10 yrs rapel Vac + procain penicillin 1.600.000 IU, 3-5 dys Active Immunisation *****

– Long lasting protection greater than or equal to 10 yrs for most recipients. – Boosters are recommended at 10-yr intervals.

– 3 doses of 0.5 ml (TT) by IMI; 0-1- 6&12 months • 1st : on the day of attendance • 2nd: 1 to 2 ms after 1st dose • 3rd: 6 to 12 ms after 2nd dose

– Complications: © by author • Fever /painful local erythematous or nodular rx at injection site

ESCMID– Contraindications Online Lecture Library • Previous anaphylactic rx • Acute respiratory infection or other active infection

VT-19 Tetanus management: Passive immunisation *****

VT-20 Tetanus management: Wound care and antibiotics

• Prompt and thorough surgical wound toilet is of key importance. • Drug addicts and elderly people may be presented with neglected wounds.

• Antibiotic pxs cannot replace proper wound cleaning,© by author debridement and proper immunisation. ESCMID Online Lecture Library

VT-21 Tetanus management: Wound care and ABs

• Eradication of organism from infection source:

– through cleaning of wound and – extensive debridement of necrotic tissue after – antitoxin has been injected. – ABs to destroy spores:

• metronidazole 500mg© by IV 8author hrly for 10 days.

ESCMID• (More effective Online than penicillin Lecture). Library • erythromycin has been used but shouldn’t be routinely used.

VT-22 Rabies • Rabies is an acutely serious condition and chances can't be taken. • Rabies infects mammals only. • Rabies has not been reported in TK since 20... • …..

VT-23 Rabies • Animal highly suspicious of being rabid: • Animal is from rabies infected area • The biting incident was unprovoked and the animal has bitten more than one person or other animal • The animal shows clinical signs and symptoms of rabies, e.g. increased salivation, shivering, change in behaviour, paralysis or restlessness • Wild mammals:© raccoons,by author skunks, foxes, coyotes ESCMID Online Lecture Library

24 VT-24 Rabies, Transmission

- The bite of infected animal, - Tx of infected corneas and other organs (Liver, kidney etc). - Rare by aerosols in caves populated by rabies- infected bats. © by author ESCMID Online Lecture Library

25 VT-25 Rabies WHO;>3.3 billion people are at risk for rabies in >85 countries... 55 000 deaths from rabies are estimated to occur every year 99% of which are the consequence of dog bites 31 000 are estimated to occur in Asia (20 000 in India alone) 24 000 in Africa. annual incidence of animal bites in many countries can be as high as 100-200 bites per 100 000 population. In 2005, >12 million individuals received a post-exposure pxs treatment against rabies, preventing an estimated 280000 deaths © by author ESCMID Online Lecture Library

VT-26 © by author ESCMID Online Lecture Library

VT-27 Pasteur & Istanbul 10.000 “Ottoman Golden liras” Special rosettes and Madalion Special inviting to Ottoman capital city 3 Res. Scholar sent by Abdulhamid, II. June 8, 1886.

Pasteur Aykut Kazancıgil, Osmanlılar'da Bilim ve Teknoloji, 2. baskı, İstanbul, VT-28 2000, Ufuk Kitapları, s. 286-287. Rabies

• Canine rabies& stray dogs • Asia, Africa and Latin America. • Control is often hampered by rel. beliefs and cultural habits. • Budhist and Hindu ethics restrain culling of the canine ... • India &Thailand have prohibited the euthanasia of stray dogs by municipalities.© by author • stray dogs account for • >90% of human rabies ESCMIDexposures, Online Lecture Library • 5-14 years old children • rural or peri-urban areas. VT-29 Human Rabies & India

…endemic in India • immemorial times, • actual incidence? • largely underestimated • poor reporting 10.8 million persons© in by mainland author India led to conclude that the annual incidence of rabies was 2 per 100 000 population.ESCMID Online Lecture Library

VT-30 Animal Bites & Gulhane School of Medicine, 2008

Dog ESCMIDCat Online Lecture Library wolf

VT-31 Management of Rabies *****

Animal Type Evaluation and Disposition of Postexposure Prophylaxis Animal Recommendations Dogs, cats, and Healthy and available for 10 days of Px only if animal develops signs of ferrets observation rabies Rabid or suspected of being rabid Immediate immunization and RIG Unknown (escaped) Consult public health officials for advice Bats, skunks, Regarded as rabid unless geographic Immediate immunization and RIG raccoons, foxes, area is known to be free of rabies or until and most other animal proven negative by laboratory carnivores; tests woodchucks © by author Livestock, Consider individually Consult public health officials. Bites of rodents, and squirrels, hamsters, guinea pigs, lagomorphsESCMID Online Lecturegerbils, Library chipmunks, rats, mice, other (rabbits and rodents, rabbits, and hares almost hares) never require antirabies treatment.

33 VT-33 Management of Rabies

• Rabies should be considered in patients suspected acute progressive viral encephalitis, regardless of a hx of animal bite. • Once a patient develops symptomatic rabies, available diagnostic tests include: – Assays for viral Abs in the serum or CSF; – Viral isolation from© CSFby orauthor saliva; – Viral Ag detection in biopsies of skin, corneal impressions or brain tissue; ESCMID– Reverse transcription Online PCR Lecture of saliva, CSFLibrary or related tissues (such as salivary glands or brain tissue).

VT-34 Management of Rabies *****

• Active immunization of Human diplod cell vaccine (HDCV) on day 0,3,7,14,28 – Adults: Deltoid muscle – Infants and small children: Mid anterior thigh muscles – Victims who have previously immunised either with a 5 dose course or as pxs against rabies within the past 5 yrs should receive 2 doses of HDCV on day 0,3. HRIG is not recommended. © by author – 5 dose full course is recommended if vaccination is incomplete or received more than 5 yrs ago. ESCMIDConsider passive Online immunisation Lecture with Library HRIG.

VT-35 Management of Rabies *****

• Passive immunisation with HRIG • Single administration of 20 IU/kg – Infiltrated around the wounds as much as possible and any remaining volume should be administrated IM at an anatomical site distant from vac administration.

– Adverse reaction: local pain or low grade fever. – Immunosuppressive agents,© anti-malarials,by author immunocompromised state can interfere the development of active immunity after vac. – Pregnancy is not a contraindication to post-exposure pxs. No fetal abnormalities ESCMIDhave been assocaited Online with rabies vac. Lecture Library

VT-36 Wound is cleansed with plenty of water&soap (may diminish probability of rabies 90%)

Suturing is avoided when the conditions are suitable. If it is obligatory, HRIG 0.1 ml injected I.C. to every needle inserting point. © by author ESCMID Online Lecture Library biting animal should be taken under- observation. VT-37 Pasteurella multocida

• Commonly associated with cat bite infection (75%), • occasionally dog bite (50%). • A cause of rapidly progressive infections similar to Group A Streptococcus or Vibrio (i.e. patient may present within a few hrs of a cat bite with established severe inf.) • wound inf. within a few hrs of a bite injury, a scratch or lick – Cellulitis or abscesses +/- bacteremia – Occasional cause© of bypneumonia author and endocarditis – Other: metastatic seeding of internal organs from bacteremia. ESCMID– CNS: meningitis Online (rare), mostLecture often in youngLibrary children or the elderly.

VT-38 Pasteurella multocida

• Dx – Cx based (swab, blood, body fluid). – May be confused with Haemophilus or Neisseria spp. (Gram stain).

• Tx – S: amox-clav, amp-sulb, pen G, cipro, levo, doxy – R: 1st gen ceph, cloxacillin,© by author erythro and clin. ESCMID Online Lecture Library

VT-39 Capnocytophaga canimorsus • Clinical presentation – Facultatively anaerobic gram-negative rod, part of normal oral flora of dogs and cats. – Many pts have hx of dog bite or scratch, less commonly in cats • Cellulitis • Bacteremia/sepsis • Meningitis and endocarditis (rare) • Severe: shock, DIC, acral gangrene, disseminated purpura, renal ©failure, by meningitisauthor and pulmonary infiltrates ESCMID• Fulminant Online sepsis following Lecture dog > catLibrary bites, particularly in asplenic patients, alcoholics or immunosuppressed.

VT-40 Capnocytophaga canimorsus

• Tx – Mild Cellulitis /Dog or Cat Bites • Preferred : Amox/clav • Alternative: Clinda, doxy Severe Cellulitis /Sepsis • Pen G 2-4 mU q 4h IV or Clin 600mg IV q 8h. • Alternative : Ceftriaxone 1-2q IV qd, cipro 400mg IV q12h or mero© by1g IV author q8h. • Prevention ESCMID– In all asplenic Online patients withLecture amox/clav Library for 7-10d

VT-42 Bartonella henselae Cat Scratch Disease(CSD)

• Affect both normal and immunocompromised hosts. • 80 % of cases occur in children. • Linked to exposure to cats, especially kitten and cats with fleas. CSD can result from a cat scratch or bite, as well as from a fleabite. • Characterized by self-limited regional LAP near the site of organism inoculation. • Occasionally life threatening manifestations (5-14%) include visceral organ, neurologic, and ocular involvement because of the dissemination of organism. • In AIDS pts: Bacillary ©angiomatosis by author • Dx: a positive B. henselae ab titer or a positive Warthin Starry stain ESCMIDor PCR analysis of Online tissue. Very difficultLecture to isolate Library from tissue sp s.

VT-43 Bartonella henselae Cat Scratch Disease(CSD) • Tx • ABs are not indicated in most cases but they may be considered for severe or systemic disease.

• Reduction of lymph node size (no REDUCTION in the duration of symptoms) has been demonstrated with a 5-day course of azithromycin and may be considered in patients with severe, painful LAP. © by author • Immunocompromised pts should be treated with : • TMS, Genta, Cipro,Rifampin • B.ESCMID henselae is generally Online R to Lecture pen & amox Library

VT-44 Streptobacillus moniliformis Rat bite fever • Caused by Streptobacillus moniliformis • A major cause of Rat Bite Fever (Spirillum minus occurs mostly in Asia). • Normal commensal of rodent oropharynx also in ferrets, weasels, gerbils. • Transmission: bite/scratch from rat, mice, squirrels--also cats, dogs, pigs. • Symptoms: • Fever, • Chills, • Headache, © by author • Nausea/Vomiting, • migratory arthralgias, ESCMID• leukocytosis (~30K). Online Lecture Library • nonpruritic maculopapular, petechial, or pustular rash (palms soles, extremities). May be purpuric/confluent (day 2-4).

VT-45 Streptobacillus moniliformis Rat bite fever

• Dx • Gr or Giemsa stain blood, joint fluid, pus. – Cx – Serology (sero-negative within 5 mts-2yrs) – PCR • Tx – Pen, ceftriaxone, clinda. © by author ESCMID Online Lecture Library

VT-46 SNAKE BITES

Frequently detected microorganisms: © by author • Ps. aeruginosa, • ProteusESCMID spp, Online Lecture Library • Coagulase neg. staph.,

• Clostridiums. VT-47 Resources & References 1. IDSA practice guidelines for the diagnosis and management of skin and soft –tissue infection. 2005 http://www.journals.uchicago.edu/doi/pdf/10.1086/497 143 2. Soft tissue infection due to dog and cat bites in adults . Zoonoses from cats and dogs. Animal and human bites in children. http://www.uptodate.com 3. A&E clinical guidelines on management of rabies, snake bites and tetanus infection from HA internet website http://www3.ha.org.hk/idctc/default.asp© by author 4. Companion animals and human health risk: Animal ESCMIDbites and rabies. Online Lecture Library http://www.medscape.com/viewarticle/560768

• AsimESCMID Ulcay, MD. Online Lecture Library • Hakan Erdem, MD.

• Hossam M. Al-Tatari

• Wong Tin Yau, MD

VT-49