National Institute for Health and Care Excellence APG human and animal bites: draft Human and animal bites: antimicrobial prescribing guideline Evidence review November 2019 Draft for consultation DRAFT FOR CONSULTATION Contents Disclaimer The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties. NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn. Copyright © NICE 2019. All rights reserved. Subject to Notice of rights. ISBN: DRAFT FOR CONSULTATION Contents Contents Contents .............................................................................................................................. 4 1 Context .......................................................................................................................... 6 1.1 Background ........................................................................................................... 6 1.2 Antimicrobial stewardship ...................................................................................... 7 1.3 Antimicrobial resistance ......................................................................................... 7 2 Evidence selection ....................................................................................................... 9 2.1 Literature search ................................................................................................... 9 2.2 Summary of included studies................................................................................. 9 3 Evidence summary ..................................................................................................... 12 3.1 Antibiotics ............................................................................................................ 12 3.1.1 Antibiotic efficacy in adults, young people and children ............................ 12 3.1.2 Choice of antibiotic in adults, young people and children ......................... 17 3.1.3 Antibiotic course length in adults, young people and children ................... 17 3.1.4 Antibiotic route of administration in adults, young people and children ..... 17 4 Terms used in the guideline ...................................................................................... 18 Appendices ...................................................................................................................... 19 Appendix A: Evidence sources .................................................................................. 19 Appendix B: Review protocol .................................................................................... 21 Appendix C: Literature search strategy ..................................................................... 29 Appendix D: Study flow diagram ................................................................................ 35 Appendix E: Evidence prioritisation .......................................................................... 36 Appendix F: Included studies ..................................................................................... 37 Appendix G: Quality assessment of included studies .............................................. 38 G.1 Antibiotic choice ........................................................................................................ 38 G.2 Antibiotic choice ........................................................................................................ 42 Appendix H: GRADE profiles ...................................................................................... 44 H.1 Antibiotic prophylaxis versus no antibiotic prophylaxis or placebo ...................... 44 H.1.1 Dog, cat and human bites ................................................................................. 44 H.1.2 Dog bites ............................................................................................................ 44 H.1.3 Cat bites ............................................................................................................. 45 H.1.4 Human bites ....................................................................................................... 46 H.1.5 Type of wound ................................................................................................... 47 H.1.6 Location of wound ............................................................................................ 47 H.2 Antibiotic compared with antibiotic in adults, young people and children ............ 48 H.3 Antibiotic dose in adults, young people and children ............................................. 48 H.4 Antibiotic dose frequency in adults, young people and children ........................... 49 H.5 Antibiotic course length in adults, young people and children .............................. 49 Appendix I: Studies not prioritised ........................................................................... 50 Appendix J: Excluded studies ................................................................................... 51 4 DRAFT FOR CONSULTATION Contents 5 DRAFT FOR CONSULTATION Context 1 1 Context 2 1.1 Background 3 A bite injury inflicted by the teeth of a human or animal can take a number of forms including 4 lacerations, puncture wounds, and crush or degloving injuries. The most common 5 mammalian bites are associated with humans, dogs, and cats, which may cause bruising, 6 deep anatomical structure disruption and infections. Human bites can be deliberate, 7 accidental or self-inflicted and are either caused by actual biting (occlusal injuries) or when a 8 clenched fist hits a person’s teeth causing small wounds over the hands (clenched-fist 9 injuries). Most human bites occur on the hand. Dog bites generally involve puncture wounds 10 from the canine teeth which anchor the victim, with other teeth biting, sheering and tearing 11 tissues. They vary in severity depending on the type and size of dog. Cats have a weaker 12 bite than dogs but inflict deep puncture wounds inoculated with saliva. Cat bites are capable 13 of penetrating bone, joints and tendons, and infections such as abscesses and osteomyelitis 14 are more common. The incidence of bites is likely to be underestimated because some 15 people will not seek medical assistance or report them. However, dog bites are most 16 common, followed by cat bites and human bites. It is estimated that approximately 17 250,000 people attend minor injury and accident and emergency departments in the UK each 18 year for the treatment of dog bites (NICE clinical knowledge summary: Bites – human and 19 animal [2018]). 20 Bites can result in bacterial infection if there is a break in the skin. The risk of infection is 21 higher in areas of poor perfusion, where the wound is deep or contaminated, where there 22 has been significant tissue damage, where bites have occurred on the hands, feet, face or 23 genitals, or where they involve bone, joint or tendons. The type of bite injury, individual 24 patient risk factors such as being immunocompromised, and the animal species causing the 25 bite are also factors in the development of infection. Infective complications from bite injuries 26 include abscesses (collection of pus that has built up within the tissue of the body), 27 tenosynovitis (inflammation of the fluid-filled sheath that surrounds a tendon), septic arthritis 28 (inflammation of a joint caused by a bacterial infection), osteomyelitis (bone infection) and 29 systemic spread, such as sepsis. The longer an infected bite wound is untreated, the more 30 likely severe local and systemic complications are to occur (NICE clinical knowledge 31 summary: Bites – human and animal [2018]). The likely causative organisms of bacterial 32 infection from a human bite differ from that of an animal bite. Human bites are most 33 commonly infected by Streptococcus, Staphylococcus aureus, Haemophilus, Eikenella 34 corrodens, Bacteroides and other anaerobes (NICE clinical knowledge summary: Bites – 35 human and animal [2018])). Most infections from an animal bite are polymicrobial containing 36 both aerobic and anaerobic organisms, with causative organisms for infections from dog and 37 cat bites including Pasteurella, Streptococcus, Staphylococcus, Neisseria, Corynebacterium, 38 Fusobacterium nucleatum