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 © by author ESCMID Online Lecture Library 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) © by author 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 © by author ESCMID Online Lecture Library 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 ***** © by author ESCMID Online Lecture Library 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... • ….. © by author ESCMID Online Lecture Library 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. © by author ESCMID Online Lecture Library 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