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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Overview

A bite is a wound received from the mouth (and in particular, the teeth) of an animal or person. Most animal bites are from dogs or cats, and the pathogens in the wound are composed by the normal oral flora of the biting animal and human skin flora.

Animals may bite in self-defense, in an attempt to predate food, as well as part of normal interactions. Other bite attacks may be apparently unprovoked, especially in the case of bites committed by psychologically or emotionally disturbed humans. Some disorders such as Lesch-Nyhan syndrome may cause people to bite themselves.

Bite wounds can be very complex and it is important to address the following aspects:

Common Pathogens

Almost every bite will have a polimicrobial contamination and some bites have characteristic pathogens associated to the oral flora of the animal that bit.

Most common pathogens according to the type of bite
Bite Most Common Pathogens
Human Viridans streptococci, S. epidermidis, Corynebacterium, S. aureus, Eikenella, Bacteroides, Peptostreptococci
Dog Pasteurella canis,Pasteurella multocida, S. aureus , Streptococci , Anaerobes (Bacteroides spp, Fusobacterium, Prevotella heparinolytica, Proprionibacteria, and Peptostreptococci)
Cat Pasteurella multocida, S. aureus, Streptococci , Anaerobes (Bacteroides spp, Fusobacterium, Prevotella heparinolytica, Proprionibacteria, and Peptostreptococci)
Pig Pasteurella spp, Gram-negative bacilli, Gram-positive cocci, Anaerobes
Monkey Herpesvirus simiae (B Virus)
Rat Spirillum minus, Streptobacillus moniliformis
Seal Mycoplasma spp
Camel S. aureus, S. epidermidis, Moraxella catarrhalis, Klebsiella pneumoniae, S. pyogenes,E. coli, Pseudomonas aeruginosa, Bacillus spp.

Treatment

  • All bite wounds should be cleaned profusely with iodide soap and water.
  • Bites are contaminated by a polimicrobial flora and antibiotic prophylaxis treatment is recommended to avoid subsequent infection.

Antibiotic TherapyAdapted from Guidelines for Skin and Soft-Tissue Infections CID 2005[1]

▸ Click on the following categories to expand treatment regimens.

Antibiotic Prophylaxis

  ▸  Any Type of Bite

Specific Therapy

  ▸  Bat Bite

  ▸  Camel Bite

  ▸  Cat Bite

  ▸  Dog Bite

  ▸  Human Bite

  ▸  Monkey / Primate Bite

  ▸  Pig (Swine) Bite

  ▸  Racoon Bite

  ▸  Rat Bite

  ▸  Seal Bite

  ▸  Skunk Bite

Antibiotic Prophylaxis
Preferred Regimen
Amoxicillin-clavulanate 500-875/125 PO q8-12h
Alternative Regimen
Clindamycin 300 mg q8h
OR
Metronidazole 500 mg PO q8h
PLUS
Doxycycline 100 mg q12h
OR
TMP-SMX 160/800 mg PO q12h
OR
Penicillin VK 500 mg PO q6h
OR
Cefuroxime 500 mg PO q12h
OR
Moxifloxacin 400 mg PO q24h
Human Bite
Preferred Regimen
Ampicillin sulbactam 1.5 g IV q6h
OR
Cefoxitin 2 gm IV q8h
OR
Ticarcillin clavulanate 3.1 g IV q6h
OR
Piperacillin-tazobactam 3.375 g IV q6-8h
Alternative Regimen (beta-lactam allergy)
Clindamycin 300 mg PO q8h
PLUS
Ciprofloxacin 500-750 mg IV q12h
OR
Moxifloxacin 400 mg IV q24h
OR
TMP-SMX 160/800 mg q12h
Dog Bite
Preferred Regimen
Amoxicillin-clavulanate 500-875/125 PO q8-12h
Alternative Regimen (beta-lactam allergy)
Clindamycin 300 mg PO q8h
PLUS
Ciprofloxacin 500-750 mg IV q12h
OR
Moxifloxacin 400 mg IV q24h
OR
Gatifloxacin 400 mg q24h
Cat Bite
Preferred Regimen
Amoxicillin-clavulanate 500-875/125 PO q8-12h
Alternative Regimen (beta-lactam allergy)
Cefuroxime 500 mg q12h
OR
Doxycycline 100 mg q12h
Pig (Swine) Bite
Preferred Regimen
Amoxicillin-clavulanate 875/125 mg PO q12h
Alternative Regimen
Ampicillin sulbactam 1.5 to 3 g IV q6-8h
OR
Imipenem cilastatin 1 g IV q6-8h
OR
Ceftriaxone 1 g q12 h
OR
Cefotaxime 2 g q6 h
OR
Ticarcillin clavulanate 3.1 g IV q6hr
Monkey / Primate Bite
Profilaxis
Valacyclovir 1 g PO q8h x 14 days
OR
Acyclovir 800 mg PO 5 times/day
Preferred Regimen (without CNS symptoms)
Acyclovir 12.5–15 mg per kg IV q8h
OR
Ganciclovir 5 mg per kg IV q12h
Preferred Regimen (with CNS symptoms)
Ganciclovir 5 mg per kg IV q12h
Adapted from Prevention of and Therapy for B Virus Exposure • CID 2002:35[2]
Uncomplicated Rat Bite
Preferred Regimen
Amoxicillin-clavulanate 875/125 mg orally q12h
Alternative Regimen (beta-lactam allergy)
Doxycycline 100 mg orally q12h
Rat Bite Fever
Preferred Regimen
Penicillin G 400,000 - 600,000 IU/day IV x 10-14 days (dose should be increased to 1.2 M if no clinical response)
Alternative Regimen
Streptomycin 15 mg/kg/day IM divided q12-24h x 10-14 days
OR
Tetracycline 250 to 500 mg orally q6h
Adapted from Clin. Microbiol. Rev. January 2007 vol.20 no.1 13-22 [3]
Seal Bite
Preferred Regimen
Tetracycline 1.5 g 1 dose, then 0.5 g q6h x 4-6 weeks
Alternative Regimen
Doxycycline 100 mg q12h x 4-6 weeks
Adapted from Journal of Infection (2002) 45: 71±75 [4]
Camel Bite
Preferred Regimen
Dicloxacillin 250–500 mg PO q6h
PLUS
Ciprofloxacin 750 mg PO q12h
Alternative Regimen
Cephalexin 500 mg PO q6h
PLUS
Ciprofloxacin 750 mg PO q12h
Adapted from Eur J Clin Microbiol Infect Dis. 1999;18(12):918-9.[5]
Bat Bite
Preferred Regimen
Amoxicillin-clavulanate 875/125 mg orally q12h
Alternative Regimen
Doxycycline 100 mg orally q12h
Racoon Bite
Preferred Regimen
Amoxicillin-clavulanate 875/125 mg orally q12h
Alternative Regimen
Doxycycline 100 mg orally q12h
Skunk Bite
Preferred Regimen
Amoxicillin-clavulanate 875/125 mg orally q12h
Alternative Regimen
Doxycycline 100 mg orally q12h

Vaccination

Tetanus Prophylaxis Adapted from CDC Vaccines and Immunizations - Tetanus [6]

The need for active immunization, with or without passive immunization, depends on the condition of the wound and the patient’s immunization history. The following table summarizes the indications for tetanus prophylaxis.

Vaccination History Clean, minor wounds All other wounds
Td Tetanus immune globulin (TIG) Td Tetanus immune globulin (TIG)
Unknown or less than 3 doses YES NO YES YES
3 or more doses
     If > 10 yrs since last dose YES NO YES NO
     If > 5 yrs since last dose NO NO YES NO
Tdap may be substituted for Td if the person has not previously received Tdap and is 10 years or older
Table adapted from CDC Vaccines and Immunizations - Tetanus [6]

Rabies Prophylaxis Adapted from CDC - ACIP Recommendations for postexposure prophylaxis (PEP) to prevent human rabies.[7]

Animal bites inflicted by carnivores (except rodents) are considered possible cases of rabies. The animal is caught alive or dead with its head preserved, so the head can later be analyzed to detect the disease.

If the animal lives for ten days and does not develop rabies, then it is probable that no rabies infection has occurred.

If the animal is gone, prophylactic rabies treatment is recommended.

Signs of animal rabies include:

  • Foaming at the mouth
  • Self-mutilation
  • Growling
  • Jerky behavior
  • Red eyes.
Indications for rabies prophylaxis[7]
Animal Type Evaluation of the Animal Prophylaxis Recommendation
Dog, cat, ferret Healthy and available for observation for 10 days Prophylaxis should not be started unless the animal develops symptoms
If rabies symptoms develop, immediately begin rabies prophylaxis
Confirmed or suspected rabies infection Immediately begin rabies prophylaxis
Unknown Immediately begin rabies prophylaxis
Skunk, raccoon, bat, fox, coyote, other carnivores Considered as rabies infection Immediately begin rabies prophylaxis
Livestock, rodents, rabbit, squirrels, hamster, guinea pig, gerbil, chipmunk, rat, mouse, woodchuck Almost never require anti-rabies prophylaxis, but consult public health officials

▸ Click on the following categories to expand prophylactic regimens.

Rabies Prophylaxis

  ▸  Patient Not Previously Vaccinated

  ▸  Patient Previously Vaccinated

Patient Not Previously Vaccinated
Prophylactic Regimen
Wound cleansing
PLUS
Human rabies immune globulin† (HRIG) 20 IU/kg
If anatomically feasible, the full dose should be infiltrated around and into the wound, and any remaining volume should be administered IM
PLUS
Human diploid cell vaccine (HDCV) 1.0 mL IM
OR
Purified chick embryo cell vaccine (PCECV) 1.0 mL IM
Administer 4 doses in total; on days 0, 3, 7 and 14¶
†HRIG should not be administered in the same syringe as vaccine.
¶ For suppressed patients administer an additional dose on day 28
Patient Previously Vaccinated
Prophylactic Regimen
Wound cleansing
PLUS
Human diploid cell vaccine (HDCV) 1.0 mL IM
OR
Purified chick embryo cell vaccine (PCECV) 1.0 mL IM
Administer 2 doses in total; on days 0 and 3
HRIG should not be administered.

Post Exposure Measures

Minor wounds

  • Wash the wound thoroughly with soap and water.
  • Apply an antibiotic cream.
  • Cover the wound with a clean bandage.
  • See a healthcare provider if the wound becomes red, painful, warm, or swollen; if you develop a fever; or if the dog that bit you was acting strangely.

Deep wounds

  • Apply pressure with a clean, dry cloth to stop the bleeding.
  • If you cannot stop the bleeding or you feel faint or weak, call 911 or your local emergency medical services immediately.
  • See a healthcare provider as soon as possible.[8]

See Also

References

  1. Dennis L. Stevens, Alan L. Bisno, Henry F. Chambers, E. Dale Everett, Patchen Dellinger, Ellie J. C. Goldstein, Sherwood L. Gorbach, Jan V. Hirschmann, Edward L. Kaplan, Jose G. Montoya & James C. Wade (2005). "Practice guidelines for the diagnosis and management of skin and soft-tissue infections". Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 41 (10): 1373–1406. PMID 16231249. doi:10.1086/497143.  Unknown parameter |month= ignored (help)
  2. Cohen, Jeffrey I.; Davenport, David S.; Stewart, John A.; Deitchman, Scott; Hilliard, Julia K.; Chapman, Louisa E. (2002). "Recommendations for Prevention of and Therapy for Exposure to B Virus (Cercopithecine Herpesvirus1)". Clinical Infectious Diseases. 35 (10): 1191–1203. ISSN 1058-4838. doi:10.1086/344754. 
  3. Elliott, S. P. (2007). "Rat Bite Fever and Streptobacillus moniliformis". Clinical Microbiology Reviews. 20 (1): 13–22. ISSN 0893-8512. doi:10.1128/CMR.00016-06. 
  4. Hartley, J.W.; Pitcher, D. (2002). "Seal Finger—Tetracycline is First Line". Journal of Infection. 45 (2): 71–75. ISSN 0163-4453. doi:10.1053/jinf.2002.1027. 
  5. Badejo, O. A.; O. Komolafe †, ‡ , D. L., O. (1999). "Bacteriology and Clinical Course of Camel-Bite Wound Infections". European Journal of Clinical Microbiology & Infectious Diseases. 18 (12): 918–919. ISSN 0934-9723. doi:10.1007/s100960050433. 
  6. 6.0 6.1 "CDC Vaccines and Immunizations - Tetanus". 
  7. 7.0 7.1 "Advisory Committee on Immunization Practices (ACIP) for postexposure prophylaxis (PEP) to prevent human rabies (CDC. Human rabies prevention)". 
  8. Dog Bite Prevention. CDC. http://www.cdc.gov/features/dog-bite-prevention/ Accessed on February 10, 2016

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