Sandbox/Bites

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

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Bites

Human Bites

Medical Therapy

▸ Click on the following categories to expand treatment regimens.

Human Bites   ▸  Adults   ▸  Children

Early (not yet infected) Preferred Regimen ▸ Amoxicillin-clavulanate 875/125 mg orally q12h X 5 days Alternative Regimen (beta-lactam allergy) ▸ Moxifloxacin 400 mg orally q6h AND Clindamycin 300 mg orally q6h OR ▸ Trimethoprim-sulfamethoxazole 1 double-strength tablet orally q12h AND metronidazole 250 to 500 mg orally q6h Late (infected) Preferred Regimen ▸ Ampicillin sulbactam 1.5 gm IV q6h OR ▸ Cefoxitin 2 gm IV q8h OR ▸ Ticarcillin clavulanate 3.1 gm IV q6h OR ▸ Piperacillin-tazobactam 3.375 gm IV q6h or 4.5 gm q8h or 4-hr infusion of 3.375 gm q8h Alternative Regimen (beta-lactam allergy) ▸ Clindamycin 1.5 gm IV q6h PLUS ▸ Moxifloxacin 400 mg IV q6h Early (not yet infected) Preferred Regimen ▸ Amoxicillin-clavulanate (> 12weeks) 45 mg/kg/day orally in 2 divided doses for 5 days Late (infected) Preferred Regimen ▸ Ampicillin sulbactam 100 to 300 mg/kg/day IV q6h OR ▸ Cefoxitin 80 to 160 mg/kg/day IV in 4 divided doses OR ▸ Ertapenem (3months - 12years) 15 mg/kg IV twice daily (maximum 1 g/day) OR Ertapenem (>13years) 1 g IV once daily

Vaccination

• Diphtheria, Tetanus, and Acellular Pertussis Vaccine:
  • Adults (19 years and older, including pregnant women): 1 dose (0.5 mL) IM once to replace a single dose of tetanus and diphtheria (Td) for adults who have not received a prior dose of Tdap
  • Pediatrics (13 to 18 years, catch-up): 1 dose (0.5 mL) IM to those who missed the 11- to 12-year Tdap booster dose if they have completed the recommended childhood DTP/DTaP vaccination series
  • Pediatrics (11 to 12 years): 1 dose (0.5 mL) IM to those who have completed the recommended childhood DTP/DTaP vaccination series and have not received a Tdap booster dose

• Diphtheria and Tetanus Toxoids:
  • Adults (19 years and older): 1 dose (0.5 mL) Td IM every 10 years for persons who previously received a one-time dose of Tdap

Dog Bites

Medical Therapy

▸ Click on the following categories to expand treatment regimens.

Dog Bites   ▸  Adults   ▸  Children

Early (not yet infected) Preferred Regimen ▸ Amoxicillin-clavulanate 875/125 mg orally q12h OR ▸ Amoxicillin-clavulanate 500/125 mg orally q8h Alternative Regimen (beta-lactam allergy) ▸ Clindamycin 300 mg orally q6h PLUS ▸ Ciprofloxacin 500 to 750 mg orally q12h Late (infected) Preferred Regimen ▸ Ampicillin sulbactam 1.5 to 3 g IV q6-8h OR ▸ Piperacillin-tazobactam 3.375 gm IV q6-8h OR ▸ Ertapenem 1 gm IV q24h OR ▸ Imipenem-Cilastin 1 gm IV q6-8h OR ▸ Imipenem-Cilastin 1 gm IV q6-8h OR ▸ Meropenem 1 gm IV q8h Alternative Regimen (beta-lactam allergy) ▸ Cefazolin 1 gm IV q8h OR ▸ Cefuroxime 1 gm IV q24h OR ▸ Cefoxitin 1 gm IV q6-8h OR ▸ Ceftriaxone sodium 1 gm IV q12h OR ▸ Cefotaxime 2 gm IV q6h OR ▸ Ciprofloxacin 400 mg IV q12h OR ▸ Moxifloxacin 400 mg IV q24h Early (not yet infected) Preferred Regimen ▸ Amoxicillin-clavulanate 45 mg/kg/day orally in two divided doses X 3-7 days Alternative Regimen (beta-lactam allergy) ▸ Clindamycin 20 to 30 mg/kg/day orally in 4 divided doses PLUS ▸ Trimethoprim component 8 mg/kg/day orally in 2 divided doses Late (infected) Preferred Regimen ▸ Ampicillin sulbactam 100 to 300 mg/kg/day IV q6h OR ▸ Cefoxitin 80 to 160 mg/kg/day IV in 4 divided doses OR ▸ Ertapenem (3months - 12years) 15 mg/kg IV twice daily (maximum 1 g/day) OR Ertapenem (>13years) 1 g IV once daily

Vaccination

• Unvaccinated patients exposed to an animal suspected of having rabies:
  • Adults: Rabies immune globulin 20 International Units/kg IM; infiltrate as much as possible of the full dose around wound(s); give the remainder IM at an anatomic site distant from vaccine administration AND rabies vaccine 1 mL IM in deltoid region as soon as possible after exposure; repeat rabies vaccine dose on days 3, 7, 14, and 28
  • Pediatrics: Rabies immune globulin 20 International Units/kg IM; infiltrate as much as possible of the full dose around wound(s); give the remainder IM at an anatomic site distant from vaccine administration AND rabies vaccine 1 mL IM in lateral thigh as soon as possible after exposure; repeat rabies vaccine dose on days 3, 7, 14, and 28

• Vaccinated patients exposed to animals suspected of having rabies:
  • Adults: 1 mL rabies vaccine IM in deltoid region as soon as possible after exposure; repeat dose 3 days later
  • Pediatrics: 1 mL rabies vaccine IM in lateral thigh as soon as possible after exposure; repeat dose 3 days later

Cat Bites

Medical Therapy

▸ Click on the following categories to expand treatment regimens.

Cat Bites   ▸  Adults   ▸  Children

Early (not yet infected) Preferred Regimen ▸ Amoxicillin-clavulanate 875/125 mg orally q12h OR ▸ Amoxicillin-clavulanate 500/125 mg orally q8h Alternative Regimen (beta-lactam allergy) ▸ Doxycycline 100 mg orally q12h OR ▸ Cefuroxime 500 mg orally q12h Late (infected) Preferred Regimen ▸ Ampicillin sulbactam 1.5 to 3 g IV q6-8h OR ▸ Piperacillin-tazobactam 3.375 gm IV q6-8h OR ▸ Ertapenem 1 gm IV q24h OR ▸ Imipenem-Cilastin 1 gm IV q6-8h OR ▸ Imipenem-Cilastin 1 gm IV q6-8h OR ▸ Meropenem 1 gm IV q8h Alternative Regimen (beta-lactam allergy) ▸ Cefazolin 1 gm IV q8h OR ▸ Cefuroxime 1 gm IV q24h OR ▸ Cefoxitin 1 gm IV q6-8h OR ▸ Ceftriaxone sodium 1 gm IV q12h OR ▸ Cefotaxime 2 gm IV q6h OR ▸ Ciprofloxacin 400 mg IV q12h OR ▸ Moxifloxacin 400 mg IV q24h Cat scratch disease Preferred Regimen ▸ Azithromycin 500 mg orally on day 1, then 250 mg orally once daily X 4 days Early (not yet infected) Preferred Regimen ▸ Amoxicillin-clavulanate 45 mg/kg/day orally in two divided doses X 3-7 days Alternative Regimen ▸ Cefuroxime 10 to 15 mg/kg orally q12h Cat scratch disease Preferred Regimen ▸ Azithromycin 10 mg/kg orally on day 1, then 5 mg/kg orally X 4 days Late (infected) Preferred Regimen ▸ Ampicillin sulbactam 100 to 300 mg/kg/day IV q6h OR ▸ Cefoxitin 80 to 160 mg/kg/day IV in 4 divided doses OR ▸ Ertapenem (3months - 12years) 15 mg/kg IV twice daily (maximum 1 g/day) OR Ertapenem (>13years) 1 g IV once daily

Monkey Bites

Medical Therapy

▸ Click on the following categories to expand treatment regimens.

Monkey Bites   ▸  Adults   ▸  Children

High risk bites (deep bites, symptomatic animals 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 High risk bites (deep bites, symptomatic animals 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

Rat Bites

Medical Therapy

▸ Click on the following categories to expand treatment regimens.

Rat Bites   ▸  Adults   ▸  Children

Uncomplicated 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 benzathine 600,000 to 1,000,000 units/day IM X 10-14 days OR ▸ Tetracycline 250 to 500 mg orally q6h Alternative Regimen ▸ Streptomycin 15 mg/kg/day IM in a single dose or in 2 divided doses X 10-14 days Early (not yet infected) Preferred Regimen ▸ Amoxicillin-clavulanate 45 mg/kg/day orally in two divided doses X 3-7 days Alternative Regimen ▸ Cefuroxime 10 to 15 mg/kg orally q12h Rat bite fever Preferred Regimen ▸ Penicillin G benzathine 25,000 to 50,000 units/day IM X 10-14 days OR ▸ Tetracycline (>8 years) 25 to 50 mg/kg/day orally in 4 divided doses X 10-14 days Alternative Regimen ▸ Streptomycin 15 mg/kg/day IM in a single dose or in 2 divided doses X 10-14 days

Pig Bites

Medical Therapy

▸ Click on the following categories to expand treatment regimens.

Pig Bites   ▸  Adults   ▸  Children

Pig (Swine) Preferred Regimen ▸ Amoxicillin-clavulanate 875/125 mg orally q12h X 5 days Alternative Regimen ▸ Ampicillin sulbactam OR ▸ Imipenem OR ▸ Cephalosporin Pig (Swine) Preferred Regimen ▸ Amoxicillin-clavulanate 875/125 mg orally q12h X 5 days Alternative Regimen ▸ Ampicillin sulbactam OR ▸ Imipenem OR ▸ Cephalosporin

Tick Bites

Medical Therapy

▸ Click on the following categories to expand treatment regimens.

Tick Bites   ▸  Adults   ▸  Children

Suspected Leptospirosis Preferred Regimen ▸ Doxycycline 200 mg orally once within 72 hours of tick removal Suspected Leptospirosis Preferred Regimen ▸ Doxycycline (≥8 years) 4 mg/kg (maximum 200 mg) orally once within 72 hours tick removal

References

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