Dog Bite-associated Infection: Clinical Analysis and Management

Woong Kyu Choi M.D., Young Joon Kim, M.D., Young Woong Choi, M.D., Ph.D., Sang Hyun Nam, M.D., Hoon Kim, M.D., Department of Plastic and Reconstructive Surgery Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea

Correspondence: Young Joon Kim, M.D. Department of Plastic and Reconstructive Surgery Sanggye Paik Hospital, Inje University College of Medicine, 1342, Dongil-ro, Nowon-gu, Seoul 139-707, Korea Tel: +82-2-950-1048 Fax: +82-2-932-6373 E-mail: S2639@inje.ac.kr

ABSTRRACT Purpose: Dog bite wounds are commonly encountered in everyday life, and about 90% of animal bites are caused by either dogs or cats. It represents a major health issue because it can infect the wound and cause secondary problems. Despite their importance, the treatment is inappropriate in most cases and the outcome is unsatisfactory. This study is aimed to retrospectively verify the correlation between wound severity and the culture results, and furthermore, to provide a more appropriate plan for dog bite wound management. Methods: From 2007 to 2013, 92 patients with dog bite injuries were included in this study, to review and compare the epidemiology, clinical characteristics, and the sequelae. All the patients received only povidone-iodine solution dressing without debridement or high pressure irrigation, and were sent to our department for follow-up therapy within 24 hours. 24 out of 92 patients who were suspected of infection were admitted to our department, and swab wound culture was done. Wounds were categorized by location, age, culture results, delayed number of days until secondary repair, and severity according to the Lackmanns classification(Table1). Patients were treated with empirical antibiotic treatment, such as 3rd generation cephalosporin, bactrim, and metronidazole after the initial evaluation. Result: In a total of 92 patients, 60 female, 32 male patients were included in this study. Age distribution varied, the youngest patient being 1-year-old girl, whereas the oldest patient was a 80 year-old male. 57 cases were injuries of the upper or lower extremities, 2 injuries were of the trunk, and 33 injuries were of the head or neck. The wounds were classified into the Lackmann

classification, and as a result there were 26 class I wounds, 48 class II wounds, 15 class III wounds, 2 class IV wounds, and 1 class V wound. 24 patients were admitted to the hospital and in the swab culture, 8 out of 24 patients were infected. In a total of 18 cases, debridement and delayed repair was performed and the average number of days until surgical repair was 7.88 days. The most common pathogen was coagulase negative staphylococcus. There were no remarkable correlation between positive culture results

and the wound severity (p value > 0.05) or the delayed days until surgical repair (p value > 0.05). Conclusion: It has been reported that up to 18% of dog bites become infected and usually increases when the hand is involved. However, in our study, 36% of the enrolled patients were infected. Dog bite wounds are not sutured primarily because of infection risks, and are treated by regular dressing and delayed repair. We wanted to see if the initial povidone-iodine dressing was really effective in this study, by examining patients who were suspected of wound infection. Initial treatment with povidine-iodine cleansing and antibiotic administration showed no significance decrease in the rate of infection. Our data shows that wound severity cannot be a factor for predicting the risk of wound infection, and furthermore, povidine-iodine dressing cannot lower the risk of anaerobic infection.

Fig1. Dog bite injury of the upper extremity classified as Lackmann V.

Fig2. Finger amputation caused by dog bite classified as Lackmann V.

Fig3. Dog bite wound of the lower leg, muscle level classified as Lackmann III.

Fig4. Infected puncture wound classified as Lackmann III.

Clinical findings Stage I Stage II Stage III Stage IV Stage V Superficial injury without involvement of muscle Deep injury with involvement of muscle Deep injury with involvement of muscle and tissue defect Stage III in combination with vascular or nerve injury Stage III in combination with bony involvement or organ defect

Table1. The severity of the wound Lackmanns classification.

33

Extremities

57

Table2. Location of dog bite wounds in 92 patients bitten by dogs.

Patient no.

Admission diagnosis

Days until surgery

Lackmann Classification
1 2 1 5

Culture

1 2 3 4

Lower leg, Rt & thigh, Lt Lower leg, Rt Hand dorsum, Lt Distal phalanx, middle finger, Rt Amputation, distal phalanx, middle finger, Rt

8 5 4 5

No growth No growth No growth Nonfermenting Gram-Negative Bacillus (asaccharolytic)

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Lower leg, Rt Lower leg, Lt Forearm, Rt Back & upper arm, Rt Auricle, Rt Perioral area Upper arm, Rt Ring finger & little finger, Rt Hand, Lt Ankle, Rt Nasal tip Chin & earlobe, Rt Middle finger, Rt Upper arm, Lt Forehead & temple, Rt Palm , Lt Hand, Lt Nailbed injury Leg, Rt Hand, Rt & face

19 9 8 4 8 7 5 23 5 12 2 5

3 3 3 3 1 2 2 2 2 2 1 1 2 1 2 2 2 2 2 2

No growth No growth No growth No growth Coagulase negative Staphylococcus Coagulase negative Staphylococcus No growth No growth Pseudomonas aeruginosa No growth Coagulase negative Staphylococcus Nonfermenting Gram-Negative Bacillus (asaccharolytic) No growth No growth No growth No growth No growth No growth Pseudomonas aeruginosa Nose - Klebsiella oxytoca Arm - E. coli

Fig7. 24 patients with dog bites suspected of infection.