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PEER REVIEWED FEATURE 3 CPD POINTS

Human and
animal bites
Managing and
preventing infection
STEPHEN MUHI MB BS, BSc, BMedSc, MPHTM, FACTM
JUSTIN DENHOLM MB BS, MPHTM, PhD, FRACP

H
Animal bites are an increasing public health uman and animal bites may lead to serious injury, including
problem, with half the Australian population transmission of infection to the recipient. The nature of the
expected to experience a significant animal bite, the species of the animal and the conditions of the host
bite at some time in their life. Infections from are all factors to consider when managing a patient with a
bites can range from the self-limiting to the ­ bite injury. The organisms involved in infection often originate from
the oral cavity of the offending biter, as well as the environment where
life-threatening, with characteristics often
the injury has occurred.1 Although some overlap exists, the profile
dependent on the specific animal inflicting of infection transmitted differs depending on the animal inflicting
the bite. the bite.
In one Australian study, dog bites represented the vast majority
of bite injuries (79.6%), followed by human bites (8.7%), cat bites
(7.2%), horse bites (1%) and rat bites (0.8%).2 Many Australian house-
KEY POINTS holds report pet ownership, and exotic animals are becoming increas-
ingly popular as pets. Patients who are immunocompromised are
• The nature of the bite, the species of the biting animal at a higher risk of infection,3 as are people with more comorbidities.
and the conditions of the host must all be considered
when managing patients with bite injuries.
Urbanisation has brought humans in close proximity to our native
• Although some overlap exists, the profile of the
species, and increasing travel abroad brings people into proximity
infection transmitted differs depending on the animal with less-familiar species as well as emerging zoonoses.
inflicting the bite. Animal bites are a growing public health risk, and half of all
• Human bites result in greater infection and Australians will experience a significant animal bite at some time
complication rates than other animal bites and are in their life.4 The management of animal bites should involve an
typically polymicrobial. integrated approach that includes careful consideration of the
• Dogs are responsible for most mammalian bites, with human–animal–ecosystem interaction.
almost 20% of these bites becoming infected, This article reviews the characteristics of some of the infections
followed by cats, with up to 80% of cat bites
from bites by a range of domestic, occupational and exotic animal
becoming infected.
• Immediate management of bites includes
assessment, surgery, antibiotic therapy and tetanus
toxoid vaccination. MedicineToday 2017; 18(11): 30-40
© SCHANKZ/STOCK.ADOBE.COM

• GPs have an important role in preventing bite wounds,


and follow up of patients treated for bite wounds Dr Muhi is an Infectious Diseases Registrar at the Victorian Infectious Diseases
represents an important opportunity to educate, and Service, Royal Melbourne Hospital. Associate Professor Denholm is Medical Director
offer vaccinations to, those at risk of further bites. of the Victorian Tuberculosis Program; Senior Staff Specialist at the Victorian Infectious
Diseases Service, Royal Melbourne Hospital; and Principal Research Fellow in the
Department of Microbiology and Immunology, University of Melbourne, Melbourne, Vic.

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species as well as humans; describes the
TABLE 1. THERAPEUTIC GUIDELINE RECOMMENDATIONS FOR EMPIRICAL
immediate management of bites; and ANTIBIOTIC THERAPY OF ANIMAL AND HUMAN BITES 9
­discusses strategies to prevent bites and
minimise infective complications. Arthro- Infection status Antibiotic recommendation
pod bites are not discussed.
Infection not • Amoxicillin/clavulanic acid 875/125 mg (child: 22.5/3.2 mg/kg up
established to 875/125 mg) orally, 12-hourly
Human bites (therapy • If commencement of oral therapy is likely to be delayed give procaine
Human bite injuries comprise clenched-fist duration: penicillin 1.5 g (child: 50 mg/kg up to 1.5 g) intramuscularly as a
injuries, sustained when a closed fist strikes 5 days) single dose, followed by amoxicillin/clavulanic acid
the teeth of another person, and occlusive • For patients who are hypersensitive to penicillins, see below
bites, resulting from direct closure of teeth Established • Amoxicillin/clavulanic acid 875/125 mg (child: 22.5/3.2 mg/kg up
on tissue.5 Clenched-fist injuries are more mild infection to 875/125 mg) orally, 12-hourly
common than occlusive bites, particularly (therapy • For patients who are hypersensitive to penicillins, give ciprofloxacin
duration: 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 12-hourly
in men,6 with most human bites occurring
5 days) Plus
on the hands.7 Human bites result in a Clindamycin 450 mg (child: 10 mg/kg up to 450 mg) orally, 8-hourly,
greater infection and complication rate Or
than animal bites. Cultures of human bites Metronidazole 400 mg (child: 10 mg/kg up to 400 mg) orally, 12-hourly
are typically polymicrobial.7 Mixed aerobic Plus either
Doxycycline 200 mg (child 8 years or older: 4 mg/kg up to 200 mg)
and anaerobic organisms are common,
orally, for the first dose, then 100 mg (child 8 years or older:
with the most common isolates including 2 mg/kg up to 100 mg) orally, daily
Streptococcus spp. and Eikenella corrodens, Or
which occurs in up to one-third of isolates.7 Trimethoprim/sulfamethoxazole 160/800 mg (child 1 month or
E. corrodens is a fastidious Gram-negative older: 4/20 mg/kg up to 160/800 mg) orally, 12-hourly
organism that has been associated with Established • Piperacillin/tazobactam 4/0.5 g (child: 100/12.5 mg/kg up to
septic arthritis and culture-negative infec- moderate to 4/0.5 g) intravenously, 8-hourly
tive endocarditis (as part of the HACEK severe Or
group [Haemophilus spp., Aggregatibacter infection Ticarcillin/clavulanic acid 3/0.1 g (child: 50/1.7 mg/kg up to 3/0.1 g)
(therapy intravenously, 6-hourly
ssp., Cardiobacterium hominis, E. corrodens duration: Or the combination of
and Kingella spp.]).8 14 days)* Metronidazole 400 mg (child: 10 mg/kg up to 400 mg) orally, 12-hourly
Some authors suggest that all patients Plus either
with human bites should be commenced Ceftriaxone 1 g (child 1 month or older: 50 mg/kg up to 1 g)
on antibiotic prophylaxis, given the high intravenously, daily
Or
risk of infection.6 The choice of antibiotic Cefotaxime 1 g (child: 50 mg/kg up to 1 g) intravenously, 8-hourly
therapy should cover E. corrodens, which
is resistant to first-generation cephalospor- * Total treatment duration is usually 14 days (intravenous plus oral therapy) for severe and penetrating wounds,
but a longer duration of directed therapy is needed for injuries involving bones, joints and/or tendons, and
ins (such as cefalexin), flucloxacillin and specialist referral is recommended.
clindamycin, antibiotics that are often used
for skin and soft tissue infections. Table 1 surface Ag (HBsAg); and hepatitis C virus exposed person should receive a dose of
provides the Australian Therapeutic Guide- (HCV) serology, should be performed in hepatitis B immunoglobulin (HBIG) within
lines’ antibiotic recommendations for human bite recipients. HIV post-exposure 72 hours of a percutaneous exposure.47 HCV
empirical therapy of bite infections,9 and prophylaxis is generally not recommended, serological testing is performed three
Table 2 lists additional antibiotic recom- but may be considered in very high-risk months after exposure.46 When relevant
mendations according to specific animal ­situations (i.e. in patients with bites from and possible, testing of both parties for
and pathogens.5-8,10-45 known HIV-positive sources where com- blood-borne viruses is also recommended,
Blood-borne viruses, particularly hep- plicated wounds occur).46 If the recipient as these can also be transmitted from the
atitis B virus (HBV), may also be transmit- has no immunity to hepatitis B, and chronic patient to the biter (reverse exposure).48
ted by human bites, although the risk is low HBV infection has been excluded, vaccina-
and evidence is limited to case reports.6 tion should be initiated. If the recipient is Dog bites
Baseline serology, including human immu- unvaccinated, and the source is known to Most mammalian bites (about 80%) are
nodeficiency virus (HIV) serology; HBV be HBsAg positive, or if the HBV status of dog bites,2 usually occurring from a dog
surface Ab (HBsAb), core Ab (HBcAb) and the source cannot be ascertained, the that is known to the bite recipient.49

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Human and animal bites continued

TABLE 2. EMPIRICAL ANTIBIOTIC THERAPY FOR SPECIFIC ANIMAL BITES

Animal Examples of pathogens Empirical therapy


­ hildren are especially vulnerable to dog
C
Humans5-8 Eikenella corrodens Refer to Table 1 and text
Viridans streptococci bites, and have increased risk of head and
Streptococcus pyogenes neck injury due to their smaller size, and
Staphylococcus aureus possibly also due to increased provocation.2
Coagulase-negative Most dog bites occur in males (56%), who
Staphylococcus
also suffer most animal-bite fatalities.2
Anaerobes
Hepatitis B, C virus and HIV Mixed anaerobic and aerobic cultures
are often present in dog bites.10 Almost
Dogs10-11 Pasteurella dagmatis, Refer to Table 1 ­one-fifth of dog bites become infected,
canis, septica
Capnocytophaga canimorsus
­especially when the hand is involved.10 The
S. aureus most ­common pathogens in dog and cat
Streptococcus spp. bites are Pasteurella spp., isolated in most
Moraxella spp. cat bites and in half of all dog bites.10
Anaerobes ­Pasteurella canis is most often isolated
Cats12-14 Pasteurella multocida Refer to Table 1 from dog bites, whereas Pasteurella mult-
Streptococcus spp. Plus ocida and Pasteurella septica are more
S. aureus Consider azithromycin for B. henselae often ­isolated from cat  bites.10 This is
Anaerobes
Bartonella henselae
­relevant for treatment, as Pasteurella spp.
are generally resistant to many antibiotics
Rats15-20 Streptobacillus moniliformis Refer to Table 1
Spirillum minus Plus
used to treat cellulitis, including anti­
Pasteurella spp. Consider doxycycline for Leptospira spp. staphylococcal ­penicillins (such as fluclox-
Leptospira spp. acillin), first-­generation cephalosporins
Ungulates13, 21-30 Actinobacillus spp. Refer to Table 1 and clinda­my­cin.10 However, P. multocida
Mixed aerobes/anaerobes is usually ­susceptible to penicillin, amoxi­
Pasteurella spp. cillin, quinolones, doxycy­ cline and
Streptococcus equi, suis trimethoprim-sulfamethoxazole.11
Parapoxviruses
Although Capnocytophaga canimorsus
Monkeys31 Mixed aerobes/anaerobes Refer to Table 1 is rarely associated with dog bite wounds,10
Neiserria spp. Plus
Streptococcus spp. Consider valaciclovir 1 g three times
it can invade the host and cause a fulminant
Haemophilus influenzae daily for 14 days32 infection, including disseminated intra-
Simian herpes B virus vascular coagulation and septic shock,
Lizards33-36 Salmonella spp. Ciprofloxacin usually affecting immunocompromised
Pseudomonas aeruginosa and asplenic patients.6 C. canimorsus has
Serratia marcescens been described as an emerging infection
Crocodiles37,38 Aeromonas spp. Ceftazidime with a case fatality rate of 26% in one recent
P. aeruginosa Plus study.11 Penicillin is the drug of choice, and
Enterobacteriaceae Penicillin third-generation cephalosporins and beta-
Burkholderia pseudomallei Plus
Salmonella spp. Metronidazole
lactamase inhibitor combinations are other
Anaerobes (incl. Clostridium) options with good activity.
Marine Vibrio spp. First-generation cephalosporin Or
animals39-44 Aeromonas hydrophila clindamycin (if beta-lactam allergy) Cat bites
Erysipelothrix rhusiopathiae Plus Cat bites are the second most common type
Mycobacterium marinum Ciprofloxacin of animal bite, responsible for more than
Edwardsiella tarda Plus 7% of mammalian bites in Victoria, most
Doxycycline if seawater exposure
Plus
of which occur in females.2 Although less
Metronidazole if sewerage or soil prevalent, cat bites become infected in up
contaminated water/wound (not required to 80% of cases, with P. multocida isolated
if clindamycin used) in three-quarters of infections.12 One
Refer to text for empirical management ­proposed mechanism for the very high
of suspected M. marinum infection
infection rate is that the sharp teeth of the
Seals45 Mycoplasma spp. Doxycycline cat may result in deep tissue puncture and

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Human and animal bites continued

Spirillum minus, so-called due to the tightly to rat urine, although cases of transmission
coiled spiral shape of this unculturable following rat bite have been reported.19-20
Gram-negative organism.15 Although Doxycycline remains the drug of choice to
S. moniliformis occurs predominantly in treat leptospirosis.
North America, Australian cases have been
reported.16 S. minus occurs predominantly Monkey bites
in Asia, where the disease is known as Although monkey bites are uncommon,
‘sodoku’ (Japanese: so, rat; doku, poison). they do pose major health risks requiring
Rats primarily transmit the disease, prompt medical follow up. Theoretically,
although other rodents such as mice, guinea emerging infections resulting from
pigs and ferrets are also associated with ­monkey-to-human cross-species transmis-
Figure 1. Cellulitis following a cat bite. transmission.17 RBF occurs in about 10% sion could occur quite easily given the
of all rat bites, and those at risk include the genetic similarity.53 Travellers, zoo workers
subsequent inoculation of bacteria.12 homeless, children with pet rats, pet store and laboratory personnel are at risk of mon-
Patients with P. multocida infection may, workers and laboratory technicians.17 key bite, and travellers are at risk of the
therefore, present with deep infection, Symptoms of RBF usually present almost universally fatal rabies virus infec-
including tenosynovitis and septic arthri- within one week of the bite and include tion, which can be transmitted by monkeys.
tis,12 which may initially be underestimated. fever, myalgia, sore throat, migratory The increasing incidence of rabies in Indo-
In contrast, Pasteurella spp. cellulitis is arthralgia, headache and maculopapular nesia, and in particular Bali,54 has ensured
often characterised by rapid onset of rash.17 In S. moniliformis infection, the that Australian travellers remain at risk of
spreading cellulitis (Figure 1), usually original wound and adenopathy have usu- exposure. Rabies post-­exposure prophylaxis
within 24 hours of the bite injury.13 ally resolved before presentation, which must therefore be offered to all returned
Bartonella henselae is a fastidious, may hamper the diagnosis.15 In contrast, travellers from a rabies endemic area with
Gram-negative bacillus, and the aetiolog- S. minus has a longer incubation period of a history of m ­ onkey bite.47
ical agent of cat-scratch disease (CSD).14 one to three weeks, and the indurated and Simian herpes B virus is a herpes sim-
Although classically associated with cat painful wound often reappears or persists plex virus-like infection of macaque
(and particularly kitten50) scratches, it during systemic illness.17 Complications of ­monkeys. It is transmissible to humans
has been described following cat bites.51 infection may include meningitis, pneu- and has caused cases of fatal encephalo-
CSD is characterised by the development monitis and endocarditis.18 myelitis.55 A few cases have occurred in
of a vesicle at the inoculation site, followed Diagnosis requires a high index of laboratory personnel following macaque
by a self-limited regional lymphadeno­ s­ uspicion, and S. moniliformis requires bites, scratches, needle-stick exposures
pathy about two weeks later that can per- enriched media with prolonged incuba- and ­handling of infected bodily tissues.
sist for weeks to several months. Low-grade tion,17 thus the microbiologist must be ­Travellers may be exposed to herpes B
fever, malaise and myalgia are often informed if this diagnosis is being consid- virus, with 81% of macaques in the Bali
reported by affected patients.14 Most cases ered. The mortality rate of RBF is about ‘monkey forest’ known to harbour the
of CSD are self-limited and do not require 13% in untreated patients, and a lack of virus.56 Despite this frequent human–­
antibiotic therapy,14 although a short antibiotic therapy is associated with death.16 monkey interaction, no infections have
course of a­ zithromycin may be used for Although penicillin is the treatment of ever been reported from any of these
severe or unresolving lymphadenitis. choice for S. moniliformis, it is also usually d ­ estinations.57 Given the unknown risk
Other manifestations include culture-­ sensitive to cephalosporins and tetracy- and potentially fatal complications,
negative endocarditis, neuroretinitis, clines, but may demonstrate resistance patients bitten by m ­ onkeys should be
pyrexia of unknown origin and bacillary to fluoroquinolones and trimethoprim-­ referred to an infectious diseases physician
angiomatosis in ­immunocompromised sulfamethoxazole.17 Antibiotic susceptibil- for consideration of prophylaxis.32
individuals, particularly those with ity of S. minus is much less studied, given
AIDS.52 Specialist referral is required for the difficulty in culturing the organism.15 Bat bites, rabies and Australian
patients with these complex conditions. A differential diagnosis which should bat lyssavirus
be considered in unwell patients following Despite being free of rabies, Australian
© DR P. MARAZZI/SPL

Rodent bites rat exposure is leptospirosis, which is the bats are enzootic for the closely-related
Rat bite fever (RBF) is caused by infection most common zoonosis and distributed Australian bat lyssavirus (ABLV), which
with either Streptobacillus moniliformis, a globally. It is classically transmitted follow- carries a similarly high mortality rate.
fastidious, slow-growing organism, or ing transcutaneous or mucous exposure Three cases of fatal encephalitis due to

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ABLV have been reported, with the most Bites from ungulates
1. MODIFIED WHO CATEGORIES
recent case occurring in 2013, and a case Ungulates (hoofed animals) include horses, FOR RABIES AND BAT LYSSAVIRUS
in 2000 with a reported incubation period cows, sheep and pigs. Bites from these ani- EXPOSURE47
of two years.58 All people exposed to bats mals are often polymicrobial, including
should, therefore, be assessed for post-­ mixed anaerobes, Gram-positive bacteria Category I
exposure prophy­laxis, regardless of the including Staphylococcus and Streptococcus Touching or feeding animals, licks on
time elapsed since exposure. Recipients of spp. and Gram-negative bacteria including intact skin, as well as exposure to blood,
urine or faeces or to an animal that has
bites from several other mammalian spe- Pasteurella and Actinobacillus species.13
been dead for more than four hours
cies, especially dogs, cats and monkeys, Actinobacillus spp. are Gram-negative
also require post-­exposure prophylaxis if bacilli that are part of the normal flora of Category II
Nibbling of uncovered skin, minor
they have returned from rabies-endemic many ungulates (including horses, sheep, scratches or abrasions without bleeding
areas. cattle and pigs).13 Numerous cases of bites
Category III
Rabies and ABLV exposures are cate- infected by Actinobacillus spp. have been
Single or multiple transdermal bites or
gorised according to the WHO classifica- reported, and they may result in a purulent, scratches, contamination of mucous
tion system (Box 1).47 People with category malodorous abscess at the site of injury.21 membrane with saliva from licks, licks
I exposures require no prophylaxis if the Actinobacillus spp. are closely related to on broken skin
contact history is reliable.47 Immunocom- Pasteurella spp., so additional molecular
petent patients with category II exposures testing to identify the organism should be organism has rarely been reported but has
require vaccination without human rabies requested in the appropriate setting.22 Act- resulted in serious disease. Transmission
immunoglobulin (HRIG).47 Post-exposure inobacillus spp. are broadly sensitive to of S. equi subspecies zooepidemicus after
rabies vaccination in immunocompetent many classes of antibiotics used for bite-­ horse bite has been reported, causing men-
people is given in a four-dose schedule (on associated skin and soft ­tissue infection.13 ingitis and brain abscesses with long-term
days 0, three, seven and 14). An additional neurological sequelae.24
dose is suggested on day 28 in the immu- Cattle, sheep and goat bites Rhodococcus equi is a Gram-positive
nocompromised, although deviations of Parapoxviruses include the orf virus, bacteria carried in the gut of many domes-
a few days are probably unimportant.47 transmitted from sheep and goats (‘scabby ticated animals and distributed world-
The vaccine should be given in the deltoid mouth’), and bovine papular stomatitis wide.25 It is weakly acid-fast and related to
muscle, as neutralising antibodies may be virus, transmitted from cattle.23 These Nocardia spp. R. equi infection is typically
reduced if administered in other areas.5 viruses may produce a lesion at the site of associated with horses and particularly
Both immunocompetent and immuno- inoculation (usually on the fingers or foals. Transmission is incompletely under-
compromised patients who have received hands), developing from a papule to a stood, but may occur via inhalation or
a pre-exposure rabies vaccine course only vesicle and eventually a red target-shaped inoculation into a wound or mucous mem-
require two further doses (on day 0 and ulcer over the course of one to two brane.25 Various symptoms may occur,
three) in the event of an exposure.47 months.23 The lesion often resolves by although many have pulmonary involve-
HRIG is recommended for non-­immune six  weeks, although infection in the ment.22 The incidence of this infection has
patients with category II exposures if: immunocompromised may require anti- increased markedly, particularly as an
• they are immunocompromised and viral therapy and requires specialist opportunistic pathogen in the immuno-
exposed to rabies, or referral. compromised host.25
• the exposure is ABLV, regardless of Hendra virus is transmitted by physical
their immunocompromised or Horse bites contact with oral and nasal secretions of
immunocompetent status.47 Similar to other ungulates, horse bite infec- an ill or dead horse. Only seven cases have
In addition to vaccination, HRIG is tion is often polymicrobial and associated occurred since the first detection of this
recommended for all non-immune patients with several infections, particularly Actin- virus in 1994, and four people have died.26
with category III exposures, as long as no obacillus spp. infection. Horse bite infection Although transmission via horse bite has
more than seven days has elapsed since was shown to be the third leading cause of not been reported, personal protective
administration of the first dose of vaccine animal bite injury in one Victorian study.2 equipment should be used when handling
(or the vaccine may be inactivated by Streptococcus equi is a commensal of the an unwell horse and prevention with equine
immunoglobulin).47 HRIG should be infil- upper respiratory tract of horses; infection vaccination is vital.27 Given the high case
trated in and around the wound, and any in horses results in massive lymphadenop- fatality rate, patients with suspected ­Hendra
remaining HRIG should be administered athy and airway obstruction known as virus infection should be referred to hos-
in an area proximal to the wound.47 ‘strangles’.21 Human disease due to this pital for specialist assessment. Diagnosis

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Human and animal bites continued

relies on polymerase chain reaction (PCR) transmit between biting hosts, has thank- Fresh and marine animal bites
identification and serology, which is avail- fully not been reported in humans.62 Girt by sea, Australians may sustain
able at reference laboratories.26 No specific wounds in marine environments, exposing
treatment or human vaccine is available. Reptile bites them to a unique range of organisms not
Lizards are becoming increasingly com- often encountered in everyday practice.
Pig bites mon as pets, and are known to transmit These include Vibrio spp., A. hydrophila,
Of all ungulates, pigs are the most likely to Salmonella species.33 Generally, lizard oral Erysipelothrix rhusiopathiae and Myco-
bite and are often associated with polymi- flora is polymicrobial and reflective of the bacterium marinum.39 Bites transmitting
crobial infection including Pasteurella and gut and skin flora of their recent meals. these organisms may result in a range of
Actinobacillus spp.28 Streptococcus suis is Although most lizards do not bite, case presentations, from simple cellulitis to
an emerging zoonotic infection, responsible reports have described Serratia marcescens necrotising fasciitis and septic shock.
for septicaemia and meningitis in pigs and cellulitis following iguana bite,34 and Although bites are an uncommon cause
humans with significant occupational ­Pseudomonas aeruginosa septic arthritis of marine animal injury in Australia,40 the
exposure.29 More than 1600 cases in humans following a monitor lizard bite.35 Until significant morbidity and high mortality
have been reported, predominantly in Asia, recently, Komodo dragons were thought of subsequent infection warrants further
with transmission occurring cutaneously,29 to harbour a deadly cocktail of oral flora, consideration.
including following pig bite.30 resulting in the gradual death of its prey Vibrio spp. are classically located in
following a bite. This has been challenged warm estuarine waters, with a worldwide
Bites from possums and other with data suggesting Komodo flora is com- distribution. Vibrio vulnificus is a highly
native species parable to that of other carnivorous species, virulent pathogen associated with rapid
Wombats, koalas and kangaroos seldom with injury resulting from venom produced and severe necrotising skin and soft tissue
bite, although the rising urban exposure in previously unidentified venom glands infection following traumatic injury, often
to possums increases the risk of bites.31 in the lower jaw.36 requiring aggressive surgical debride-
Possum bites have been associated with Due to their territorial nature, crocodile ment.39 Cases have been reported following
a number of infections, including tula­ attacks are often unprovoked, and survi- shark and stingray bites.41,42 Blood cultures
raemia.59 Tularaemia is caused by the vors are likely to suffer deep and complex are positive in 30% of wound infections,43
Gram-negative intracellular bacterium infections following the powerful bite of a and should be taken before antibiotic
Francisella tularensis, which is widespread crocodile.37 If the patient survives the injury ­therapy is started. On the basis of animal
in the northern hemisphere and rarely (noting a 27% mortality rate in Australian studies demonstrating efficacy, the US
causes infection in Australia. Tularaemia attacks37), polymicrobial infection may Centers for Disease Control and Prevention
may be transmitted from a wide variety of result, including Clostridium spp, Aero- recommends combination treatment with
animals, causing several classical syn- monas hydrophila, P. aeruginosa and Sal- a third-generation cephalosporin plus
dromes depending on the route of expo- monella spp. involvement.37 In Australia doxy­cycline as initial empirical antibiotic
sure.59 The most common form (about 80% crocodile bite wounds are also at risk of for V. vulnificus infection,39 although other
of cases) is ulceroglandular tularaemia, becoming infected with the environmental authors suggest doxycycline monotherapy
with ulcerated skin lesions and painful bacterium Burkholderia pseudomallei, for empirical Vibrio spp. therapy.44
lymphadenopathy.59 Only a handful of which causes the potentially fatal infection A. hydrophila and other Aeromonas spp.
cases have ever been reported in Australia, melioidosis.37 Some Australian authors are ubiquitous in aquatic environments,
most recently in 2011, when two women have therefore suggested that patients with particularly fresh and brackish water, and
were bitten by a ringtail possum in Tasma- crocodile wound infections be treated are universally resistant to penicillins,
nia and developed the ulceroglandular broadly with antibiotics, including ceftazi- amoxicillin/clavulanic acid and first­
syndrome.59 This organism’s high virulence dime for B. pseudomallei (and most Aero- generation cephalosporins.39 Carbapenems,
and infectivity (as few as 10 organisms monas spp.), penicillins for Clostridium fluoroquinolones and aminoglycosides
required for infection) has led to its repu- spp. and metronidazole for anaerobes.38 usually demonstrate activity against these
tation as a potential bioterrorism agent.60 Snake bites in Australia rarely lead to organisms. Empirical therapy for bite infec-
As its name suggests, the Tasmanian severe localised tissue necrosis, and Aus- tion following aquatic exposure includes a
devil is a more aggressive marsupial which tralian snake venom is believed to be carbapenem or fluoroquinolone to cover
has resulted cases of bite infection, including ­antibacterial in nature.31 Routine use of these organisms and other co-infecting
P. multocida.61 The devastating devil facial antibiotic prophylaxis is not recommended, Gram-negative bacteria.39
tumour disease (DFTD), a unique infectious although referral of patients for antivenom Infection with E. rhusiopathiae, a Gram-
cancer in which tumour cells themselves should always be considered.63 positive bacillus, is mainly seen following

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Human and animal bites continued

identification.45 Treatment with a pro- Wound closure


longed course of combination clarithro- The subject of primary closure, delayed
mycin and ethambutol is recommended,45 closure or healing by secondary intention
and usually continued for two months is controversial, as evidence is limited and
after symptoms have resolved.39 recommendations differ.13 Indications for
Although uncommon, seal bites are primary closure include bite wounds where
known to cause ‘seal finger’ due to Myco- cosmesis is important (especially the face).
plasma spp., including Mycoplasma pho- Bite wound infection of the head and neck
cacerebrale, which has been isolated from is less common, likely due to the excellent
the bite of a seal-trainer’s finger.68 Infected blood supply and lack of dependent oedema.
bites present as painful, erythematous Wounds at high risk of infection should not
lesions, which respond rapidly to doxycy- be closed by primary closure.13,69
cline monotherapy.68
Use of prophylactic antibiotics
Figure 2. Nodular lesions of fish tank granuloma.
Assessment and management Patients with wounds at high risk of
Steps in the assessment and management ­infection require prophylactic antibiotics.
occupational cutaneous exposure to fish of human and animal bite wounds are Such wounds include:9,13
and shellfish,64 and is known as ‘shrimp discussed below and summarised in Box 2. • crush injuries
picker’s disease’, ‘crab poisoning’ or ‘fish • puncture wounds, especially from
poisoning’. The bacterium is also ubiqui- Initial management cat and human bites
tous in birds, reptiles and mammals, All recipients of bite injuries should be • wounds overlying bone, joints,
including pigs (which are thought to be a assessed for haemodynamic instability and tendons and prostheses
major reservoir), cats and dogs, which have penetrating traumatic injuries should be • wounds in patients whose presentation
also transmitted it following bites.10 E. managed emergently, with a focus on is delayed more than eight hours
­rhusiopathiae also causes erysipeloid, a haemorrhage control with direct pressure • wounds on the hands and feet
disease characterised by well-circumscribed, and assessment of neurovascular supply to • wounds in immunocompromised
violaceous plaques, most often on the distal structures. Even apparently minor hosts (including those with
hands. Unlike erysipelas, erysipeloid occurs injuries may cause deep penetration (e.g. anatomical and functional asplenia)
slowly over the course of one week and cat bites) and may need exploration, which • wounds in areas of venous or
usually resolves within four weeks, even also aids in identifying foreign bodies or lymphatic compromise (e.g.
without treatment.65 Rarely, bacteraemia broken animal teeth. lymphoedema, diabetic feet).
and endocarditis may also occur.39 Diag- Musculoskeletal injuries should be
nosis is confirmed by isolating the organ- assessed with radiography for bony injury Treatment of infected wounds
isms in culture, and it remains ­susceptible or foreign bodies, and clinical assessment Gram stain, culture and sensitivity testing
to penicillins, cephalosporins, clindamycin (e.g. joint range of motion) with ultrasonog- guide subsequent antibiotic therapy;
and ciprofloxacin. Of note, E. rhusiopathiae raphy for injuries involving joints, deep ­however, there is no need to take wound
is intrinsically resistant to vancomycin, ligaments or tendons. Patients with these cultures unless the wound appears clini-
which is often used to empirically treat injuries should be referred for surgical cally infected. Clinical signs of infection
Gram-positive bacteraemia.39 assessment and repair. include fever, erythema, oedema, wound
‘Fish tank granuloma’ is caused by discharge and surrounding lymphangitis.
M. marinum, a slow-growing acid-fast Wound care It is prudent to obtain blood cultures (for
bacteria, characterised by nodular, ery- Meticulous wound care includes cleaning both aerobic and anaerobic organisms)
thematous lesions most often on the the surface and flushing the injury for and wound cultures before antibiotics are
hands and arms (Figure 2). It occurs in 15 minutes with soap and water, or povi- started. Full blood count and inflamma-
fish handlers and aquarium workers with done iodine if available,13 and physical tory markers (e.g. C-reactive protein level)
a history of lacerations or punctures. Bites removal of major contamination. Vigorous should also be measured. Surgical consul-
are one mechanism of inoculation, with irrigation and debridement should be per- tation of patients is often required to con-
case reports including dolphin bite and formed to reduce the concentration of sider debridement, exploration to assess
exotic fish bite.66,67 Diagnosis includes bacteria. Elevating the injury and applying involvement of underlying structures,
mycobacterial culture of biopsy samples an ice pack may provide analgesia and abscess drainage and removal of suture
or of the wound discharge, and/or PCR reduce swelling.13 material, if present.

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Recommended antibiotics for empirical
therapy of bite wound infections are listed 2. STEPS IN THE ASSESSMENT AND MANAGEMENT OF HUMAN AND ANIMAL
in Tables 1 and 2. Patients with complex BITE WOUNDS
infections that involve deeper structures,
1. Resuscitation 5. Antibiotics
such as tenosynovitis, septic arthritis and
osteomyelitis, require treatment for pro- • Immobilise and elevate the bite injury • Assess the need for empirical antibiotics
• Assess for neurovascular for patients at high risk of infection
longed durations (usually with an initial
compromise and compress the • Provide cover for aerobes and anaerobes
parenteral course for two to four weeks, bleeding broadly, including isolated species from
depending on the structure involved and infected wounds
• Treat life-threatening injuries
duration of infection),9 and infectious dis- according to standard guidelines • Assess history of allergies, intolerances,
eases specialist referral is recommended. • Assess for damage to deeper drug interactions, renal dysfunction
Cases involving infected wounds that structures, such as tendons, • Consider contraindications (e.g. prolonged
respond poorly to empirical antibiotics or ligaments and bone QTc interval and ciprofloxacin)
patients with multiple allergies or drug
2. Wound care 6. Tetanus prophylaxis
intolerances should also be discussed with
• Remove debris and foreign bodies, • Assess previous history of tetanus
an infectious diseases physician.
debride any devitalised tissue immunisation status
• Vigorously flush the wound with soap • Consider tetanus immunoglobulin in
Tetanus prophylaxis and water or povidone iodine patients with high-risk wounds if
Tetanus is caused by the neurotoxin pro- • Take wound cultures only if evidence unvaccinated
duced by Clostridium tetani, leading to of infection and communicate with • Provide tetanus prophylaxis even for
tetanic contractions, myotonia and trismus. laboratory staff about suspected patients with apparently low-risk wounds
It is rare in Australia, with 156 hospitalisa- pathogens
• Document vaccinations given, including
tions between 2001 and 2006 and three • If infected, take blood cultures brand, batch number, dose number, date,
deaths (case fatality rate, about 2%). In addi- (aerobic and anaerobic) as well as time, site
wound cultures
tion to animal bites, human bites have also
been reported to transmit tetanus.70 Tetanus 7. Transmissible virus prophylaxis
3. Clarify and document history
vaccination is only available in combination • Blood-borne viruses: consider HIV and
• Confirm the species of the animal,
HBV PEP and HCV follow-up serology
with other agents (such as diphtheria, tet- document and report to authorities
anus, acellular pertussis; DTPa), and given as required • Rabies/Australian bat lyssavirus:
administer PEP, including vaccination and
as a three-dose primary schedule at 2, 4 and • Document the injury (site, depth,
HRIG
6 months of age.47 ­Tetanus may occur even pattern of injury) and circumstances
of the attack • Herpes B virus: consider specialist referral
after apparently trivial wounds, although of patients for valaciclovir following
• Clarify past medical history,
bites are categorised as tetanus-prone macaque monkey bites
medications, allergies and
wounds requiring assessment for tetanus immunisation status • Document PEP given, including brand,
vaccination (Table 3). • Clarify whether patient is
batch number, dose number, date,
time, site
immunocompromised
Follow up
4. Wound closure 8. Follow-up care
If patients are managed in the community,
• There is limited evidence in this area • Review patient at 24 to 48 hours
they should be educated regarding the
and recommendations vary • Provide education on the importance of
symptoms of infection, should they
• Consider closure for areas where medication compliance and signs and
develop (or worsen despite antibiotic symptoms of infection
cosmesis is an issue (usually for
­treatment). Patients should be clinically facial wounds) • Advise patient to return if features of
reviewed between 24 and 48 hours after • Avoid primary closure in wounds at cellulitis, sepsis or clinical deterioration
presentation, not only to assess the wound, high risk of infection occur
but to monitor tolerance and compliance • Apply appropriate dressings if • Provide, or refer patient for, counselling,
with antibiotic therapy, if initiated. closure is not performed psychological assessment if needed and
If empirical antibiotics were com- prevention strategies
menced, the results of Gram stain, aerobic
and anaerobic cultures should be used to Abbreviations: HBV = hepatitis B virus; HCV = hepatitis C virus; HIV = human immunodeficiency virus;
modify therapy based on organism and HRIG = human rabies immunoglobulin; PEP = post-exposure prophylaxis.

susceptibility testing.9 If intravenous

MedicineToday ❙ NOVEMBER 2017, VOLUME 18, NUMBER 11 39


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Human and animal bites continued

• Hepatitis B vaccination. Those at


TABLE 3. INDICATIONS FOR TETANUS TOXOID AND IMMUNOGLOBULIN47
occupational risk of human bites,
Tetanus vaccination history Clean, minor wounds All other wounds such as police, staff of correctional
facilities and those who work with
Toxoid Immunoglobulin Toxoid Immunoglobulin people with intellectual disabilities,
Three or more doses <5 years ago No No No No may be at higher risk of human bites,
and should receive HBV vaccination
Three or more doses 5 to No No Yes No
on employment.47
10 years ago
• Immunocompromised and asplenic
Three or more doses >10 years ago Yes No Yes No patients should be educated about the
Unknown or less than three doses Yes No Yes Yes
risk of life-threatening infection in the
event of an animal bite, and the need
therapy was initiated, switching to oral Strategies to minimise harm in the to seek urgent medical attention.3
therapy is reasonable once the patient is future should include the following
stable. If the pathogen remains unknown, measures. Conclusion
oral antibiotic therapy should be continued • Behavioural measures. Avoid patting Animal bites are a growing public health
as for mild infection (Table 1), remember- or touching dogs that demonstrate risk, which may lead to serious injury and
ing that polymicrobial infections are pre- territorial behaviour and ensure that transmission of infection. The nature of the
dicted and should be covered broadly. children are not left alone with dogs bite, the species of the animal and the con-
Immunocompromised patients, who or other animals at risk of biting.73 ditions of the host are all factors to consider
are at increased risk of transmission and Avoid dogs that are eating, sleeping or when managing a patient with a bite injury.
more severe illness after a bite, are particu- caring for puppies. Dogs should not Management includes immediate wound
larly vulnerable. An Australian study be greeted with an outstretched hand, care, prevention of tetanus transmission and
recently found that more than half of an unfamiliar dog should be allowed antibiotic prophylaxis. Prevention of infec-
immunocompromised patients surveyed to smell the person’s hand first.73 tion with education, behavioural modifica-
owned a pet, most exhibited risky behav- Some breeds of dogs are known to tion and timely vaccination are also key to
iour and 30% had been scratched or bitten have a higher attack rate despite reducing the risk of transmission of infection
by their pet.3 Immunocompromised training, so families should consider in the future.  MT
patients with bite injury should be referred this when purchasing a new dog.73
to hospital for assessment, and education • Rabies and ABLV prevention. References
remains the key to bite prevention in this Avoidance of close contact with either A list of references is included in the online version of

group. wild or domestic animals is strongly this article (www.medicinetoday.com.au).

Another important, but underappreci- encouraged, particularly for children


COMPETING INTERESTS: None.
ated, complication of animal bites that must travelling overseas. In Australia,
be addressed at follow up is post-traumatic unwell, injured or trapped bats and
stress disorder (PTSD). In particular, chil- flying foxes should not be handled, ONLINE CPD JOURNAL PROGRAM
dren who have been attacked by a dog may and local wildlife rescue services
What is the most common cause of
suffer from PTSD later in life.71 Half of should be contacted immediately for
infection of dog and cat bites?
adults in one Australian survey lived in fear assistance. Pre-exposure vaccination
of future dog attacks, and many modified should be offered to people at high
their behaviour towards dogs thereafter.72 risk of exposure, including those in
occupations at high risk, risk-averse
Prevention travellers and particularly children
Although animals have become our travelling to endemic areas.47
much-loved companions, responsible pet • Tetanus immunisation. A booster
© GRUBARIN/STOCK.ADOBE.COM

ownership should always be encouraged. dose should be offered to those who


GPs have an important role in preventing travel and are at risk of sustaining a Review your knowledge of this topic
bite wounds, and follow up represents an bite wound if more than five years and earn CPD points by taking part
important opportunity to educate and have elapsed since their last dose, in MedicineToday’s Online CPD Journal
Program. Log in to
offer vaccinations to people at risk of especially if access to travel services
www.medicinetoday.com.au/cpd
­animal and human bites. will be difficult.47

40 MedicineToday ❙ NOVEMBER 2017, VOLUME 18, NUMBER 11


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MedicineToday 2017; 18(11): 30-40

Human and animal bites


Managing and
preventing infection
STEPHEN MUHI MB BS, BSc, BMedSc, MPHTM, FACTM; JUSTIN DENHOLM MB BS, MPHTM, PhD, FRACP

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