Microbiology and Management of ANIMAL BITES

7/28/2019 Microbiology and Management of ANIMAL BITES

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Microbiology and Management ofAnimal BitesByHeba AL Sayed AL Degla

Assistant lecturer of Medical Microbiology and Immunology


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Animal bites

frequency

1% of annual ER visits and cost $30 million per year

HCP treat 1-2 million animal bite patients per year

10% of animal bite wounds require medical attention

1 to 2% require hospitalization

10 to 20 human deaths per year primarily of infantsand children


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1. Infection which may be life threatening

2. Mechanical trauma

Superficial skin breaks with or without bleeding, Puncture wounds,

Lacerations,

Fractures,

Tendon damage

Disability and cosmetic problems due to scar formationand loss of tissue

Problem of animal

bites


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Infections

Most bacteria reside in the animal's oral cavity.

Bacteria on the victim's skin.

Most infections involve several pathogens

Over 130 disease-causing microbes have beenisolated

Dog bites do more damage, but only 5 to 15 %

become infected.Cat bites: up to 80 % become infected if proper careis not taken


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Disease Risk by Species

Dogs and Cats:

Rabies

Bacterial infections

Cats: Cat scratch fever (Bartonella henselae, B. quintana)

Sporothrix schenckii (bite or scratch)

Rodents (domestic): bacterial infections.

Rodents (wild):

Rabies

Bacterial infection (including tetanus and tularemia)

Rat bite fever rare


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Wild Animals e.g., skunk, fox, raccoon, opossum

Rabies

Bacterial pathogens (tetanus and tularemia).

Bats: rabies. Primates (non-human)

Rabies

Bacterial infections

Simian B herpesvirus (macaques)

Hepatitis A, B, and C (certain great apes).

skunk

raccoon

opossum
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Horse, donkey, pig and sheep bites

Actinobacillus spp, staphylococci, streptococci,Pasteurella spp , Yersinia and anaerobes

Camel bites Pseudomonas, Staphylococci,Streptococci and Clostridium tetani

Seal bites: give rise to the

seal finger: swelling and blisteringat the site of injury due to infection

with a Mycoplasma organism
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Risk group

Occupational: veterinarians, farmers.

Children (5 to 15 years): head or neck

With dog bites, adults are bitten on an extremity Boys are twice as likely to be bitten by a dog

Girls receive twice as many cat bites.

Most of the animals live in the victim's neighborhood(75%) or home (15%)

Bites are provoked by humans.


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Infection risk

Factors related to the victim

1. Age over 50 years

2. Diabetes, circulatory problems, liver disease,alcoholism, or HIV/AIDS

3. Organ transplant

4. Chemotherapy or long-term steroids treatment5. Splenectomy


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Factors related to the animal:

Cat bites (40-50%) Dog bites (5-15%)

Human bites (15-40%)

Factors related to the bite wound

Location: Hand (20-35%), arm or leg (10-15%),face (5-10%)

Type of wound: Puncture with laceration (15-25%),laceration alone (10-12%)

Interval between bite and medical care: If >24 hr,risk of infection increases

Infection risk


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Dog bites

Children younger than 10years

Involve the head and neck. Male dogs are six fold more

likely to bite than are femaledogs.

The wounds are crushing andlacerations rather thanpuncture wounds


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Certain breeds: German Shepherds

pit bull terriers, and mixed breeds.
http://puppydogweb.com/gallery/americanpitbullterrier/americanpitbullterrier_grullon.jpghttp://puppydogweb.com/gallery/americanpitbullterrier/americanpitbullterrier_asabella.jpg


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Infections associated

with dog bite

A. Infectious organisms specific to canine saliva.1- Pasteurella spp.

Small Gram-negative facultative anaerobic rods

The most common bite-associated infection

Up to 80% with cat bite, 12%-50% with dog bite infections

Multiple species: P. multocida subsp. multocida, subsp.septica, P. stomatis, P. dagmatis, and P. canis

Inflammatory response, within the first 24 hours

Fulminant soft tissue inflammation in 3 hours.

Purulence, lymphangitis, regional adenopathy andnecrotizing fasciitis

P. multocida can cause septic arthritis


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2- Capnocytophaga canimorsus and C. cynodegmi.

Fastidious gram-negative rods

C. canimorsus is more dangerous

Very rare infection, but so dangerous Fulminant sepsis, meningitis and severe soft tissue

infection particularly in compromised people.

Up to 30 % of septicemia cases are fatal.

Early symptoms: nausea, headache, muscle aches, andtiny reddened patches on the skin.

C. cynodegmi cause localized soft tissue inflammation


with dog bite


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B- Dogs may be infected by infectious organisms

and transmit this pathogen to humans through saliva

Brucella canis resulting in local wound infection, and the

nonspecific symptomatology associated with brucellosis. Rabies

C-Other pathogens: Staphylococci, Streptococci, Proteus,anaerobes, Moraxella, Corynebacterium, Neisseria, tetanus,

and tularemia.

With this plethora of potential pathogens in canine saliva only 5-15% of dog bites result in soft tissue infections


with dog bite


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Cat bite

Victims are adult females

On the upper extremities and face.

Feline bites are of particular concern

because the sharp and long teeth of

cats can penetrate skin,

creating a deep puncture wound with

microorganisms inoculated into thesoft tissues or even deeper

into the periosteum or into a joint

and result in osteomyelitis or septic arthritis.
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1-Pasteurella spp. (with the exception ofP. canis)

Cats are the source of 60 to 80% of human P.

multocida infections Commensals of the feline respiratory tract and can be

cultured from the oral cavities of >90 % of cats

Wounds inflicted by cats more commonly progress tothe serious sequelae such as osteomyelitis, sepsis,and meningitis.


with cat bite


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2- C. canimorsus and C. cynodegmi

Part of the normal feline oral flora Local soft tissue infection, fulminant sepsis and

meningitis, are more common with cat bites.

Corneal infection with C. canimorsus following eye

trauma due to a cat bite cat's tooth keratitis


with cat bite


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with cat bite

3- Cat scratch disease

Slowly progressive, self-limiting, chronic lymphadenopathy

Children (2-14years)

Due to infection with Bartonella henselae Gram negative rods formerly placed in the genus

Rochalimaea.

It infects kittens and remains in their blood for long periods.

Bacteremic cats infect their owners via bites or scratches

Also transmission to humans via contact with the cat fleas(Ctenocephalides felis)


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Transmission


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Cat scratch

disease

Incubation period of 1-2 weeks

Primary lesion: cutaneous red

painless papules or pustules atthe scratch or bite.

After 3-10 days regionallymphadenopathy in 90% of

cases. Fever, malaise, and other

systemic symptoms
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In the most severe cases,the organism disseminatewidely throughout the

human host

Infecting the liver, spleen,eye, and CNS, which

present as seizures dueto encephalitis

Cat scratch

disease


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DiagnosisClinical diagnosis is made if 3 of the following 4 criteria

are met:

1. History of cat contact resulting in a scratch orprimary lesion of the dermis, eye, or a mucousmembrane

2. Positive skin test response to antigen or positive

indirect fluorescent antibody test

3. Negative lab investigation for lymphadenopathy

4. Characteristic lymph node lesions.

Cat scratch

disease


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Therapy

Symptomatic care

Swollen lymph nodes will resolve in 1-6 months.

The infection will resolve in 90% of untreated patients

For extensive lymph node swelling Azithromycin for 4weeks

Retinitis: Doxycycline + Rifampin for 4-6 weeks. Endocarditis: Doxycycline 6 weeks + Gentamicin for 14

days.

Encephalopathy; Rifampin, Ciprofloxacin,

trimethroprim/sulfamethoxazole, or azithromycin.

Cat scratch

disease


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4- Cowpox, or catpox

Uncommon viral infection of cats found in Europeancountries.

Member of the family Orthopoxvirus.

Infection contained to the soft tissue surroundingthe bite itself.

Painful hemorrhagic pustule, which may developinto a black eschar.


with cat bite


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5- Francisella tularensis

Cause a potentially fatal infection in cats

Tick-borne infection, rarely by cat bite

Tender papule progress to an ulcer with a yellow orblack base

Extraordinarily rare.

6- Other bacteria found in cat wounds Actinomyces, Proprionibacterium, Bacteroides, and

Fusobacterium.


with cat bite


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Rat bite fever (RBF), also known as Haverhill fever

Caused byActinobacillus muris and Spirillum minus

Both are part of the normal oropharyngeal flora of rats

Most cases occur in Japan, but also in Australia, Africa,North and South America, and Europe.

Human infection most commonly occurs via a bite

Some cases may occur through contact with urine, oral orconjunctival secretions

The source of the infection is a rat, other animals such assquirrels, weasels, and gerbils.


with rat bite


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Rat-bite fever due toActinobacillus muris

Fever, chills, headache, and muscle pain within 10

days of exposure. After three days diffuse rash in the extremities.

Inflammation of One or several large joints

If untreated, severe complications including infectionof the heart valves may occur.

Rat bite fever


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RBF caused by Spirillum minus

Common in Asia, particularly Japan, called sodoku.

Skin rash characterized by red or purple plaques

Previously healed wound bite may reactivate

Relapsing fever and regional lymphadenitis

Joint involvement is rare

Rat bite fever


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Diagnosis

Detection of the organism in skin, blood, joint fluid, orlymph nodes

Blood antibody tests.

Treatment

Penicillin, Amoxicillin Clavulanate, Erythromycinor Tetracyclines for 7-10 days.

Rat bite fever


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Prognosis

Excellent with early treatment.

Complications

Pericarditis

Endocarditis

Parotitis

Tenosynovitis

Abscesses of the brain or soft tissue

Rat bite fever


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Snakebite

Soft tissue infection may not be the victim's foremostpriority

Infection withAeromonas hydrophila Local soft tissue necrosis and cutaneous abscesses

at the site of injury.
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Grizzly or black

bear bites

Have been cultured forA. hydrophila.

Soft tissue infections are polymicrobial

consisting ofE. coliand Proteus spp.,

S. epidermidis and S. aureus

It is unknown if these organisms are particular tobear saliva or carried by the claws from soil orother sources.
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Horse bites

2% of all animal bites.

Young girls.

Severe bite may result in amputation, or severehematoma, fat necrosis, and muscle rupture,without an external wound.

Few bites develop into an infective state

Mainly Pasteurella, Actinobacillus, and Yersinia. A. actinomycetemcomitans, causes infective

endocarditis

Other bacterial pathogens, such as S. aureus.


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Monkey bites

Bacteroides spp, Fusobacterium spp, streptococci,enterococci, tetanus and Eikenella corrodens

Simian herpes virus (herpes B virus) is, rarely,

transmitted by bites from monkeys of the macaquegenus (native to Asia and northern Africa)

Rapidly progressive encephalomyelitis, with a mortality

around 70% Asymptomatic patients: prophylactic aciclovir

Established infection should be treated with aciclovir


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Wild animal bites

Rare but more serious, given the risk of rabies and otherinfections.

Rabies is caused by a virus that infects nervous system and

can affect all warm-blooded animals, including people. Once symptoms appear, infected people almost always die.

Rabies is found naturally in wild animals especially skunks,wolfs, foxes and bats.

Wild animals can transmit infection to dogs and cats whichthen transmit it to people (or people can catch it directly fromwild animals).


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Rabies

Transmission

Bite of a rabid animal

Non-bite exposures to rabies are very rare.

Scratches, abrasions, open wounds, or mucousmembranes contaminated with saliva from a rabidanimal

Other contact, such as petting a rabid animal orcontact with the blood, urine or feces of a rabidanimal, does not constitute an exposure and is not anindication for treatment.


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Clinical presentation (human)

Two stages.

The first stage (10 days): headache, fever,

decreased appetite, vomiting, general malaise, pain,itching, and tingling at the wound site.

Stage two, difficulty in swallowing, agitation,disorientation, paralysis, and coma.

At this point there is no known effective treatment.

Without treatment, it is 100 % fatal

Rabies


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How do I know if an animal has rabies?1-Vicious rabies

Changes in personality.

Refusal to eat; unusual excitability or restlessness;snarling at moving objects; and excessive drooling andfoaming at the mouth.

Ends in paralysis and death within several days

2- Dumb rabies Rapidly progressing paralysis in 3-5 days ends in death.

Dropped jaw.

Rabies


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What should I do if an animal bites me?

Wash the bite wound

Contact a physician to assess

rabies risk

Begin rabies ttt, if necessary. .

Animal quarantined or tested.

If the animal cannot be found,

treat with (HRIG/RIG) and human diploid cell vaccine

Rabies
http://doggies.com/blog/wp-content/uploads/2008/07/dog-bite.jpg


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Rabies

What should be done with the biting

animal?

Capture the animal and cage it.

If cannot be captured, kill it butDO NOT shoot it in the head.

The head should be removed and

the brain examined for rabies by

direct fluorescent antibody test

Non- stray animals will require

to be quarantined.


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How long should the animal be confined for

observation?

10 days.

If animal had rabies at the time of biting, it will showsigns of rabies and/or die within ten days.

Stray or wild animals should be killed immediately

and the brain examined for rabies.

Rabies


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Rabies prophylaxis

Indications

1- laboratory evaluation found that the animal wasrabid

2- Animal was not captured

3- After exposure to bats even if no bite.

As soon as possible after exposure.

Rabies


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Regimen

1- Patients not vaccinated previously

receive both human rabies vaccine

(5 doses IM in the deltoid area) and

rabies immune globulin (20 IU/Kg),

infiltrated in and around the wound

and the remainder IM.2- Individuals received a complete vaccination

receive only two does of vaccine three days apart.

Rabies prophylaxis


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Prevention

Do not try to separate fighting animals

Avoid animals that appear sick or act strangely.

Leave animals, alone when they are eating or sleeping.

Keep pets on a leash when out in public.

Never leave a young child alone with a pet.

Dont tease an animal by waving sticks,

throwing stones, or pulling a tail.

Be sure your pet is vaccinated.

Do not play with any wild animal.


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Human bites

In child, on the face, upper extremities, or trunk.

The force of bite drive oral bacteria into the tissueand spread to the adjacent joints or it directlypenetrate the joint.

Staphylococci, Streptococci, Eikenella corrodens,Clostridium tetani, and Bacteroides.

Possible transmission of hepatitis B, hepatitis C,herpes simplex virus, and HIV.


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Management

History

The length of time since injury,

The type of animal and its present location,

Immunization status and health,Physical examination

Musculoskeletal and neurologic examination

Inspection of the wound for signs of infection.

Rapidly developing Cellulitis is a clue to P. multocida A cellulitis that develops gradually is more likely the result of

Gram-positive cocci or other pathogenic bacteria


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History

The length of time since injury,

The type of animal and its present location,

Immunization status and health,Physical examination

Musculoskeletal and neurologic examination

Inspection of the wound for signs of infection.

Rapidly developing Cellulitis is a clue to P. multocida A cellulitis that develops gradually is more likely the result of

Gram-positive cocci or other pathogenic bacteria

Management


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Radiological studies

Necessary for deep puncture wounds to look forforeign objects and bone injuries.

Initial assessment:

Primary assessment of bites must involve ABCs.

Hemostasis must be achieved.

The effect on vital organs should be assessed.

Next, the wound itself should be addressed:

Management


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Cleaning and exploration:

Clean the wound with copious amounts of soap andwarm sterile water or saline for 15 min and inspect it.

Wash with an antiseptic solution

Apply antibiotic ointment and cover the wound withgauze or a bandage.

If severe wound, or if you have risk factors, seekmedical advice at once.

Be sure no foreign bodies into the wound.

Elevation of the affected part and immobilization

Management


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Suturing: Cutaneous wounds should be treated and left open if

1. They are punctures rather than lacerations,

2. Not disfiguring,

3. Inflicted by humans,4. Involve the legs and arms (particularly hands)

5. Bites to the arms and legs seen after 6 to 12 hours.

6. Bites to the face seen after 12 to 24 hours.

Facial lacerations are almost always closed.

Debridement of all devitalized tissue and attention to wound care

Wounds that are clearly infected should not be closed.

Management


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Infection prophylaxis:Standard management:

85 % of bites harbor potential pathogens.

Adherence to standard principles of woundmanagement

Copious irrigation at high pressure

Dbridement of devitalized tissue

Cultures obtained at the time of injury cannot predictwhether infection will develop or, if it does, thecausative pathogens.

Management


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Antibiotics:Indications

High-risk patients: young children, older patients,

patients with chronic medical problems, andimmunocompromised patients.

High-risk injuries: crush injuries, deep puncturewounds, systemic signs of infection, rapidly

spreading cellulitis, septic arthritis, osteomyelitisthose require surgical repair, and those involvinghands and face.

Management


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Ampicillin-sulbactam.

In penicillin allergy: clindamycin plus trimethoprim-sulfamethoxazole.

Broad-spectrum antibiotics If the wound infected withhospital acquired or community acquired bacteria,until culture sensitivity results.

Intravenous antibiotics for infected hand bites, severeinfections at other sites, and systemic symptoms

Management


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Rabies prophylaxis

Tetanus prophylaxis:

After bites of all kinds, tetanus immune globulin andtetanus toxoid should be administered to patientswho have had two or fewer primary immunizations.

Tetanus toxoid alone can be given to those who have

completed a primary immunization In human bites, proper vaccination for hepatitis and

prophylactic treatment for HIV

Management


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Late Care Scarring needs to corrected.

Tendon injuries and nerve injuries should be corrected assoon as feasible.

When to refer

Complex wounds that require surgical repair

Bites to the face or hand that require plastic surgery

Infected wounds not responding to initial treatment

Children with human bites from an adult

When to admit

Infected wounds requiring intravenous antibiotics

Extensive facial wounds requiring skilled nursing care

Management


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Date post:	03-Apr-2018
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Microbiology and Management of ANIMAL BITES

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