KNOWLEDGE

CLINICAL
The management of animal
and human bite wounds

RefeRences
Bhattacharjee, C. et al (2000) Do
animals bite more during a full
moon? Retrospective observational
analysis. British Medical Journal;
321: 7276, 15591561. (Chaudhry et al, 2004; Smith et al, 2003) an The peak incidence of dog and cat injuries is in the
estimated 200,000 cases a year. However, several summer months between May and August, according
Bower, M. (2003) An update on studies have shown that less than 50 per cent of bites to Ostanello et al (2005), while Bhattacharjee et al
managing dog, cat and human bite are reported (Ostanello et al, 2005; Medeiros and (2000) conclude that the full moon is associated with
wounds. Physician Assistant; 27: 8,
Saconato, 2004; Kahn et al, 2004; 2003). Wounds in a significant increase in animal bites to humans.
3843, 45.
adults are usually on the arms or legs and in children
Broder, J. et al (2004) Low risk
on the face or scalp. Gender and age
of infection in selected human According to Medeiros and Saconato (2004), bite Dog bite injuries are more common in males and
bites treated without antibiotics. wounds include superficial abrasions (3043 per cent), younger individuals, with the highest incidence
American Journal of Emergency lacerations (3145 per cent) and puncture wounds (13 occurring in those aged 2029 years. Bites are most
Medicine; 22: 1, 1013. 34 per cent). Most patients who present at A&E with a common on the lower extremities, although children
bite wound are not severely injured, although about 10 under nine have a significantly higher risk of being
per cent require sutures and one per cent require bitten on the head, face and neck. Cat injuries are
hospital admission (Ostanello et al, 2005; Chaudhry et more than twice as common in females as in males,
al, 2004; Medeiros and Saconato, 2004). Wounds that and the highest incidence is in those aged between
become infected require further treatment. 60 and 69 years (Ostanello et al, 2005).
Human bites are most common in children and can
be the result of playing or fighting with other children
but they may also indicate abuse (Broder et al, 2004).
Learning objectives In adults they are more likely to be the result of
Author Marion Richardson, BD, CertEd, RN, What makes animals bite?
Each week Nursing Times publishes a guided
DipN, RNT, is learning articleand
senior lecturer withprogramme
reflection leader, sexual
In over or
70physical
per centassault.
of casesThere
peoplearearemore malebythan
bitten their
points to help you with your CPD. After reading the article you should be able female victims in most age groups.
Emergency Nursing, University of Hertfordshire. own pets or by an animal known to them (Medeiros
to:
AbstrAct Richardson, M. (2006) The and Saconato, 2004). It appears that most dog bites, if
management of animal and human bite wounds. Potential
not other animalcomplications
bites, result mainly from the victims
Nursing Times; 102: 3, 3436. In the UK the
behaviour main
(Kahn et complications
al, 2003). Medeirosof animal
and bites
Saconato
l Understand how bites are most commonly sustained;
Every year, large numbers of people are bitten by are related to infection but rabies is an additional
(2004) found that children under five years old were
l Know the potential complications following
animals, a bite;number by humans. The
and a smaller problem in many
significantly more countries.
likely than older children to have
Getty Images SPL

consequences can be serious. However, better provoked an animal before being bitten.
l Recognise the correct immediate
health treatment
education for a bite
to help wound;
prevent bites and teaching Infection
Dogs are more likely to inflict bites that require
a bite-avoidance strategy when someone is being Animal and
medical human(Fig
attention mouths
1), andcontain a mixture that
it is estimated of
l Be familiar with the correct treated
assessment
for a and
bite management of thisthe
may help to reduce injury.
problem. aerobic and anaerobic organisms. The
they account for about 8090 per cent of animal most commonly
This article discusses treatment options and the isolated
bites bacteria etareal,Pasteurella
(Ostanello 2005; Chaudhry multocida,
et al, followed
2004).
possible complications of bite wounds. Cats are responsible for nearly 20 per cent of bites,
and rabbits, guinea pigs, hamsters, rats and mice
34 Most bite wounds are caused by dogs, cats or cause a small percentage
NT 17 January 2006 (Ostanello
Vol 102 No 3 et
wwal, 2005). s.net
w.nursingtime
humans. In the UK dog bite wounds account for 0.52 Although human bites are relatively uncommon,
per cent of new attendances at A&E departments they can have serious consequences.
 kEywoRDs n Animal bites n Cleansing n Wound management

joint space easily. The wound may appear small but RefeRences
when the fist is unclenched the tendons retract and
infection can be carried under the skin (Bower, 2003). Brook, I. (2005) Management of
human and animal bite wounds: an
Tetanus overview. Advances in Skin and
Wounds containing devitalised tissue, dirt and saliva are Wound Care; 18: 4, 197203.
at risk of contamination with Clostridium tetani, the
Chaudhry, M.A. et al (2004) Is the
bacteria that cause tetanus. Bower (2003) recommends
management of dog-bite wounds
that all crush injuries and wounds that are deeper than evidence-based? A postal survey
1cm are considered at risk of this infection. Tetanus and review of the literature.
prophylaxis should be given according to Department Emergency Medicine;
of Health guidelines (DoH, 2004). 11: 6, 313317.

Fig 1. A dog bite on the arm: dog bites are Correira, C. (2003) Managing dog,
Rabies
most likely to occur in children cat and human bite wounds. Journal
This disease is carried by animals including dogs, foxes
of the American Academy of
and bats, and may be contracted as a consequence of
by streptococci, staphylococci, moraxella, Physicians Assistants; 16: 4,
being bitten or scratched by a rabid animal. Although 2832, 34, 37.
corynebacterium and neisseria (Medeiros and
it is not a problem in the UK, it should be considered
Saconato, 2004). Mellor et al (1997) note that local or
when patients have been bitten abroad. Department of Health (2004)
systemic infections after a bite are more likely in
Immunisation Against Infectious
patients who are immunocompromised by
Hepatitis B and HIV Disease. London: DoH.
haematological malignancy, splenectomy or cirrhosis. www.dh.gov.uk
These infections can be spread by bite wounds if the
Bower (2003) notes that even minor bites can
person who bites carries the virus.
penetrate a tendon sheath, joint capsule, bone or Garbutt, F., Jenner, R. (2004)
nerve, resulting in more serious complications such as Wound closure in animal bites.
cleaning and closing the wound
septic arthritis and osteomyelitis. These complications Emergency Medicine Journal;
Careful and thorough cleaning is one of the most 21: 2, 589590.
are more common with cat bites because the narrow,
important factors in the care of bite wounds. Medeiros
sharp feline incisors can puncture tissue and penetrate
and Saconato (2004) note that there are no reliable Goldstein, E.J.C. et al (2002) In vitro
a bone or joint.
studies related to debridement, irrigation and activities of the des-fluoro(6)
Dog bites are associated with a risk of crush
decontamination measures, but there is consensus in quinolone BMS-284756 against
injury, and infection in the resultant devitalised aerobic and anaerobic pathogens
the literature that such measures are likely to be
tissue is isolated from skin and soft tissue
beneficial. Smith et al (2003) suggest that rigorous
often a problem. Approximately 1520 per cent of dog animal and human bite wounds.
initial wound care appears to be more effective than
bite wounds become infected and it is not possible to Antimicrobial Agents and
antibiotic prophylaxis.
predict when or if this will occur with any certainty Chemotherapy; 46: 3, 866870.
Superficial bite wounds should be washed with
(Bower, 2003). Patients often present with swelling
water and plenty of soap (Brook, 2005; Bower, 2003)
and a grey malodorous discharge, usually within 24 Kahn, A. et al (2004) Prevalence of
rather than antibiotic solutions, which can cause dog bites in children: a telephone
hours of sustaining a bite injury.
irritation. Deeper wounds require large volume survey. European Journal of
Cat-scratch disease can result from cat bites and
(250ml or more), high-pressure irrigation with normal Paediatrics; 163: 7, 424.
scratches. The infection usually presents with an
saline (Smith et al, 2003) delivered via a large
erythematous inoculation papule 810 days after the Kahn, A. et al (2003) Child victims
syringe. However, because dogs jaws are designed for
injury, followed by adenitis (inflammation of the lymph of dog bites treated in emergency
tearing, the resultant crush injury wounds almost
glands) and fever. The infection usually resolves within departments: a prospective survey.
always contain devitalised tissue. Debridement of this
two months, although severe infections may require European Journal of Paediatrics;
tissue is very important, as it helps to reduce the risk
treatment with tetracycline (Bower, 2003). 162: 4, 254258.
of wound infection. Both irrigation and debridement
are uncomfortable, and Smith et al (2003) recommend
Human bite wounds
the use of local anaesthetic before these procedures.
Human oral flora include Streptococcus viridans,
Deep puncture wounds are common and can be
Staphylococcus aureus and Eikenella corrodens.
difficult to clean, so require special care. As with any
Infection following a bite can lead to cellulitis,
wound, it is important to look at its base to rule out
osteomyelitis and septic arthritis. About five per cent
nerve or tendon damage. If there is any sign of these,
of people presenting with human bite wounds require
or of the blood supply being compromised, the patient
amputation because the vascular blood flow to the
must be referred to a surgeon (Bower, 2003).
wound is compromised or there are complications This article has been double-blind
associated with infection (Bower, 2003). peer-reviewed.
closure of bite wounds
Injuries to a clenched fist are regarded as more
There has been a great deal of debate about whether For related articles on this subject
serious than occlusal injuries, such as a bite to an arm,
dog bite wounds should be left open to heal by and links to relevant websites see
because the metacarpophalangeal joint is in flexion
secondary intention or closed. Garbutt and Jenner www.nursingtimes.net
during a punch, allowing the teeth to penetrate the

NT 17 January 2006 Vol 102 No 3 www.nursingtimes.net 35

KNOWLEDGE
RefeRences (2004) reviewed 74 papers and concluded that bite
wounds on the hand should be left open and that
Medeiros, I., Saconato, H. (2004) non-puncture wounds elsewhere may be treated
Bites (mammalian). Clinical safely with primary closure after thorough cleaning.
Evidence. www.clinicalevidence. Chaudhry et al (2004) found that most A&E
com/ceweb/conditions/wnd/0914/ departments close bite wounds to the face. Bower
0914_13.jsp (2003) agrees that these wounds heal well when
sutured but suggests that they should be sutured
Mellor, D.J. et al (1997) Mans best by a plastic surgeon to limit scarring.
friend: life-threatening sepsis after
Medeiros and Saconato (2004) found insufficient
minor dog bite. British Medical
evidence to determine whether primary wound
Journal; 314: 7074, 129.
closure had any effect on infection rates. The best
Ostanello, F. et al (2005) Incidence advice seems to be to leave the wound open or to
of injuries caused by dogs and cats consider delaying primary closure of infected wounds,
treated in emergency departments puncture wounds and wounds that are more than 24
in a major Italian city. Emergency hours old (Bower, 2003) and to ensure that all other
Medicine Journal; 22: 4, 260262. wounds are irrigated and meticulously debrided
before suturing. The use of skin-closure strips is not
Richardson, M. (2004) Procedures advocated as a wound closure method as they can
for cleansing, closing and covering
lead to seroma formation (a collection of serous fluid)
acute wounds. Nursing Times;
and subsequent infection (Smith et al, 2003).
100: 4, 5458.
Smith, M.R. et al (2003) Barking up Administering antibiotics
the wrong tree? A survey of dog There is debate about whether prophylactic antibiotics
bite wound management. should be given to every patient with an animal bite
Emergency Medicine Journal; wound. Because wound infection cannot be predicted
20: 3, 253255. with any certainty (Smith et al, 2003), the maxim
better safe than sorry has often been followed.
Mellor et al (1997), for example, recommend
antibiotic prophylaxis for all animal bite victims.
However, Chaudhry et al (2004) believe prophylactic
antibiotics are over-used, with associated cost
implications, and current literature suggests they should
be used with caution. Smith et al (2003) note that
limiting antibiotic prescribing to those with infected
wounds would have cost benefits and avoid the
unnecessary treatment of large numbers of patients.
Bower (2003) found that up to half of cat bites and
scratches result in infection and that the signs are
usually evident after 12 hours, while in dog bites
(where the infection rate is only 23 per cent,
according to Chaudhry et al, 2004) signs of infection are
not usually evident until 24 hours after the bite occurs.
Guided reflection
Use the following points to write a reflection for your PREP portfolio:
l Identify your place of work and why this article is relevant to you;
l Write about the last time you dealt with a bite injury;
l What new information have you learnt about the management of bites?
l How would this information change the way you treat a patient following a
bite?
l Describe how you will follow up this new learning.
The literature indicates that prophylactic antibiotics
only reduced infections of the hand (Broder et al,
2004; Chaudhry et al, 2004; Medeiros and Saconato,
2004). There is only limited evidence but, when all
causes and sites of bites inflicted by mammals were
combined, antibiotics did not seem to reduce the
infection rate.
Partial thickness bite wounds have a low rate of
infection, as do facial, head and neck wounds. Bite
wounds in children are less likely to become infected
(Smith et al, 2003), therefore unless there is some
other reason to prescribe them, antibiotics are
probably not necessary in these cases. Smith et al
(2003) recommend that patients are instructed on
recognising the signs of infection and advised to
return to A&E or to see their GP only if they occur.
Clearly, patients who present with an infected bite
wound will require antibiotics and, as indicated above,
there is some evidence for prescribing them
prophylactically for bite wounds of the hand. Infection
is more likely in patients who are
immunocompromised and in those who present for
treatment more than eight hours after injury with a
wound that has not been adequately cleaned. Correira
(2003) believes antibiotic prophylaxis should also be
prescribed for patients with wounds in which there is
a high risk of infection developing.
choice of antibiotics
Correira (2003) emphasises the need for treatment
with antibiotics for bites containing beta-lactamase-
producing aerobic and anaerobic organisms, including
the Pasteurella species in animal bites and Eikenella
corrodens in human bites.
Bower (2003) recommends the use of penicillin and
co-amoxiclav (a beta-lactamase inhibitor). Some of the
newer cephalosporins or cefuroxime axetil may be
used in patients who are sensitive to penicillin
(Goldstein et al, 2002). Antibiotic therapy will be
needed for 35 days for wound infection, 1014 days if
cellulitis is present and longer when there are
complications such as osteomyelitis (Bower, 2003).
conclusion
The prevention of animal bites should be encouraged,
and Ostanello et al (2005) believe that better health
education may reduce the problem. Medeiros and
Saconato (2004) found that an educational programme
for schoolchildren increased precautionary behaviour
related to dogs. Also, teaching a bite-avoidance
strategy when someone is being treated for a bite will
help to avoid future similar injuries.
A review conducted by Chaudhry et al (2004)
concluded that the management of dog bite wounds
in the UK is not entirely evidence-based. It is
important to clean all bite wounds rigorously, and to
determine which ones should be considered for
primary closure. n
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