ry

Animal Bites and Prophylaxis ra

Li b
r e
Dr. Vedat Turhan , MD., c tu
L
Infectious Diseases and ClinicaleMicrobiology
r
e t h o
l i n
Gulhane School of Medicine
u
n
Haydarpasa Training a
Hospital,
y
O
Uskudar-Istanbul/ b
TURKIYE
ID ©
C M
E S

VT-1
 Planning & Overview ra ry
L i b
I. Common pathogens associated with
specific animals r e bites from

c tu
e r
II. Principles on animal biteLmanagement
e t ho
l i n u
n a
III. Prophylactic or therapeutic AB
O by
IV. TetanusIpx D ©
C M
E S
V. Rabies px

VI. Other animal bite & ID management

2
VT-2
I. PATHOGENS ASSOCIATED WITH ry
ra
BITES FROM SPECIFIC ANIMALS
b Li
Animal Pathogen
r e
Any vertebrate
Mammal tu
*Clostridium tetani

c
* Rabies Lyssaviruse

Le r
Dog
e t ho
*Capnocytophaga canimorsus
Cat
l i n u
*Bartonella henselae
n a *Pasteurella multocida
O by *Francisella tularensis

Rat ID © *Streptobacilus moniliformis

C M *Spirillum minus

E S
Fresh-water species Aeromonas hydrophila
Mycobacterium marinum

Salt-water species Vibrio vulnificus

Mycobacterium marinum

Macaque 3 virus)
Herpesvirus simiae (B VT-3
 y
II. General principles on animal bite
r
management
ira
b
e L
tu r
c
e r
e L o
i n u t h
n l a
O by
ID ©
C M
E S

VT-4
 Anamnesis & ry
History taking ib ra
• Provoked or unprovoked
L e
tu r
• Type of animal involvedc
Le r
• Current location of the
e
animals/ ownership/ t ho
l i n u
n
vaccination status a
O by
• Patient’s underlying medical
ID ©
conditions
C M
• Drug allergy
E S
• Tetanus immunization status

VT-5
 Physical exam ra ry
Li b
• Location/type/depth of wound re
c
• Range of motion, neurovasculartu function
Le r
• Signs of infection
e t ho
• Lymph node l i n u
n a
y or bone
Onearbjoint
• X-ray if wound
ID ©
C M
E S

VT-6
Principle of wound management ra ry
L i b
r e
c tu
Le r
e t h o
l i n u
n a Followed by
Clean with
25% soap
O by
Dilute
povidone-
irrigation
with copious
ID ©
solution or
iodine
solution,
normal
saline with

C M syringe

E S may diminish development risk of

Rabies and/or wound infections 90%

VT-7
 Principle of wound management ra ry
Li b
• Take Cx- after topical decont
r e
(if infection suspected)
c tu
• e
Remove foreign bodies and necrotic
L r
tissue.
e t ho
• l i n
Delayed suturing for contaminated,u
large or deep wounds n a
and hand
y
O
wounds (is advised) b
ID ©
•
C M
Orthopedic/ surgical consultation
• (as Sappropriate)
• E and immobilization of wound
Elevation

VT-8
Bacteria commonly isolated from Dog/Cat bite wounds
ry
(Often Polymicrobial) ra
Aerobes Anaerobes
Li b
Streptococci spp. :
r
Actinomyces e
c tu
S. aureus and other spp.
e r
Bacteroides
L
e t ho
Pasteurella multocida
l i n Fusobacterium
u
n a 
O by 
Moraxella spp. Peptostreptococcus

ID
Corynebacterium© spp. Prevotella

C M 

E S Neisseria spp. Capnocytophaga spp.



Eikenella
 corrodens

VT-9
 ry
Prophylactic Antibioticsra
Li b
r e
c tu
Empirical Rx: Le r
e t ho
l i n u
n a
Oral Amox-Clav
O by
ID ©Duration 5-7 ds
C M
E S

VT-10
 ry
ra
Li b
Puncture-style bite:
r e
the possibility of infection c tu
and abscess development
Le r
MORE e t ho
l i n u
n
Make no mistake about it,
a
O by
cat bites can be very serious.

ID ©
C M
E S
“Those thin sharp teeth …bite infections are serious and a high percentage of cat bites
go deep into the flesh”. will become infected so you will likely be prescribed an AB.
VT-11
 III. Prophylactic Antibiotics Regimens for
animal bite wounds a ry
i b r
e L
For pt with allergy hx of life u r
For pt with allergy hx of non-life
t
threatening rxs to pen: c
threatening rxs to pen:
e • Oral
• Oral clindamycin +
L o r cefuroxime +
 Fluoroquinolone
i ne t h metronidazole
 Tetracycline
n
 Septrin (paediatric)
l a u
O by
I D ©
C M
E S

VT-12
 Indications for Antibiotic Pxs: y
r
***** ra i b
I. Severe wounds involving significant edema
e L and “crush
injury” in first 8 hrs,
tu r
II. Probable penetrations to the e c
bone or joint,
L o r
III. Wounds closer to the e t
Prosthetic h joint,
l i n u
IV. Bites involving Handn a
& Face,
y Genital regio,
O b
V. All wounds ID immunocompromised
© individuals

C M
E S Pts with Lymphedema at Limbs
• SLE
• Immunosuppressed pts
• Asplenic pts
• Liver Failure pts VT-13
 Tx of established bite wound infection ry
ra
Li b
• Tx after wound swab for Cx/Ab-ST r e
c tu
• Depends on the progress;
Le r
e
usually 7-14 ds; extend ho
if there
t are joint/ bone
involvement l i n u
n a
O by
ID ©
C M
E S
14
VT-14
 Tx of established bite wound infection r y
ra
– Parenteral therapy preferred for admitted L i b pt with
infected bites r e
tu
• IV/Oral amoxicillin-clavulanic acid
• Other alternatives: secondc/third generation
L e agents r
cephalosporin + antianaerobic
• OR carbapenemse
t h o
l i n u
– Life threateningn rx toapenicillin:
O +by
• Oral clindamycin
IDfluoroquinolone/tetracycline/TMS
© ( paediatric)

–C
M
ES Non-life threatening rx to penicillin:
• Oral cefuroxime + metronidazole

VT-15
 Pts with Penicillin allergy ry
ra
i b
Contraindicated L
r e
• Pregnant
c tu Children:
women : e tetracycline and
• Tetracycline, L o r Fluoroquinolones
i ne t h
• TMS,
n l a u
• metronidazole O by
ID ©
C
• MayMconsider Macrolide e.g. azithromycin 250mg –
S
500mg per day under such situation
E• Patient observed closely for tx failure
VT-16
 TETANUS (Lockjaw) ry
ra
– Tetanus only occurs when Li b
spores of C. tetani gain accessr e
into tissues. c tu
Le r
– usual mode of entry is through
e t
puncture wound or laceration.ho
l i n u
Injury itself is often trivial and
n a
O by
in 20% of cases there is no
ID ©
evidence of wound.
M
– spores germinate from wound
C
and toxin tetanospasmin is
S
E
released into blood stream. It is
then taken up into motor nerve
endings and transported into
CNS.
17
VT-17
 TETANUS
PROPHYLAXIS ry
ra
Vaccination in Last 10 yrs
L i b
Simple Wounds
(Non Tetanus-prone)
r e
Tetanus –prone wound: *****
Vac <= 5 years: wound cleanliness
c t u Vac <= 1 year: wound cleanliness
Vac > 1 year: wound cleanliness+ 0.5 ml
booster Vac
L e r
Vac > 5 years: wound cleanliness+ 0.5 ml
booster Vac

e o
in Lasth10
t
l i n
No Vaccination
u
yrs

n
Simple Wounds
a
Tetanus –prone wound:
O by
(Non Tetanus-prone)
wound cleanliness & booster Vac
250 U HTIG + wound cleanliness
+ procain penicillin + Every 10 yrs rapel Vac

ID ©
+Every 10 yrs rapel Vac

C M No Tetanus Vaccination Lifelong

E S
Simple Wounds (Non Tetanus-prone)

Wound cleanliness+ Full course vac (0.5 ml x 3,

monthly) + Every10 yrs rapel Vac
Tetanus –prone wound:
Wound cleanliness
+ 250 U HTIG Or 3000-5000 U heterolog serum
+Full course vac (0.5 ml x 3, monthly) + Every10
yrs rapel Vac + procain penicillin 1.600.000 IU,
3-5 dys
 Active Immunisation *****ry
a r
L i b
recipients. r e
– Long lasting protection greater than or equal to 10 yrs for most

– Boosters are recommended at 10-yr c tu intervals.

L e r
– 3 doses of 0.5 ml (TT) bye
ho
IMI; 0-1- 6&12
t months
l n
• 1st : on the day ofiattendance u
• 2nd: 1 to 2 ms n a
after 1st dose
ydose
• 3rd: 6 to 12Oms after b2nd
ID ©
– M
Complications:
C• Fever /painful local erythematous or nodular rx at injection site

E–
S Contraindications
• Previous anaphylactic rx
• Acute respiratory infection or other active infection

VT-19
 Tetanus management: ry
ra
ib
Passive immunisation *****
L
e
r
c tu
Le r
e t ho
l i n u
n a
O by
ID ©
CM
E S

VT-20
 Tetanus management: ry
ra
ib
Wound care and antibiotics
L
• Prompt and thorough surgical er
wound toilet is of key
c tu
importance.
Le r
• Drug addicts and elderly people
may be presented with e t ho
l i n u
neglected wounds.
n y a
O b
ID
• Antibiotic pxs cannot replace
©
proper wound cleaning,
C M
debridement and proper
S
immunisation.
E
VT-21
 Tetanus management: ry
Wound care and ABsib ra
e L
•
u r
Eradication of organism from infection source:
t
– through cleaning of wound and e rc
e L o
i n u t h
– extensive debridement of necrotic tissue after

n l
– antitoxin has been injected.
– ABs to destroy spores: a
O by
ID 500mg
• metronidazole © IV 8 hrly for 10 days.

C M
S
E • (More effective than penicillin).
• erythromycin has been used but shouldn’t be routinely used.

VT-22
 Rabies ry
ra
• L
Rabies is an acutely serious condition and
i b
chances
can't be taken. r e
• Rabies infects mammals only. tu
•
c
Rabies has not been reportedein TK since 20...
• L o r
…..
i ne t h
n l a u
O by
ID ©
C M
E S

VT-23
 Rabies ry
ra
• Animal highly suspicious of being rabid: L
i b
• Animal is from rabies infectedrareae
t u
• The biting incident was unprovoked
c and the
animal has bitten moree than one person or other
animal L o r
• The animal shows i n e t h
n
of rabies, e.g.l a
increased u
clinical signs and symptoms
salivation, shivering,
change inO behaviour,
b y paralysis or restlessness
ID ©
• Wild mammals: raccoons, skunks, foxes, coyotes

C M
E S
24
VT-24
 Rabies, Transmission y
a r
i b r
e L
- The bite of infected animal,
r
c tu
- Tx of infected corneas and other organs (Liver,
kidney etc). Le r
e t ho
i n u
- Rare by aerosols in caves populated by rabies-
l
n
infected bats. a
O by
ID ©
C M
E S
25
VT-25
 Rabies r y
ra
WHO;>3.3 billion people are at risk for rabies in >85 countries...
55 000 deaths from rabies are estimated to occur every L i b
year
99% of which are the consequence of dog bites
r e
31 000 are estimated to occur in Asia (20 000
c tu in India alone)
24 000 in Africa.
L e countriesr can be as high as
annual incidence of animal bites in many
e
100-200 bites per 100 000 population.
t ho
l i
In 2005, >12 million individuals nreceivedu
a post-exposure pxs treatment
against rabies, preventing n a
O by an estimated 280000 deaths

ID ©
C M
E S

VT-26
 ry
ra
Li b
e
r
c tu
Le r
e t ho
l i n u
n a
O by
ID ©
CM
E S

VT-27
 Pasteur & Istanbul
10.000 “Ottoman Golden liras”
ry
Special rosettes and Madalion
Special inviting to Ottoman capital city ra
3 Res. Scholar sent by Abdulhamid, II.
June 8, 1886. Li b
r e
c tu
Le r
e t ho
l i n u
n a
O by
ID ©
CM
E S
Pasteur
Aykut Kazancıgil, Osmanlılar'da Bilim ve Teknoloji, 2. baskı, İstanbul, VT-28
2000, Ufuk Kitapları, s. 286-287.
 Rabies y
a r
• Canine rabies& stray dogs i b r
• Asia, Africa and Latin America. e L
• Control is often hampered by rel. tu r
beliefs and cultural habits.
e c
• Budhist and Hindu ethics L o r
e
canine ... th
restrain culling of thein
n
• India &Thailand have
l a u
the euthanasia Oof straybydogs
prohibited

ID ©
by municipalities.
C
• stray dogsM account for
S
E • >90% of human rabies
exposures,
• 5-14 years old children
• rural or peri-urban areas.
VT-29
 Human Rabies & India ry
ra
Li b
…endemic in India e
• immemorial times, tu r
c
e r
• actual incidence?
L
e t ho
•
l n
largely underestimated
i u
n
poor reporting a
• O by
ID ©
10.8 million persons in mainland India led to conclude
M
that the annual incidence of rabies was 2 per 100 000
C
S
population.
E
VT-30
 Animal Bites & ry
ra
Gulhane School of Medicine,ib2008
e L
tu r
c
e r
e L o
i n u t h
n l a
O by
ID ©
C M
E S Dog
Cat
wolf

VT-31
 Management of Rabies *****
ry
r a
Animal Type Evaluation and Disposition of
L i b
Postexposure Prophylaxis
Animal Recommendations
r e
Dogs, cats, and
ferrets observation
c tu
Healthy and available for 10 days of Px only if animal develops signs of
rabies

L e r
Rabid or suspected of being rabid Immediate immunization and RIG
Unknown (escaped)
e t ho Consult public health officials for advice
Bats, skunks, l i n u
Regarded as rabid unless geographic Immediate immunization and RIG
raccoons, foxes, n a
area is known to be free of rabies or until
y
and most other
carnivores; tests O
animal proven negative by laboratory
b
woodchucks ID ©
Livestock, C
MConsider individually Consult public health officials. Bites of

E
lagomorphs
S
rodents, and squirrels, hamsters, guinea pigs,
gerbils, chipmunks, rats, mice, other
(rabbits and rodents, rabbits, and hares almost
never require antirabies treatment.
hares)

VT-32
 ry
ra
Li b
e
r
c tu
Le r
e t ho
l i n u
n a
O by
ID ©
CM
E S

33 VT-33
 ry
Management of Rabiesib ra
e L
tu r
• Rabies should be considered incpatients suspected
L e r regardless of a
acute progressive viral encephalitis,
hx of animal bite.
e t ho
• Once a patient develops
l i n u
symptomatic rabies, available
n
diagnostic tests include: a
O Abs binythe serum or CSF;
– Assays for viral
ID from©CSF or saliva;
– Viral isolation
– Viral M
Ag detection in biopsies of skin, corneal
S C
impressions or brain tissue;
E– Reverse transcription PCR of saliva, CSF or related
tissues (such as salivary glands or brain tissue).

VT-34
 Management of Rabies ***** y
a r
i b r
• L
Active immunization of Human diplod cell vaccine (HDCV) on day
e
0,3,7,14,28
– Adults: Deltoid muscle
tu r
c
– Infants and small children: Mid anterior thigh muscles
e r
L o
– Victims who have previously immunised either with a 5
e
n t h
dose course or as pxs against rabies within the past 5
i u
n l a
yrs should receive 2 doses of HDCV on day 0,3.
O by
HRIG is not recommended.
ID ©
C M
– 5 dose full course is recommended if vaccination is
S
incomplete or received more than 5 yrs ago.
EConsider passive immunisation with HRIG.
VT-35
 Management of Rabies ***** ry
ra
L i b
• Passive immunisation with HRIG re
• Single administration of 20 IU/kgc tu
e asrmuch as possible
– Infiltrated around the wounds
L
and any remaining volume should
e t ho be administrated
IM at an anatomical
l i n site
u
distant from vac
administration.n a
O by
ID ©
– Adverse reaction: local pain or low grade fever.

M
– Immunosuppressive agents, anti-malarials, immunocompromised state can
interfere the development of active immunity after vac.
C
E S
– Pregnancy is not a contraindication to post-exposure pxs. No fetal abnormalities
have been assocaited with rabies vac.

VT-36
 Wound is cleansed with plenty of water&soap
ry
a
(may diminish probability of rabies 90%)
r
Li b
re
c tu
Suturing is avoided L ewhen the
r conditions are
suitable. e t ho
l i n u
n
If it is obligatory, a
HRIG
y point.0.1 ml injected I.C. to
every Oneedlebinserting
ID ©
CM
E S
biting animal should be taken under-
observation.
VT-37
 Pasteurella multocida y
a r
• Commonly associated with cat bite infection i b r
(75%),
• occasionally dog bite (50%).
e L
• u r
A cause of rapidly progressive infections
t similar to
Group A Streptococcus or Vibrio c (i.e. patient may present
e established
within a few hrs of a cat biteLwith
o r severe inf.)
•
i ne
wound inf. within a few hrs of ath bite injury, a scratch or
lick
n l a u
O by+/- bacteremia
– Cellulitis or abscesses
– OccasionalID cause©of pneumonia and endocarditis
C M
– Other: metastatic seeding of internal organs from

E S
bacteremia.
– CNS: meningitis (rare), most often in young children or
the elderly.

VT-38
 Pasteurella multocida ry
ra
• Dx Li b
– Cx based (swab, blood, body fluid). e
r
c tu
– May be confused with Haemophilus or Neisseria spp.
(Gram stain).
L e r
e t ho
• l i n u
Tx
– S: amox-clav,O
n
amp-sulb, y a
pen G, cipro, levo, doxy
I
– R: 1 gen
st
b
Dceph, cloxacillin, erythro and clin.
M ©
S C
E
VT-39
 Capnocytophaga canimorsus ry
ra
• Clinical presentation
– Facultatively anaerobic gram-negative L
i b
rod, part of
normal oral flora of dogs and cats.re
– Many pts have hx of dog bitecor tuscratch, less commonly
in cats
Le r
• Cellulitis e t h o
• Bacteremia/sepsis l i n u
• Meningitis O
n y a
and endocarditis (rare)
• Severe: I b
Dshock,©DIC, acral gangrene, disseminated
C M
purpura,
infiltrates
renal failure, meningitis and pulmonary
S
E • Fulminant sepsis following dog > cat bites,
particularly in asplenic patients, alcoholics or
immunosuppressed.
VT-40
 Capnocytophaga canimorsus ry
ra
• Tx Li b
r
– Mild Cellulitis /Dog or Cat Bites
e
c tu
• Preferred : Amox/clav
Le r
e t ho
• Alternative: Clinda, doxy
l i n u
Severe Cellulitis /Sepsis
n a
• Pen G 2-4 mU q 4h IV or Clin 600mg IV q 8h.
O by
ID ©
• Alternative : Ceftriaxone 1-2q IV qd, cipro 400mg
IV q12h or mero 1g IV q8h.
C M
• Prevention
E S
– In all asplenic patients with amox/clav for 7-10d

VT-41
 ry
ra
Li b
e
r
c tu
Le r
e t ho
l i n u
n a
O by
ID ©
CM
E S

VT-42
 Bartonella henselae
ry
Cat Scratch Disease(CSD)ra
Li b
• r e
Affect both normal and immunocompromised hosts.
•
c tu
80 % of cases occur in children.
• e r
Linked to exposure to cats, especially kitten and cats with fleas. CSD
L
e t ho
can result from a cat scratch or bite, as well as from a fleabite.
•
l i n
Characterized by self-limited regional LAP near the site of
u
n
organism inoculation.
a
•
O by
Occasionally life threatening manifestations (5-14%) include visceral
organ, neurologic, and ocular involvement because of the
ID ©
dissemination of organism.
•
• C M
In AIDS pts: Bacillary angiomatosis
Dx: a positive B. henselae ab titer or a positive Warthin Starry stain
S
or PCR analysis of tissue. Very difficult to isolate from tissue sps.
E
VT-43
 Bartonella henselae y
Cat Scratch Disease(CSD)ra
r
Li b
• Tx
e
r
• ABs are not indicated in most cases but they may be
tu
considered for severe or systemic disease.
c
L e r
• Reduction of lymph nodee size (no h
t o
REDUCTION in the
duration of symptoms)l i n
has beenudemonstrated with a 5-day
n
course of azithromycin a
and may
y LAP.be considered in
O painful
patients with severe,
b
ID ©
• M
Immunocompromised
C pts should be treated with :
S• TMS, Genta, Cipro,Rifampin
• Ehenselae is generally R to pen & amox
B.

VT-44
 Streptobacillus moniliformis
Rat bite fever ry
a r
• Caused by Streptobacillus moniliformis Lib
• e
A major cause of Rat Bite Fever (Spirillum
r minus occurs

•
mostly in Asia).
c t
Normal commensal of rodent oropharynx
u also in ferrets,
weasels, gerbils. L e r
• Transmission: bite/scratchefrom rat,
t h o
mice, squirrels--also
cats, dogs, pigs. l i n u
n a
• Symptoms:
O by
•
• ID ©
Fever,
Chills,
•
• C M
Headache,
Nausea/Vomiting,

E S
•
•
migratory arthralgias,
leukocytosis (~30K).
• nonpruritic maculopapular, petechial, or pustular rash (palms soles, extremities).
May be purpuric/confluent (day 2-4).

VT-45
 Streptobacillus moniliformis y
r
Rat bite fever ra i b
• Dx e L
u r
• Gr or Giemsa stain blood, joint fluid, pus.
t
– Cx c
e r
L o
– Serology (sero-negative within 5 mts-2yrs)
e
– PCR
i n u t h
• Tx n l a
O by
– Pen, ceftriaxone, clinda.
ID ©
C M
E S

VT-46
 ry
ra
Li b
er
c tu
Le r
SNAKE BITES e t ho
l i n u
n
Frequently detected y a
O b
D ©
microorganisms:
I
M
• Ps. aeruginosa,
C
S
E spp,
• Proteus
• Coagulase neg. staph.,
• Clostridiums. VT-47
 Resources & References a r y
i b r
1. IDSA practice guidelines for the diagnosis
management of skin and soft –tissue e L and
infection. 2005
u r
http://www.journals.uchicago.edu/doi/pdf/10.1086/497
t
143
e c
L
2. Soft tissue infection due to dog ando r cat bites in adults
. Zoonoses from cats n e t
and dogs.hAnimal and human
li au
bites in children.nhttp://www.uptodate.com
O byon management of rabies,
3. A&E clinical guidelines
ID
snake bites and tetanus infection from HA internet
©
C M
website http://www3.ha.org.hk/idctc/default.asp
4. Companion animals and human health risk: Animal
S
E bites and rabies.
http://www.medscape.com/viewarticle/560768

48
VT-48
 ry
ra
Li b
e
r
c tu
Le r
e t ho
l i n u
n a
O by
ID ©
C
Acknowledgments M
•
E S
Asim Ulcay, MD.

• Hakan Erdem, MD.

• Hossam M. Al-Tatari

• Wong Tin Yau, MD

VT-49